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Governor's Newsletter, Summer 1999

IT'S OFFICIAL! - The Merger of the Pennsylvania Chapter is Approved

The Pennsylvania Chapter of the American College of Physicians-American Society of Internal Medicine (PA ACP-ASIM) is now a reality. While the chapter will formally be named the PA-ACP-ASIM, we will do business as the Pennsylvania College of Internal Medicine. The bylaws governing our chapter were approved by the Board of Regents in New Orleans in April.

The bylaws were the result of 18 months of discussions among the Pennsylvania leaders of the ACP and the PSIM. The merger task force was initially led by Bruce Thomas, MD, FACP (Governor of PA West), Ralph Schmeltz, MD, FACP (President, PSIM), Thomas Brandecker, MD, FACP (PSIM President-Elect) and Robert Aber, MD, FACP (Governor, PA East). This group began discussions on the shape of your new state chapter in November, 1997. Other members who jointed the task force were Dana Kellis, MD, FACP, Ted Onifer, MD and Robert Sklaroff, MD. The group was very ably supported by John Nikoloff, who serves as the PCIM executive director.

With the merger will come several changes for both PA-ACP and PSIM members. During the discussions, a consensus formed that Pennsylvania should have both a 501(c)(3) tax-exempt and a 501(c)(6) organization, which conforms with the merger on the national level. Each organization has strengths and advantages for the membership, and it gives us maximum flexibility with regard to our goals for promotion of educational, advocacy and member services. It is our hope that this new chapter will result in your getting the best of both the ACP and the ASIM.

Pennsylvania sought, and received the approval of the Board of Regents to create the 501(c)(6) advocacy organization as a means to work within state government and other medical/health care/pharmaceutical and insurance communities to represent the interests of internists in public policy matters.

The Chapter has assumed a key role in Harrisburg as an advocate for internists and patients alike. It has addressed such divergent subjects as "scope of practice" issues, laboratory certification, regulation of Medicaid programs, intervention with the Blues on behalf of physicians, articulating patients' public health needs, and tobacco control. Having an advocacy organization will enable us to continue this valuable member service.

The new chapter will actually consist of three Regions, Pennsylvania West, Pennsylvania East, and the newly created Pennsylvania Southeast. The old Pennsylvania East region was the largest region in the nation prior to the merger. In essence, Pennsylvania West remains the same geographically, and the East is divided with Philadelphia and portions of Bucks, Montgomery, Delaware and Chester County split into the Southeast Region.

Each region will be governed by an elected Governor as in the past. Each region will also have active committees. The Council will be the governing body of the Chapter and will manage the Chapter's business and organization. One of the three governors will serve as President of the non-profit side of the Chapter.

Eight members will serve on the statewide Council from each region: the Governor, three elected councilors, two appointed councilors, an elected associate member and an appointed representative for medical students. These 24 members will govern both the 501 (c)(3) and the 501 (c)(6) organization.

A member of the Council will be elected as President of the advocacy organization. This person will serve as the primary spokesperson for PCIM at the state level, and will work closely with the PCIM's Health and Public Policy Committee and our advocacy staff to promote and advance our issues with the General Assembly and state government agencies. The Board of Regents requested that PCIM not create a Political Action Committee at this time, to avoid jeopardizing our tax-exempt status pending an IRS review and approval at the national level.

PCIM now has an administrative office in Harrisburg, just across the street from the Capitol, with a full time administrator and staff support. John Nikoloff will serve as our Executive Director, and Natalie Slembarski is our Administrator. We have retained Capital Associates, Inc. to handle our statewide administrative and government relations efforts. Please feel free to contact either of them by calling (800)846-7746, or by e-mail at pcim@capitalassoc.com for issues, information or concerns.

Message from the Governors

Ralph Schmeltz, MD, FACP
President, PCIM Transition Council

The challenges confronting Internists are many. Among these are issues of identity, turf, professionalism and purpose. Managed care organizations and other specialties define their areas of competence and expertise. We must be willing to do the same...to draw our lines in the sand and defend our turf. We must not let the evidence based patient first approach to patient care and caring be reduced.... For it's that rigorous approach and intellectual honesty which has set the Internist apart from the rest of the house of medicine. The merger of the two major organizations of Internists in Pennsylvania into the Pennsylvania College of Internal Medicine provides us with a unique opportunity. Now some 6,000 strong (when you include our younger members), we are one of the largest physician organizations in the Commonwealth. With a full time staff in place at our office in Harrisburg, we are in a position to effectively fulfill the educational role we have always championed as well as to advocate our positions to the legislature, regulatory agencies, managed care organizations and our colleagues locally and nationally. Join with us, participate and let your voice be heard.

