 Great. Okay. Well, Mindy, thanks for that really generous introduction. And I wanted to thank you for inviting me to talk to you today about the, for the McLean Center 40th annual lecture series on medical history and ethics. Now, my work has really taken me primarily in the direction of using history to understand policy issues. And I've written about the history of critical care and how new models of care, for example, nurse practitioners have been both a response to and shaped by the context of health care. I move in and out of the regulatory arena and particularly state regulations of health providers. And I'll talk a little bit about that today. And my current work examines the idea of health as a civil right. I won't speak too much on that, but I'm happy to answer questions about that later. I'll first set the table for you with some current data and then go back in time and present some history. But before I again I think terminology is important. I'm going to be speaking primarily about nurse practitioners. But you all know the term advanced practice nurse, which includes nurse anesthetists, nurse midwives nurse practitioners, clinical nurse specialists, and they all have some similarities to nurse practitioner history, but many different so primarily be speaking about nurse practitioners. History helps us understand human behavior that nothing is inevitable. It gives us a sense of perspective. But the question of using the past to guide our future doesn't mean that we're victims of our own history. It means that there's sometimes road signs that help guide us inform us and provide a foundation for where we're going. It provides an understanding that change is constant and highly political. And as my mentor Joan line on notes, everything has a past. It helps us understand that outcomes can be different depending on time, place and context that what we see as barriers can become opportunities, for example, regulatory barriers can support new partnerships for better success. It helps us understand the importance of unintended consequences both positive and negative. In healthcare we seem at times to have answers without the right questions. So in this presentation, I'll take a stab at questions that are shaping our healthcare system today, primarily outside of acute care institutions, but lately inside of them, especially during this pandemic. These questions are hysterical, historical and hysterical, and have been debated over a century with some continuities and answers, but always contextually shaped. So what education, knowledge and skills are necessary for providers to provide safe, high quality care for particular patients at specific times and places. And in question to how do clinicians, not only physicians and nurses, negotiate among themselves with patients and with public and private interests to define the borders of responsibility and authority for care. Currently there is historic continuity of boundary disputes who can do what with physicians claiming almost all patient care activities and services as their own, and then formalizing their claims through regulatory channels. This is not a critique, but a historic reality based on class, race, and gender. And thirdly, how have these negotiations shifted through history. The negotiation today is different than it was in the 1960s when nurse practitioners emerged. And I argue that history can provide foundational data for examining these questions, and then for helping us understand how physicians and nurses can work together to provide basic care. Let's take the table a little bit. So as you can see from this graph, the numbers of nurse practitioners have rapidly increased. By 2026, the Bureau of Labor Statistics projects that the nurse practitioner profession will have grown by 36%. All right, so you can see from this, the number of nurse practitioners have rapidly increased, and the Bureau of Labor Statistics projects that the nurse practitioner profession will have grown by 36%, compared to 37% for physician assistance and 13% for physicians and this excludes anesthesiologies and surgeons. And according to, so you see the slide change now. So according to the American Academy of Nurse Practitioner website in 2021 and estimated 90% of MPs will be certified in primary care. 70% of all of them will deliver primary care. 81% of full time MPs are seeing Medicare patients and 77% are seeing Medicaid. 42% have full time privileges hospital privileges and 13% have long term care privileges. 92%, 96% prescribed medications and those in full time practice write an average of 21 prescriptions per day. They hold prescriptive privileges including controlled substances in all 50 states in the District of Columbia. And in 2020 the medium based salary for full time nurse practitioners was 110,000. And this data from the ANP annual survey shows that nearly three quarters of them work full time, 35% of them took evening and weekend call. And they're working in a variety of settings including private practices 30% hospital outpatient clinics 13 inpatient units 10% community health centers and FQHC's 8%. And if you look at the nurse practitioner and they're smitten wise alone. The profession is overwhelmingly white. And from the data I've seen there's a slightly larger proportion proportion of black DMP graduates but it's difficult really to get these numbers because the available data really conflates a lot of things. Even though a majority of nurse practitioners providing primary or providing primary care, they also tend to specialize in acute care areas similar to physicians. And the number of physicians also has grown but not as rapidly according to the double MC. And PA high use scenario assumes each additional APRN or PA beyond supply needed to maintain current staffing patterns will ease demand for physicians and their specialty as follows anesthesiology 60% of an FTE primary care 50% women's health 40%. And you can see that there are lots of things changing here. And between 38,000 and 124,000 physicians fall short, mostly in primary care general surgery family practice and anesthesiology, and except for general surgery, these are all areas where nurse practitioners and anesthesiologists provide care. There are many factors driving demand population growth the increase in numbers of older Americans. The total US population is expected to grow by 12% by 2030, and also the number of US residents and this is one of the main reasons why demand is up age 65 and older will grow by 55% and those 75% or greater by 73%. Then there's the burden of poverty increases in chronic rates of and rates of chronic illnesses, and the need for clean water housing etc, which reflect a renewed interest in the social indicators will help. So what does this all mean. We need to figure out how to have all hands on deck so that the public's health care needs are met. And if you think about population based care, for example, prevention of obesity, better nutrition management of chronic illnesses. There are multiple studies that show that different kinds of providers at different points of patient care can provide care individually and in teams for better outcomes. We also know that even when we add all the MPs and PAs to the physician population, we still will not have enough providers to meet the care needs of the public. So why are there barriers to nurse practitioner practice, and how can we understand how both physicians and nurses can work together to provide the best care where it's needed. All professions need to do things that we need to do the things that we do the best and to work together. And that is where the negotiations between physicians and nurses are most critical. All professions should be working to their full scope of practice. So going back to my question. All of them, all of these questions intersect in the area of patient care, territory, payment and authority. And these are areas that are sometimes to be set by conflict, which is underpinned by the idea of competition. So competition tendencies are illuminated in scope of practice regulations. On one hand, regulations are designed to provide for safe care by setting education certification and accreditation standards that assure patients that a provider has a basic level of knowledge and skills. But this is not always the case. The scope of practice regulations are used by a profession to protect their market share, instead of in addition to protecting the public, either through political alliances with legislators, or as a foundation for a challenge to changes and other professions scope. They restrict that profession from providing a full range of patient care services to the public. This is particularly dangerous when there's no evidence that the service provided by these practitioners quote, and this is from the Federal Trade Commission harm the public or provide benefits that offset potential costs and quote, this anti competitive stance, which restricts services beyond the purpose of patient protection can be used to control who can engage the public as providers at particular times and places, be it your regulatory definitions of providers that shape payment mechanisms, institutional privileges, or regulatory channels. Now the nursing profession itself has used scope of practice regulations in the early decades of the 20th century, and most recently to limit the work of unlicensed attendance or patient care aids and patient care settings. New regulations offering title protection can also be seen in the same vein. So on this slide, which I'm hoping you're seeing gray shows title protection legislation. Both physicians and nurses have used title protection in Pennsylvania a few years ago there's been action on the title protection of nurse and in Texas on title protection of doctor. And this is an important as one of the fastest growing education programs in nursing is the doctor of nursing practice. In 2011, the Institute of Medicine now the National Academy of Medicine released a major report on the nursing profession and its present and potential roles in US health care called the future of nursing. The first of the reports for key messages stated that nurses should practice to the full extent of their education and training. The first of the reports eight recommendations was to remove scope of practice barriers, so that they might do so. The message and recommendation were based on a particular assessment that restrictions on scope of practice have undermined the nursing profession's ability to provide and improve both general and advanced care, and that it is a substantial health policy probe problem. To ameliorate the problem the Iowans suggested among other things that regulatory restrictions on the scope of practice receive attention from the federal antitrust agencies, such as the Federal Trade Commission. Now the future of nursing 20 to 23. This is the next report has continued to see barriers to nursing's contributions as a main issue for providing access to care to all who need it. Even so, the AMA has continued to fight expansion of scope of practice regulations, and since 2019, the AMA has secured over 100 state legislative victories stopping scope extensions of nurse practitioners, pharmacists, PAs and others. This work was done in strong collaboration with state and medical national specialty societies through the scope of practice partnership, which is 105 member state, national and specialty society with the tagline hashtag stop scope creep. You can see the text from the AMA site on their efforts in Mississippi. Now, the current movement in more formal regulatory environment draws its fruits from the late 19th century, when allopathic medicine embraced new scientific advances such as bacteriology that overwhelmingly changed the course of medical care. Allopathic medicines authority came then from the power of science, as well as the class race and gender of its practitioners. The authority bestowed by science continue to rise in the early 20th century as the flex and report built upon the American Medical Association's earlier calls for better standards for medical education, particularly for greater inclusion of the sciences, laboratory work, and formal clinical practicums. Many times at the expense of schools that educated black students. These were indeed needed reforms, but part of the move to standards and science based curriculum was also based on attempts to exclude other types of practitioners who had become quite popular and mainstream. So as natural paths and homeopaths, the power of science public sentiment as was the drive to eliminate competitors became political ammunition for establishing science based medical curriculums, and later the length of the clinical practicum, as more science contact and complex medical procedures were built into the curriculum as a proxy for patient safety, all occurred within an empirical vacuum, without evidence that the growing scientific content or length the clinical practicum made a difference in the quality or safety of patient care. Even so, medical licensure and school practice were built upon these pillars, which grew into effective anti competitive strategies. Now, nursing education and practices also changed greatly over the last century and expanded to include health promotion and disease prevention community based health and public health without much concurrent regulatory channel challenge to reflect these variations. And in the same vein because of the ability to influence legislators through race class and gender commonalities medical school for practice regulations have become increasingly broad exclusionary and encompassing all locations skills and knowledge taken on by physicians. We assume this includes more complex types of things, but it also include knowledge and skills traditionally in nursing review such as community health and home care. The ability to prescribe is really a useful example that shows that education and patient safety are not necessarily the factor that determines scope of practice. We tend to assume physicians have always exercised prescriptive services, because the public and regulators believed they were best positioned because of their education to do so. But in fact, formal prescription requirements became compulsory for physician prescribing of narcotics only in 1914. The public protection against harmful proprietary pharmaceutical manufacturing with