Robert Aber, MD, FACP
Governor, Pennsylvania Eastern Region

Greetings from Hershey. I returned from New Orleans and the Annual Session with renewed enthusiasm about ACP-ASIM. The Board of Regents and Board of Governors met prior to the Annual Session, and I am happy to report the following:

1. The ACP-ASIM is in strong financial condition.
2. The BOR has postponed a final decision on a Political Action committee for ACP-ASIM Services until January, 2000, and has charged Governors to seek input as to the support for such from Chapter members.
3. The BOR approved bylaws for both 501(c)(3) and 501(c)(6) organizations in Pennsylvania. These bylaws are the result of over a year of hard work by a statewide merger committee led by the two Governors and the President of PSIM.
4. The BOR had previously approved a third Region in PA, so we will have additional representation to the BOG. The PAE will essentially be divided into two regions.
5. The BOG supported 14 resolutions and a BOR/BOG Task Force Report
6. Alan Nelson, M.D., FACP, will be retiring from his position as Assoc. VP, Washington Office, in January, 2000, unless someone persuades him otherwise.
7. Special congratulations to Herbert Y. Reynolds, MD, FACP and to Paul E. Epstein, MD, FACP on their election as Governors-Elect for PAEI and PAEII respectively.

Bruce Thomas, MD, FACP
Governor, Pennsylvania Western Region

The merger of the ACP and the ASIM is complete! The merger of the international American College of Physicians and the American Society of Internal Medicine occurred on July l, 1998. Many details have needed additional efforts to develop a new and efficient ACP-ASIM.

More work had to be done at the Chapter and Regional level to develop our new State Chapter bylaws. Many of your representatives worked for hours from February, 1998 through June, 1999 until we reached a consensus and approval of the bylaws at our Transitional Council Meeting in June. Many thanks to Ralph Schmeltz, Dana Kellis, Robert Sklaroff, Ted Onifer, and Bob Aber for the many hours that were extended to this necessary project.

Congratulations to Ralph Schmeltz, MD, FACP, your new Governor-Elect for the Western Region. Ralph attended the Annual ACP-ASIM Meeting in New Orleans in April and has already begun networking with members of the Board of Governors and the ACP-ASIM staff. Dr. Schmeltz practices Internal Medicine and endocrinology at Magee Women's Hospital in Pittsburgh. He served as the last President of the Pennsylvania Society of Internal Medicine and has been a linchpin for our transition to one organization. He is the Chairperson for the Health and Public Policy Committee of the Pennsylvania Chapter of the ACP-ASIM. Dr. Schmeltz is affiliated with the University of Pittsburgh. He is keenly aware of the challenges that Internists face in private practice, as well as in academic medicine and other venues such as managed care, third party insurers, and the legislative arena.

I look forward to seeing many of you at our annual meeting at the Hershey Lodge and Convention Center, November 19-21, 1999.

Capital Comments

From Capital Associates, Inc.

Each issue of the Pennsylvania Chapter Newsletter will feature information on issues of current interest involving state government and the General Assembly. For more information on these issues and other affecting internal medicine, contact the PCIM Office in Harrisburg.

State to Split Tobacco Settlement Funds

The $11.3 billion state share of funds from the tobacco Master Settlement Agreement continues to be the focus of health related discussions. A $400 million annual "windfall" will come to Pennsylvania as its share of the national settlement reimbursing the states for Medicaid expenses due to tobacco use. The agreement provides for payments to states for at least 25 years, and possibly longer.

The PCIM has recognized the competition that would ensue with such a pot of "found" money in the hands of the General Assembly, and developed a position on proper use of the funds, which it has communicated to legislative committees and the Ridge administration. More than a dozen public hearings have been held on this subject, by both House and Senate Committees.

PCIM's position has been that the funds should be put in a special fund and that a committee of health experts including at least one internist will make recommendations to the General Assembly. PCIM wants all funds spent on health services and public health infrastructure investments related to smoking and tobacco use. Our position is that the goal of disbursements must be to help eliminate the need for future payments. Thus, payments should concentrate on behavioral research, interventions and applied research as opposed to construction projects.