the Paris, with the Paris passage passage of the Harrison anti narcotic act. More general prescribing requirements, for example patients could only get access to particular medications to a physician prescription emerged only more recently between the 1938 enactment to the food drug and cosmetic act. In 1953 amendments, primarily as a precautionary device to protect physician scope of practice against pharmacist infringement on prescribing until this time medical school curricula was short on basic scientific pharmaceutical content. Now nurses had a long and perhaps subversive history of circumventing the usual prescribing channels, both with an independent of physicians and being quite successful. Prescribing activities were sustained because patient circumstances demanded them and because nurses effectively prescribed. Now historian Arlene Keeling described the work of Henry Street district nurses in early 20th century New York City, who carry different types of solutions and ointments, in addition to narcotics, caustics, and mustards in their black bags. Most of these items were part of the medical armamentarium, similar to medications found in middle class homes, and often the subjects of advertisements and popular now magazines at the time. During their patient visits the nurses frequently used a process of de facto diagnosing to make decisions about treatments, including dispensing and prescribing the appropriate therapy. Perhaps after the visit they might have informed the physician about their actions or referred the patient for further treatment. Still, nurses made decisions and acted to prescribe treatment, even when they had no formal authority to do so. Now nurses at the turn of the 20th century certainly knew how and what to prescribe for a growing set of patient complaints. Most nurse training schools at the time included courses on materia medica that was similar to those in medical schools. Public health nurses who were the more elite of nursing specialties acquired additional pharmaceutical knowledge during their postgraduate training and their expertise in diagnosing and prescribing approximated data physicians. Patients also expected nurses to prescribe physicians made mistakes were not always available, and we're not always interested in indigent cases. Nonetheless, as dictated by the realities of their political position in the medical hierarchy, nurses would not typically drop on the language of diagnosis or prescription, as these powerful words were already a part of the medical lexicon and used in medical journals and texts of the times, but only in reference to physicians detailing a treatment, rather than the official drug prescription refer to today. But in the house in Henry street, the founder that settlement house Lillian wall described how one visiting nurse chose language to relay her diagnosis and prescription suggestion to the physician who had left a prescription but not returned to treat a girl or a woman with fine diplomacy. Walt noted an excuse was made to call upon the doctor, my colleague the nurse presented her credentials and offered to accompany him to the case immediately. As she was sure conditions must have changed since his last visit, or he doubtless would have ordered so and so, suggesting the treatment to distinguish specialists for them using. As the nurse contested the prescription left by the physician, hinting that was not appropriate for the patient's current status, and that she knew from her assessment and diagnosis of the patient, what was needed in this case. She thought to a patient did not build a physician's prescription, and it probably already dispensed the treatment. She believed the patient needed, but the limits of her ability were clear, as Walt's narrative suggests, house was the political field she had to navigate to get the patient, the appropriate treatment. Some are examples of nurse prescribing including nurses on the frontier nursing service, rural nursing and the Indian health services, who carried syringes various drugs and suture kits and dressings in their saddlebags and nursing kits and employed them to treat patients when needed and poor rural areas in cities with large immigrant populations and in areas where physicians were unavailable. Nurses diagnosed and prescribed drugs and treatments for patients as an essential part of their practice. Many physicians in fact believe nurses should prescribe, realizing they could never know that they want to provide care to certain populations in certain areas. In very busy Miss Century hospitals, as Leonard Stein described in his classic description of the doctor nurse game, physicians relied upon nurses to diagnose and prescribe. A nurse might call a physician and describe a patient's condition and then suggest the treatment. Doctor, the patient is short of breath. Do you want me to give him 40 milligrams of Lasix? Yes, nurse, please give him 40 milligrams of Lasix. Or in order to help a physician get some rest at night, a nurse may treat the patient until the physician later. The common thread in these examples is that the nurse decided when and how to treat and when to call for help. The developing nurse practitioner movement is an example of how choices, particularly the choices made by the public, shape practice considerations. The early nurse practitioner movement of the 60s and 70s was a confluence of multiple contextual factors. A meshing of scarce physician resources in chronic and primary care in rural and urban poor communities with nursing's growing capacity and interest to effectively serve patients in these places. The role relied on nurses and physicians to NACI encourage, but the movement was sustained by a void of unmet health care services in primary care. And as nurses moved into these areas, patients found them to be satisfactory and interest providers, followed their advice and came to their clinics. This multifaceted scenario, rather than planned decision making or physician direction flowing solely from a concerted health policy, supported the generation of new types of providers, and in this case, nurse practitioners. Patients found nurse practitioners both alone and in partnerships with physicians to be acceptable and even preferable alternatives to traditional solo medical care models. They then shared their experiences with nurse practitioner care with their neighbors, their friends and their families, helping to build community support from individual encounters. Conversely, nurses who wanted to practice new types of roles found these circumstances energizing and fulfilling, opportunistically moving into the chasm created by physician shortages, or into physicians created by liberal minded physicians who understood nurses potential to meet patient needs, shared their holistic vision, and were not insecure about sharing patients and resources, even when threatened by local medical societies. In 1965, University of Colorado public health nurse Loretta Ford, along with pediatrician Henry Silver, came together serendipitously in fact at a cocktail party to address the lack of care in rural Colorado and to formalize and strengthen the types of services public health and pediatric nurses have been provided to the poor in the rural areas of the state. Ford explained that she was interested in expanding the nurses role, not because there is a shortage of physicians. She saw the nurse practitioner role as a way to legitimize what she and her public health colleagues were already doing. When it came right down to what she said, we were making decisions, there was nobody else in the poor families frankly expected you to make those kinds of decisions anyway. To meet these needs, Ford and Silver designed a post baccalaureate curriculum that included courses rarely found in nursing schools at the time, but which provided stronger foundation to serve the patients nurses were encountering. It taught students to better understand the underlying principles of healthy childcare and patient education and graduates of this program armed with increased depth and breadth of their clinical knowledge were called nurse practitioners. And as Ford and Silver developed their program, others across the country were also doing the same, but in different types of practices, and for different populations, and the response to some of the same social and political forces, shortages of physicians, physician specialization and disinterest in outpatient general care opportunities for broad broaden nursing practice in patient demand for general medical services, primary care, especially in women's health. Some of the places and people who led the way were in Rochester, New York, to name a few nurse Joan line now and physician Barbara Bates developed the medical nurse practitioner program in the early 1970s, with funding from the US Public Health Service and Kodak. Rochester was a hotbed of experimentation and new models to care. In addition, Evan Charney and nurse Harriet Kitzman, who then went on to work with David Olds to develop the nurse family partnership, develop the pediatric nurse practitioner role, even earlier. And back by public appropriations to support demonstration projects and education programs and private support from foundation such as the Robert Wood Johnson Foundation, and the Commonwealth Fund which supported for the first program. Early nurse practitioner programs formalized and provided the skills support for expanded nursing care. Ford and silver published accounts describing their program in 1967. As did physician Charles Lewis and nurse Barbara Resnick, we issued their 1964 study of new models and nurse resident teams at the University of Kansas Medical Center in Kansas City, Kansas. The first studies describe patients receiving and seeking out care and nursing services, typically within the medical realm and with various levels of physician supervision. Mahari University and Nashville started a very early pediatric nurse practitioner program in 1971 with six students. It was one of the earliest programs to educate them and Everland Tomes was one of the leaders in the movement. They had no foundation support, but did get the university to agree to support the program. By 1972 Mahari had five different nurse practitioner programs, including a program and mental health, which is extraordinary because it was one of the first in 1975. The program graduated 23 students per year in 1978, but still had issues finding placements in the south, and then place most students in the southeast, California, Ohio, and Philadelphia. In 1965, Duke University initiated their physician assistant program, and the University of Washington unveiled the medics program that trained medical corpsmen returning from Vietnam to work with general rural practitioners. North Carolina at the time was experienced a severe physician shortage in primary care, particularly in the rural areas, and the physician assistant program was meant to be a stop gap measure to fill the void onto a reorganization of medical training from general practitioners to family practice in primary care could attract more students. Of course, once out of the box, PAs were not a temporary stop gap solution, but have become an important part of our healthcare system today. Now patients demand for nurse practitioners is illustrated directly and indirectly, through the use of services and clinics and private practices, patient satisfaction surveys and coverage and popular publications. The individual actions, nevertheless were crucial driving force and leave footprints that are important for understanding the changes in healthcare delivery that occurred in the 1970s as a nurse practitioner movement gave momentum. In the 1970s, physician over extension unavailability inconsistency, or the force of various social movements, for example, the women's movement and the consumer movement, coupled with public dissatisfaction with the structural medical care. Motivated patients to seek services and clinics staffed by nurse practitioners, or teams or practitioners and physicians and influential medical profession through their organizations to be sure, erected barriers to nurse practitioner practice and payment to their connection to state licensing Third party payers in hospitals as a way to stifle competition. But despite the barriers patients in many areas found their way to nurse practitioners and settings as diverse as self pay for public supported community clinics, women's health clinics, child bearing centers, and third party hospital clinics to name a few. And by doing so, and despite physician opposition, patients gave legitimacy to nurse practitioner practice, sustained it and demonstrated its relevance to the healthcare system by continuing to seek nurse practitioner services. In the late 1960s and 70s when medical nursing journals began to report on nurse practitioners, much of the public really didn't realize or understand what these nurses could do. Typically, most people interacted with nurses only when they were acutely ill and hospitalized, or when they sought out routine care and private physician offices. The public's perception nurses traditional roles where this formed in the crucible of the most vulnerable state, or in places where nurses, most often took on dependent roles. But nurse practitioners illustrated to patients a broadened perspective what nurses could do. And most patients seeking medical care, the well and the well but worried, as well as those needing coordination of care to manage chronic illnesses could receive services provided by nurse practitioners. The quality of care by nurse practitioners was clearly illustrated by a later 1986 meta analysis by the Office of Technology Assessment, a studies done primarily in the 1970s. The estimated nurse practitioners safely care for more than 75% of patients, typically seeking the services of primary care physicians. Most physicians with their education and practice focused on increasingly complex, acute patient problems were not educated to be particularly effective in dealing with the everyday issues, a managing chronic illness, and nor was there a great deal of interest in taking on patients with these issues. And there were health policy changes, for example, Medicare Medicaid in 1965 brought large numbers of newly insured persons into the healthcare system. Private organizations such as the Robert Wood Johnson Foundation