Other organizations, not surprisingly, have presented a shopping list for the funds which includes such variant causes as expansion of the CHIP program, $2.6 billion for the state's seven cancer research centers, farmland preservation efforts, school lunch and breakfast programs, sidewalk repairs, and even renovations of the state capitol building to repair damage from "smoking related pollutants." The Ridge Administration is coordinating its efforts through Administration Secretary Thomas Paese. While not yet announcing specific plans, Secretary Paese has told the General Assembly the administration wants to use the funds to "make Pennsylvanians healthier," and to use them "as an investment" in the state's healthy future. He also suggested that a portion of the funds be kept in reserve for use in funding programs after the annual payments are reduced or stopped.

New Health Secretary, Physician General

Major changes are taking place within the Health and Public Welfare Departments in Harrisburg. These changes have significant impact on internal medicine. Since January, the State has a new Secretary of Health and a new Physician General.

Robert S. Zimmerman, 50, of Mechanicsburg, was serving as Deputy Secretary for Medical Assistance Programs for the Department of Public Welfare before he became Secretary of Health. He had served as Acting Secretary of Health early in the Ridge Administration. Zimmerman has worked closely with the PSIM during his tenure in state government. At DPW, Zimmerman was previously the chief operating officer for Medical Assistance Programs and Special Assistant to the Secretary of Public Welfare. He had also served as Executive Deputy Secretary of the Department of Health from 1991-93. From 1993-1995, he developed and directed the new Bureau of Primary Care Resources and Systems Development in the Department of Health.

Rob Muscalus, DO, of Hummelstown, is the state's new Physician General. Dr. Muscalus had served for the past several years as medical director for Xact Medicare Services, Blue Shield's Medicare company in PA. Prior to that he was assistant medical director for Keystone Health Plan Central, a blues HMO product, and practiced family and sports medicine.

Lawsuit Abuse Reform Moves Ahead

In mid-March, three state Senators announced that they would leading a charge to make significant changes in state law and court rules. Senator Bob Thompson of Chester County announced introduction of SB 5, the lawsuit abuse reform act. At the same time, Sens. Jeff Piccola of Dauphin County and "Chip" Brightbill of Lebanon County announced that they have formally asked the State Supreme Court to make changes in court rules. The changes would level the playing field for business owners and others who are subject to frequent and frivolous lawsuits.

The Senate Judiciary Committee has scheduled a September 9 hearing on Senate Bill Five, the Lawsuit Abuse Reform Act. We urge members to contact their state Senators and ask them to support SB 5 and the proposed court rules changes.

SB 5 would eliminate Pennsylvania's archaic joint and several liability system, set standards and limit punitive damages, establish a 15 year statute of repose for products, provide protection for innocent sellers and expand types of cases that can be resolved through arbitration. Changes in the court rules would discourage frivolous lawsuits, expedite time for discovery, require full disclosure to juries of collateral sources of income, set standards for expert witnesses, reduce awards to a fair present value, and make substance users accountable for their actions by telling jurors when a plaintiff used drugs or alcohol leading to an injury.

The PCIM has joined the PA Civil Justice Coalition, which consists of more than 300 medical, nonprofit, local government and business organizations and individuals. The CJC and its members have banded together to support these initiatives and try to outweigh the political and financial muscle of the personal injury lawyers.

Pennsylvania is one of only five states that have not adopted lawsuit abuse reforms, largely due to the influence of the personal injury lawyers and unions. The CJC knows this is a pitched battle, and its members are committing extraordinary amounts of influence and finances to defeat this initiative. For more information on the CJC and its efforts look on the world wide web at www.pacjc.org, or call the CJC at 1-800-224-7887.

Pennsylvania's New Governors -Elect

The members of the PA Chapter of the ACP-ASIM recently elected three individuals to serve as Governors-Elect of the three Pennsylvania Regions of the PCIM. Governors provide our chapter members with and essential link between state and local activity and the national policy making bodies that govern the entire organization.

Western Region

Ralph Schmeltz, MD, FACP has been elected to fill the role of Governor in April 2000 for a four year term. He currently serves as President of the PCIM Transition Council.