earmarked money for nursing education and practice models. And starting with Idaho in the early 1970s, states began to change their practice acts to accommodate expanded nursing practice, and many physicians integrated nurse practitioners into their practices. The preferences for and sources of information about nurse practitioners came through broad coverage and popular newspapers and magazines of the 1970s and 80s, as well. Some of the most widely circulated popular magazines such as Look, Saturday Evening Post and McCall's Magazine published stories. Look published one of the earliest stories in the popular press in 1966, with the unfortunate title, more than a nurse, less than a doctor. The Saturday Evening Post followed in 1972. McCall's leading popular women's magazine at the time ran articles about nurse practitioners starting in 1975. Ebony discussed nurse practitioners in 75 as a good profession to enter because of patient loyalty and rising salaries, and included several articles about them throughout the decades and different healthcare scenarios. The sources also include a 1979 science digest report on nurse practitioners as a new career. Sources as diverse as the Wall Street Journal and today's health as well as patients themselves in these articles, referred to nurse practitioners as super nurses, pointing to their competence as well as recognition of their ability to provide high quality services. In the 1974 Wall Street Journal article noted that super nurses worked in logging camps in Washington and on remote Indian reservations. In Cambridge, Massachusetts, 12 pediatric nurse practitioners handle 25,000 patient visits a year at five neighborhood health centers in the direction of the city. By 1985, The Times, Washington Post and Wall Street Journal reported on nurse practitioners in the main or health sections and printed letters to the editor over 150 times. All of these sources were accessible to the general public, and they showed patient support and help patients learn about nurse practitioners. In the early 1970s in Ustensia, New Mexico, nurse practitioner Martha Schwebeck worked alone in a clinic built by the area's last physician who left in 1968 and was never replaced. She communicated with six physicians 60 miles away in Albuquerque when she needed consultation. She made house calls and ran an emergency service of almost 3000 patients, 20 to 25 of whom she saw daily in the clinic you wonder how she slept. By 1974, nurse practitioner Ruth Murphy in Elk County, Kansas, set up a series of free clinics and estimated she needed over 45 house calls a year. The area had not had a physician for over 15 years, like public transportation, and the nearest hospital was 50 miles away. Lucille Kinline, one of the earliest nurse practitioners in the country in the country in 1971 in College Park, Maryland. The practice started pretty slowly. No patients came the first month. And the second month brought her first patient. But four months later she had 60 patients. Colorado pediatrician Lewis Day admitted that three of the five families that joined his practice every month in the late 1960s did so because of the nurse practitioner. He said I even have patients call me at night for her phone number physician James Johnson of Green Castle Indiana wrote in 1977 that even patients he followed in his practice for two or three decades began to request the nurse practitioner patients obviously must like her because the number of patients has doubled in my practice since I started. And as nurses moved into these roles education programs changed, although nursing still hasn't figured out the basic entry into practice. Education was now following what was happening on the ground. New kinds of knowledge and skills required new types of learning. As we can see from the original drawings from the Barbara Bates text. This textbook was designed to be used by both physicians and nurses. It was one of the first to have large diagrams. It became one of the most popular physical exam and clinical decision making text used by both physicians and nurses. An indirect evidence also pointed to patient acceptance and satisfaction and physicians perception of nurse practitioners value to their practice. Newspapers such as newspapers such as the New York Times and the Los Angeles Times consistently ran advertisements by clinics hospitals and private practices, searching for nurse practitioners and a search by pro quest historical newspaper database reveal at least 2500 such ads in the early 1970s, which typically appeared in the weekend section. Evidence of patient acceptance also came from prepaid health plans. Kaiser Permanente which started hiring nurse practitioners in 1971 in Oakland, California. By 74 the health plan employed nearly 100 nurse practitioners, allowing administrators to enroll more patients. Many of the nurse practitioners provided services and screening programs in area that saw rapid increase in patient popularity in the 1970s. The women's health movement in the 1970s provides more evidence in the feminist women's health centers of the early 1970s in Los Angeles that began with activist Carol Downer. They promoted these centers promote self care most vigorously, but the participants also saw nurse practitioners as allies in their struggle against medical paternalism. Patient influence is also seen in the legislative arena at the state level, when nurse practitioners ability to provide a full array of service just patients was challenged by state, medical or pharmacy societies. Both individual physicians and physician organizations recognize the value that nurses brought to patients and probably understood the future better than nurses did themselves. I encourage for our junior who was president of the PA medical society and 69 foreshadowed nurse practitioners power and their appeal to patients when he noted. Right now, how many of you are willing to supervise a satellite office say 10 miles away staff by a registered nurse with additional training, who will be a screening practitioner treat emergency cases, and other cases with nothing more than the availability of telephone from you. You say it will never happen. He went on such a person will come into being with or without your cooperation and guidance, and if such a person comes into existence without our active direction. This health professionals someday could become the single greatest opposing force that medical doctors have ever faced. He was right. Nurses have become normative providers of health care in all places where people need services. Nurses have in many instances by virtue of their service to individuals, families and communities become a powerful social force, a social movement and shaping health care, as well as as an example of these movements, shaping health policy. This is a little number here that was developed by British physicians as a pushback against nurse practitioners in their country. And even though there continues to be pushback from some medical associations to removing practice barriers progress has been made, and has come from alliances with patients, other stakeholders such as W. R. P. And some medical organizations, and in particular, the Association