Dr. Schmeltz's education and training includes: MD, State University of New York, College of Medicine; Straight Medical Internship, Health Center Hospitals, University of Pittsburgh; Resident, Internal Medicine, Health Center Hospitals, University of Pittsburgh, NIH Trainee, Endocrinology and Metabolic Disease, University of Pittsburgh School of Medicine.

Dr. Schmeltz presently serves as Clinical Professor of Medicine and Obstetrics and Gynecology at the University of Pittsburgh, School of Medicine. He also is Assistant Chief, Internal Medicine at Magee Womens Hospital, Pittsburgh, PA. Other active positions include: Staff, St. Clair Memorial Hospital, Pittsburgh, PA; Staff, Jefferson Hospital of the South Hills Health System, Pittsburgh, PA; Staff, University of Pittsburgh Medical Center, Pittsburgh, PA.

Southeast Region

Paul E. Epstein, MD, FACP, has been elected to serve a two-year term effective April 2000.

Dr. Epstein earned his MD from Tufts University, Internship/Residency at the University of Chicago, and his Fellowship from the University of Pennsylvania (Pulmonary Disease). Dr. Epstein currently serves as Clinical Professor of Medicine, University of Pennsylvania. Additional current hospital community service includes: Staff, Penn Medicine at Radnor, Chief, Pulmonary Division; Staff, Hospital of University of PA.

Eastern Region

Herbert Y. Reynolds, MD, FACP, has been elected serve a four-year term, beginning April 2000.

Dr. Reynolds received his medical degree from the University of Virginia. His postgraduate-training includes: Residency, 1965-1967 at New York Hospital-Cornell; Clinical Associate, NIH, 1967-1970; Chief Resident/Instructor in Medicine, 1970-1971 at the University of Washington. Previously, he was at Yale-New Haven Hospital as Head of the Division of Pulmonary and Critical Care Medicine (1976-1988) before joining the Pennsylvania State University College of Medicine.

Dr. Reynolds presently serves as J. Lloyd Huck Professor of Medicine and Chair, Department of Medicine; Chief, Medical Clinical Operations, Milton S. Hershey Medical Center; and Associate Director, Division of Medicine, Penn State Geisinger Health System. Other appointments include: Staff Physician, Lebanon Veterans Affairs Medical Center.

Pennsylvania Annual Meeting

Celebrating the Wealth and Diversity of Internal Medicine

"Celebrating the Wealth and Diversity of Internal Medicine" is the theme of the 1999 PCIM Annual Meeting that will take place at the Hershey Lodge and Convention Center, Hershey, PA. This two and a half day program may be one of the most important medical meetings you will attend this year, offering numerous educational programs as well as social events, associates programs and awards presentations.

Join us at the Hershey Lodge and Convention Center from Friday, November 19, through Sunday, November 21, 1999 for discussions and educational programs on preventative medicine, endocrinology, medical ethics, behavioral medicine, neurology, oncology, and much more!

• Don't miss the opportunity to have your voice heard by College leadership. David J. Gullen, MD, FACP, Chair of the Board of Regents of the American College of Physicians-American Society of Internal Medicine, will be on hand to discuss the policies, programs, and activities of the National Association.
• Various awards to be presented include the Robert S. Pressman Award for Outstanding Contributions to Internal Medicine, The Laureate Awards, Clinical Practice Awards, and Associate Awards. Awards will be presented at the Annual Awards Banquet on Saturday, November 20, 1999.
• An Associates Program will take place on Saturday, November 20, featuring resident abstracts presentations and awards. Winners will be eligible for entrance into a national competition. A Medical Knowledge Challenge Tournament will be held on Saturday as well featuring an East vs. West competition.
• Exhibitors will be on site to provide you with the latest in technology, products and much more. The exhibit area will be open during regular meeting hours.

These are just a few highlights we are planning for this educational program. A detailed program and registration information should be arriving in August. Additional registration information can be obtained by contacting the Chapter headquarters at 1-800-846-7746. Mark your calendar for November 19-21, 1999 and join us in Hershey, PA.

Laureate Recipients Honored

The Pennsylvania Chapter conferred its 1998 Laureate Awards upon John H. McConville, MD, FACP; Lisa B. Wallenstein, MD FACP, and Dana S. Kellis, MD, FACP.