of American Medical Colleges has shown courage and strength by supporting nurse practitioners and press releases and policy statements. In many states like NDC Guam and micro Polynesia, nurses can prescribe with full authority, they can diagnose treat without physician supervision. Actually nurse practitioners can prescribe in all states, but many states still require a collaborative agreement and what this is is a legal agreement that requires a nurse to enter into a contract with a physician. Many physicians charge for this and a study by my doctoral student Ashley Ritter showed then Florida, for example, they were charging up to $7,000 per month, and and we're not actually providing any services. In order for them to practice in Florida they have to have this contract is legally required. So, not only is the cost a problem but there's sometimes in many places in Florida which is actually quite a rural state, but there are no physicians to make to even go into a collaborative agreement with and it is a problem in terms of scope of practice. In California for example, they still a collaborative agreement is still required to practice between five to six years and similarly in Pennsylvania but only three years are required for a collaborative agreement with Delaware now joining full practice without the need for a collaborative agreement. And, by the way this map shows Illinois is having reduced practice was as of January 2021 and Illinois licensed advanced practice registered nurse certified as a nurse practitioner nurse midwife or clinical nurse specialist. This is exact language from the led the regulation, maybe granted the privilege of full practice authority which provides the ability to practice without a written collaborative agreement. Of course this does not include nurse anesthetist which is another issue. So this is a blog I published in the Hill which is a newsletter for Hill staff and read by Hill staffers. And as you can see by the comments and statements by the emergency medical specialty, how fierce this battle can be, as well as how racist and demeaning the discussion can be. Things happening that make teamwork, no matter who leads as a critical way of providing health services. For example, resident work laws in the pen health system, for example, in order to originally fill the gaps, and now to add value to the care team. There are more than 700 nurse practitioners working across all levels in clinics and house. In almost all places, there might be residents. All of these changes have required new negotiations and rules responsibilities and authorities so that all providers can work to the top of their team and to work well as part of the team. This is part of our historical continuity. But frankly this is the public's time. Nurses are the most trusted profession according to Gallup and other polls, but none of us. And I mean to include all providers, including PA's physical and respiratory therapists can do this alone. This pandemic has shown how our work together is critical to saving lives and providing effective public health initiatives. Our professions have suffered during this time, and we face a severe shortage of all types of health providers. We have to proceed in a deliberate way that capitalizes on new and old alliances, focuses on what patients need, but all the while remembering how we got to this point of care, and then leveraging it for the future. This case was very wise and not only did she develop her textbook as a new way of teaching but she also directed it towards physicians and nurses. And as Barbara Bates suggested, the best patient care includes four key ingredients. First, a nurse with confidence and with courage. Second, a doctor with the willingness to experiment and learn from a nurse. Third, continuity of these two people over sufficient time so they can learn to know and trust each other to give and to take. And fourth, a specific goal on patient care. This is really the true essence of interdisciplinary practice and education. And these ingredients are historically contingent across time and place, and together provide a strong foundation for better patient care in the future. Thank you. That was terrific and very excellent talk. Totally fascinating and, you know, it just makes me think about all the nurses and nurse practitioners that we work with on a daily basis and how not to take them for granted. How's that? Open up the question and answer period by turning it over to my urology colleague, Dr. Modi. Hi, thank you for a great talk. One question I have is, you know, a common phrase in this discussion is that all professionals or the nurse practitioners should work to the full scope of practice or the top of their license. And I wonder what is really meant by that and what restrictions do you think should be in place? So, you know, by way of example, physicians when getting a license often even before completing residency training have a scope of practice that includes every aspect of medicine and surgery. I'm a urologist. In theory, my license allows me to perform neurosurgery and pediatrics and psychiatry. I wouldn't dream of doing any of that. I'm not, you know, I'm not qualified to do so. And the question is, should there be some restrictions on the scope of practice or requirement for additional training, or is the nurse practitioners top of their license full scope of practice truly to work in any field of medicine and surgery. Well, I have to say, I haven't seen nurse practitioners working in surgery, just to put your mind at ease on that one. You know, every nurse practitioner that finishes a program has to take an accreditation exam and a certificate has to be done an accredited program and take a certification exam. And, you know, what they learn are things that are reasonable for them to do. I mean, when you think about primary care, what is it that they shouldn't be doing. And, you know, when you think about scope, you know, in the idea of collaborative care, you know, nurses want to collaborate they want to be able to work together with with physician colleagues to provide the best care. It would be very hard to say what they can or cannot do, for example, don't I, again, as I said before, I don't think anybody's doing surgery to tell you the truth, but we have nurses who are practicing very confidently. And as you can see by very low malpractice rates in every area that you described, even in neurology, they may not be doing procedures, but they are certainly working with incontinence pensions with incontinence, all kinds of issues that are that are coming up. I don't know if that answers your question, but, you know, as long as you know, as you're trained to do certain things and everything that you learned in medical school, you didn't, you weren't trained to do procedures for the most part in neurology, I would bet. And if you did, you were, you were lucky because you knew you were going into that specialty. But it's the same thing with nurse practitioners. And in many of these colleges and medical schools, nurse practitioners are actually teaching medical students how to do things. So the, the, sort of the overlap in the engagement is, is very difficult, not difficult, but it's, it's, it's quite large and maybe the right question is what shouldn't they do, but what should they be, what should they be doing. Okay, I'm going to open it up to the other three speakers in a minute, but just remind me afterwards there's a lot of good questions in the chat that I'll go to afterwards. I'll take it away. Thank you for this great talk. My question is with respect to the 1135 and tell a waiver during this pandemic which sort of introduced less restrictions and allowed physician assistants as well as registered nurses to perform medical screening exam as well as stabilized patient, as long as they use the correct coding and that they are practicing within the scope of their practice. Do you think that, well, obviously this is applicable during the pandemic. How do you think this will influence the practice moving forward after the pandemic. Well, thanks for that question. I think during the pandemic which the that blog that I wrote was actually directed to was the idea of, of, you know, Medicare and Medicaid had actually changed a lot of their, or liberalized their regulations during the pandemic and the question was what will happen when it's over. And as far as I can tell, there have, there has been no study that has shown that allowing, allowing nurses to practice via telemedicine has, has not been a positive thing. So, I know a lot of states have now gone backward have have, you know, put back into place the same restrictive regulations that they had before the pandemic some states have not. But, you know, the question was should should we put, should we push the pause button and allow these, in a sense liberalized regulations to continue to exist because they've served us pretty well during this pandemic. Hey, Alexis, you're on. Hi folks I did actually put my question in the chat but I figured I'd go ahead and just do it orally as well. I mentioned I'm, I'm faculty at Columbia and the Department of Medical Humanities and Ethics so thank you so much for sharing this event three sbh because I was glad to be able to be here. It was a great talk so you mentioned that the nurse practitioner and P education throughout the 20th century had moved toward specialization away from health promotion and public health. So I wondered if you thought that granting more powered and P's would likely lead to greater attention to public health or just sort of be more of the same of the trends that we see with a physician care of late. Interesting question because one of the reasons that the rate of nurse practitioners becoming certified in acute care for example is that many hospitals for example at at Penn if you want to work within the hospital system. It could be in a primary care clinic it could be an urology clinic it could be, you know, and student health, you have to be certified as an acute care nurse practitioner. Even though you're not providing that kind of care, it's just, it's just the way they do things and so some of that is driving what we see in the specialization. But the other thing is that, you know, nurse, even though nurse practitioners provide a fair amount of rural care. You know, in some states they have to practice where their physicians and those are and that's in acute care hospitals and urban centers and so, you know, they go into, they go into practices where they need specialty certification. And that really is driving a lot of this. Okay, thank you. Barbara and. Thank you, Dr. Fairman. I just wanted to address this idea of competition versus collaboration. Now, I've been a acute care critical care nurse practitioner since 1997. So I think the first year that that certification exam was available. I really have seen that a lot more from the political side from the medical organization in Pennsylvania it's the pencil, medical Pennsylvania Medical Society where we get pushed back on a day to day basis, working with physicians and nurse practitioners. I can think of in the early years to physicians who didn't want me to do a consult on their patients. And I've worked in cardiac surgery practices, cardiology practices and now in a heart and vascular ICU. I think maybe it's a difference of acute care versus primary care maybe there's more competition in the primary care world in acute care. It certainly is a collaborative kind of practice because it needs to be. I'd push back a bit on your idea that nurse practitioners don't work in surgery. We work in surgery. I work in an ECMO unit. I don't really emulate, but I do put central lines in as do all of my colleagues. I know nurse practitioners who assist in surgery. So it's a matter of knowing what are the competencies that are set nationally for the specialty of the nurse practitioner. And I think that's important for them to know because I teach nurse practitioners students to and they don't always understand what they are able to do when they leave we try to make that very clear to them. A primary care family nurse practitioner is not an acute care nurse practitioner and they need to understand that those competencies give them their scope of practice. Right now thank you for mentioning that when I was talking about surgery I meant it with the big S. I have to say my in my family I have two vascular surgeons and so to me. Surgery is has a big S there is not just cannulation and putting in lines. So that was my response but thank you for mentioning competencies because that really is. I think the chief way that scopes any any nurse practitioner program scope is developed it has to has to respond to the competencies. I mean it's not just each program deciding what what their nurses can do and learn. There are there are official competencies that are part of the certification actually certification exam and certification statements so thank you for mentioning that. Okay, creepy you're on. Yes. So I had a question and I already put that in the chat, but what's your take on online and be schools, which are kind of rampant in, I guess, in past few years, and they apparently what I have read and what I've heard from some people is that have almost 100% acceptance rate from nursing graduates who probably have minimal, maybe one to two years of nursing experience, and a lot of new nursing graduates are very inclined towards joining and be school for obvious reasons. And that is creating a huge nursing shortage in the United States which is, which I think is probably worse than the physician shortage I work I'm a psychiatrist and I work at a state hospital and unfortunately we we are. I'm seeing the problem with the nursing shortage like we are decreasing the volume of patients we can hire we are forensic state hospitals so we, you know we have to shut down so many units because we don't have nurses we have physicians we have nps but we don't have nurses. So what's your take on that. I don't, I can't really reply about the online training of that, I mean the courses are online and then they do their practicum, you know, obviously with where they find their, their mentors but in terms of the nursing shortage it's not because their, their nurses are going into the nurse practitioner programs. It has to do with all the other conditions and experiences in hospitals