Dr. John H. McConville, of York, PA received the Laureate Award at the 1998 Annual Meeting in Hershey. Dr. McConville served as Chair for the 1998 Program Planning Committee for the Pennsylvania Coalition for Internal Medicine. He also serves on the Governor's Advisory Council for the Pennsylvania Eastern Region. He has been active in national, state, and local societies, including the American Society of Microbiology, Infectious Diseases Society of America, Thoracic Society, Pennsylvania Medical Society, and Association of Program Directors in Internal Medicine, to name a few.

Dr. Lisa A. Wallenstein, of Philadelphia, PA received the Laureate Award at the 1998 Annual Meeting in Hershey. Dr. Wallenstein serves on the Governor's Advisory Council for the Pennsylvania Eastern Region and was a member of the ACP Community Based Teaching Task Force. She has also represented the ACP as a Primary Care Policy Fellow, as a member of the Primary Care Organization Network, and Chair of the Selection Committee for the Primary Care Achievement Award in Education.

Dr. Dana Kellis, received his Laureate Award at the Annual Meeting in Hershey as well. He was Chairman of Medicine at Conemaugh's Memorial Medical Center in Johnstown. Dr. Kellis is dedicated to "make a difference" in health care and teaching. His forward thinking produced a resolution in 1997-98 calling for a merger of ACP, ASIM, and APDIM. Dr. Kellis has taken a new position in Ft. Wayne, Indiana as Chief Medical Officer of the Parkvue Medical Center.

Frederick DeRubertis, MD, FACP was presented the 1997 Laureate Award. Dr. DeRubertis is an Internist and endocrinologist practicing and teaching at the Veterans Administration Hospital in Oakland. His research interests are the effects of protein kinase C and nitric acid in the pathogenesis of diabetic nephropathy.

The Laureate Award honors those Fellows and Masters of the American College of Physicians/American Society of Internal Medicine who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, or research, and in service to their community and their chapter. Recipients of this award shall bear the title Laureate of the Pennsylvania Chapter.

Congratulations to Our Newest Masters and Fellows

William M. Cooper, MD, JD, MACP was recently awarded a Mastership in the ACP-ASIM. Dr. Cooper has practiced Internal Medicine and hematology at the University of Pittsburgh and Shadyside Hospital for over fifty years. He received his medical education at Hahnemann Medical College, Shadyside Hospital, University of Pittsburgh, and the Cleveland Clinic. After being certified as a hematologist in 1972, Dr. Cooper proceeded to be recertified by the ABIM (general internal medicine) in 1977 at the age of 58. He attended the University of Pittsburgh School of Law in 1984 and received his JD in 1987. He served as Governor, Western Pennsylvania Region, for the ACP from 1964-70 and received the Laureate Award in 1985.

Masters are a small group of highly distinguished physicians, selected from among Fellows of the College, who have achieved recognition in medicine by exhibiting pre-eminence in practice or medical research, holding positions of high honor, or making significant contributions to medical science or the art of medicine.

PCIM Opposes HB 50

The PCIM is working actively to oppose House Bill 50, introduced in March by Rep. Patricia Vance (R, Cumberland County) and more than 120 other members of the House of Representatives. Under the bill, CRNPs, Nurse anesthetists, nurse midwives and clinical nurse specialists would be authorized to diagnose and treat illnesses, perform therapeutic and invasive procedures, prescribe, dispense and administer drugs, devices and anesthetics under rules established by the Board of Nursing. The overall change would, in effect, permit advanced practice nurses to practice medicine without physician supervision.

This is a major initiative, and Professional Licensure Committee chairman Mario Civera (R, Delaware Co.) is holding at least three public hearings on the matter. Similar legislation was introduced in 1995 and 1997, but failed to pass the House of Representatives. Only 102 votes are needed to pass legislation in the House. But PCIM and other physician organizations are already working with legislators, and have gotten several to remove their names as sponsors.

"Let us sign what we're writing," was the battle cry of more than 300 nurses who rallied at the Capitol "We're already writing the prescriptions, let us sign them," the nurses said.

The State House Professional Licensure Committee held the first in a scheduled series of three hearings in Pittsburgh June 29 and 30 on House Bill 50.

APRNs Make Their Case

At the hearing, the PA Alliance of Advanced Practice Nurses (APRNs), which says it represents more than 6,000 Advanced Practice Registered Nurses, said that they have been waiting 25 years since the General Assembly first granted them prescriptive authority. The nurses asserted that they remain the only profession in PA that is required to answer to two separate regulatory boards. They said that since 1974 the Board of Medicine has thwarted the original intent of the General Assembly to grant prescriptive authority by refusing to agree with the Board of Nursing on implementation of the statute.