today. That is causing the nurse practitioner shortage that's just one reason. So, yeah, they're moving into other areas. And I really can't fault them for doing that but our healthcare system is is a mess, let's just say that and you know in order to provide the best patient care we need to figure out how we can all work together to do this. And to tell you the truth there are a lot of nurse practitioners are who are working as staff nurses, even as even a lot of people who got go back for Dr. nursing practice degrees, they work on units. So, you know, I think that's, as I said before that's not causing the nursing, the nursing shortage, frankly. I wanted to just go down to some questions that were in the chat because I thought they were interesting. September Williams said, what is the role of what role has sexism played in the evolution of the resistance to nurse practitioners. I'm not sure I can quantify that except to say it has to play a role because nursing is highly gender, even though we have a growing population of men and trans and all kinds of people in this profession, it still remains predominantly women. And so, you know, the sexism that exists is is incredible to tell you the truth. I've experienced it myself. And, you know, does that have a lot to have to do with in terms of recognizing their capabilities, you know, there are a lot more women in medicine now too. And still, the idea of this highly gendered workforce is and sexism still wears its ugly head many times. Okay, I have another question I thought seemed interesting hold on from Andrea Wyndham said, many thanks I've been a primary care nurse practitioner at Kaiser Permanente in California for over 30 years. I'm the co chair of our service area ethics committee. My organization is less interested in employing future MPs in primary care, due to our rising salaries. Have any thoughts on this. Good. You know, I'm, you know, it's a market, it's, it's a market based force out there, you know, they're, they're paying nurse practitioners, you know, really nice salaries that reflect what they're worth. So, you know, that's about as much as I can say about that many and that, you know, they deserve everything they get, which it's interesting with nurse practitioners because their salaries are are so robust that it is very hard to recruit nurse practitioner into academic faculty roles because we can't pay them. We can't pay them that salary. And so we all have an issue in terms of being able to employ nurse practitioners. Yeah, and I'll just give you one last one because it looks. There's a woman from Mary and Harris said, do you foresee a credential and additional training to prepare for advanced practice nurses as hospitalists as an administrator and clinician, many of my family nurse practitioners want to work. Hold on a sec. Here. Hi, actually, that's my question. Sorry. So I am an administrator and an advanced practice nurse and have worked in many different types of positions and finding that depending on which state of worked at that. Sometimes adult and family nurse practitioners are not able to work in the hospital, but it seems to depend on the state because in some geographic locations it's very difficult to find acute care nurse practitioners. And there are some very competent adult and family nurse practitioners that have worked in in clinics, but also have worked as consultants in the hospital space so it seems like a lot of these folks really want to work as specialists or want additional training or an additional credential so that they could be able to do that. What are your thoughts on developing a credential to prepare advanced practice nurses to work in the hospital setting besides the adult general acute care track. What are your thoughts. Well, for example, Penn has a track, an online track actually that sort of that allows them to sit for the acute care nurse practitioner certification. So because Penn requires that in their matter where they work they requires that there are small rural hospitals that I've seen and visited and heard about that are actually using nurse practitioners in their eyes to use. They don't call them intents and intensivists, but they are the ones managing the care of the patients in those units. I mean, I mean it could be because they're competent number one, and number two there may not be physicians who they can employ to do the same. Are they hiring those individuals to be acute care nurse practitioners or are they allowing. I mean are they just using the workforce that they have and training them to work in the ICUs, because I have heard in some hospital systems because of the lack of ability to find, again, acute care MPs that they are allowing non acute care certified nurses in the ICUs. I think there is a pattern to any of this. You know everybody's just trying to make sure that they can provide care to their patients. There may be some states that require it, or it may be a hospital system requirement. But, you know, for example, as I said, Penn requires them to take an MP and acute care MP program and sit for that certification. So, you know, it's a very mixed bag, especially right now when things are so crazy in hospitals with the pandemic. So where did you want to weigh in on this since this is your air of expertise. Yeah, just to follow up on that I think this is where we have to be careful because as we said earlier, the competencies that are nationally set, or what sets that scope of practice and says the nurse practitioner that you've hired has the training to work in that area and to do those things and manage those patients and FNP is not trained to work in an ICU. They don't understand heart failure in the ICU they understand heart failure in the office as a chronic disease and it's a very different kind of management. So, you know, I think when we stretch the point. That's when you make people question nurse practitioners and say no, they can't do that job they're not prepared. I think we've got to stick with it. We just graduated the director of our NP program, and we just graduated in this last group three postgraduate certificates FNPs who are working in a hospital who saw that they did not have the knowledge they need it and all of them said they learned so much in doing that program they probably have to do about half the program because of the previous program they did, but they did all of the acute care components so I think it's really important to stick to those competencies and certifications. Yeah, I agree, I totally agree but but whether or not that's actually happening across the board is is another question so but no I totally agree. Well listen I want to thank you again Julie and give you a little bit of downtime before your next session and say that this was a very stimulating and fascinating discussion with a lot of food for thought and you know part of it is as we watch medicine change. You know this is just more of an example of the evolution of nursing, you know as a profession and as it evolves into new areas so we really appreciate your time and I'm going to give you a little time to get up and stretch before the 130 session. All right, thanks. Thanks, Midian. Thanks everybody for.