In April of 1999 the Board of Medicine finally approved, by a 5-4 vote, regulations allowing the implementation of prescriptive authority by CRNPs. The Alliance said that physicians have raised questions about the extent of APRN education and quality of care they provide, but claimed, "Physicians will be hard-pressed to supply any evidence supporting their fear and suspicion of inferior care by APRNs. All published research shows that APRNs promote access to care that is at least as good as physician care."

Melinda Jenkins, PhD, CRNP told the committee, "Physicians may be concerned that managed care may interfere with their autonomy in patient care, and may feel threatened that insurance companies will use APRNs as a lower-cost alternative to treatment by a physician." She suggested that physician opposition to HB 50, is more about control of the medical marketplace, than about patient out comes and quality of care.

Jan Towers, PhD, CRNP, a practicing family nurse practitioner speaking on behalf of the Coalition of Nurse Practitioners, told the Committee HB 50 would not expand the nurses' scope of practice, claiming that the legislature already authorized nurse practitioners to perform acts for medical diagnosis and prescription. She cited the fact that nurse practitioners are rarely named ad defendants in malpractice suits as proof of their safety.

Several who testified in support of HB 50 cited economics and need in rural areas. Three patients testified to their confidence in Nurse Practitioners and Nurse Anesthetists as a result of personal experiences.

The PCIM Response

Ralph Schmeltz, MD, president of the PA College of Internal Medicine, testified that HB 50 could expand APRNs scope of practice to include the diagnosis and treatment of illnesses, performance of therapeutic and invasive procedures, prescription and dispensing of medicines and anesthesia. He testified to the educational differences between APRNs, PAs and physicians, and questioned nurses' statements that removing them from regulation by the Board of Medicine would improve quality of care for Pennsylvania residents. He noted that only four states give APRNs the prescriptive authority they are seeking without a strong collaborative relationship with a physician, and urged the Committee to maintain that "medical team" approach.

Dr. Schmeltz challenged the nurses to show how, if they really weren't changing anything with this legislation, they could claim to be improving access to quality medical services. "You can't have it both ways," he noted. You can claim that you are making major changes in scope of practice and independent practice by APRNs, or you're not. If you're not, you'll either be testifying to the success of the status quo or suggesting you're not improving quality or access.

HAP Supports HB 50

The Hospital Association of PA (HAP) testified that in nearly every other state, certified registered nurse practitioners have the ability to prescribe certain medicines. HAP said HB 50 would improve patient care in PA by allowing APRNs to more fully serve patients by enabling prescriptive privileges consistent with the advanced practice nurses' national scope of practice. HAP supports affording prescriptive practices to advanced practice nurses given the compelling evidence that prescribing medications can be done safely and effectively by nurses with advanced training and education.

Physician Groups Respond

Dr. Lee McCormick speaking for the PA. Medical Society said that HB 50 removes medical physician involvement and establishes a competitive, not collaborative, health care system that will not benefit patients or providers. He said, the language of HB 50 was an expansion in the scope of practice, and noted that all but four states require the collaborative arrangement or protocols with physicians for prescriptive privileges. Under questioning, Dr. McCormick pointed out that Physician Assistants, which the APRNs constantly cited, are directly supervised by physicians.

Dr. Carol Rose, speaking for the PA Society of Anesthesiologists, said that you can't split medicine from nursing when nurses are making arms length decisions. She emphasized the "team" concept, and cited two studies from 1992 and 1998 which showed that death rates were lower and rescue rates higher in those patients whose care was directed by anesthesiologists.

It's Time to Stand Up and Be Counted

Additional hearings of the Committee are now scheduled for October 27 and 28. Future hearings may be scheduled in Philadelphia. The Chapter urges you to contact your House member as soon as possible and ask him/her to oppose HB 50 and ensure continued access to quality care by Pennsylvanians through the strong collaborative arrangements.

Letters should express respect and admiration for the skills, expertise and role of advanced practice nurses in the health care system, but focus on the relative education, and training, responsibility and liability of APRNs vs. physicians. Contact the Administrative office if you have any questions or need further information on this legislation.

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