How many physicians does it take to stop a bad scope expansion bill? With patient safety on the line, Texas Medical Association physicians took no chances, showing up in force in opposition to Senate Bill 3055 as it went before the Senate State Affairs Committee on May 1.
Well into the evening hours of May 1, white coat after white coat filled the seats of the Senate gallery and took to the microphones to testify that SB 3055 lowers the standard of care for rural Texas patients by giving advanced practice registered nurses (APRNs) a shortcut to independent practice.
Led by TMA President Ray Callas, MD, in an opening panel, physicians resoundingly testified to the chasms between nurse and physician education and training – and the consequences for patient care if physician oversight is removed as the legislation proposes.
“When seconds separate a lump from a life, or hyperglycemia from a hearse, the depth of training is decisive,” Dr. Callas, a Beaumont anesthesiologist, told the committee. “The training gap is not a rounding error; it is the fulcrum on which patient safety tips.”
He was one of more than 50 physicians from around the state who trekked to the Capitol to oppose the bill in person, alongside nearly 200 others who either submitted written testimony or responded to TMA’s action alert.
SB 3055 would give independent practice authority to nurse practitioners, nurse midwives, or clinical nurse specialists who apply for such authorization and have either:
- Held an active unencumbered license as an APRN in any state for at least 10 years or 20,000 hours; or
- Graduated from a program of nursing education that “has a physical presence in this state” and has a requirement of in-person clinical experience and has practiced as an APRN under a prescriptive authority agreement with a physician for at least four years or 8,000 hours.
In counties with a population under 68,750, SB 3055 would allow APRNs under the program to:
- Order, perform, and interpret diagnostic tests;
- Formulate primary and differential medical diagnoses and advanced assessments;
- Treat actual and potential health problems;
- Prescribe therapeutic and corrective measures, including Schedules III-V controlled substances;
- Serve as a primary care provider of record; and
- Perform "other acts" commensurate with their education training.
Sen. Charles Schwertner, MD, an orthopedic surgeon from Georgetown and a member of the committee, challenged nurse claims the bill does not expand their scope of practice, saying the legislation would represent a fundamental shift in the state’s existing physician-led framework for providing medical care.
“To say this act does not expand scope of APRNs does a disservice to this discussion,” he said. “It does lead to a two-tiered system of health care. … Call it what you want, but that [list] is the practice of medicine.”
“If that’s not expanding scope, I don’t know what is,” added Sen. Donna Campbell, MD, an emergency physician from New Braunfels who was invited to the hearing.
Doing the math on the spot, she calculated the bill would allow independent APRN practice in 208 of the state’s 254 counties. “[SB 3055] provides for almost statewide independent practice. A majority of counties will have a different standard of care.”
Throughout the hearing, Senators Schwertner and Campbell also questioned the ability of the Texas Board of Nursing to oversee such a drastic shift.
“We are allowing a sector of nursing to practice medicine, but they are not under the regulation of the medical board,” Senator Campbell said.
Education, training gaps
The legislation, filed unusually late beyond the legislature’s bill-filing deadline back in March, may have created an unexpected scope battle for medicine, but it gave physicians a unique opportunity to highlight its dangers.
Senator Campbell – a former nurse herself who said she maintains that license – attested to the wide training gaps between nurses and physicians, saying NPs have “a fraction of the training medical doctors do … thousands of hours compared to 750” in programs with asynchronous courses, lack of standardization, and no residency.
By comparison, “medical school vets us over and over to a much higher standard,” she said.
Those gaps were highlighted by other TMA physician testifiers like Cynthia Peacock, MD, who also started out in other health care professions before pursuing medicine.
“Looking back, I did not know what I did not know,” said Dr. Peacock, who was a nurse for 15 years and now cares for Medicaid patients with complex conditions as a pediatrician in Sugar Land.
Whereas TMA Immediate Past President Rick Snyder, MD, had to complete clinical rotations over eight years as a medical student, resident, and fellow before he could practice independently, the cardiologist testified he was surprised that as a nurse preceptor, “their training institution never interviewed me about my experience as a clinical educator, nor about their expectations for the preceptorship. I was not required to participate in annual teaching education, as ACGME (the Accreditation Council of Graduate Medical Education) requires. Nor was my office required to be an accredited teaching site.”
He echoed Dr. Peacock’s experience that the onus is on nursing students themselves to find a preceptor, and the teaching method involved observation and shadowing.
“The differences in training models have real-world consequences,” Dr. Snyder warned.
Yasser Zeid, MD, an OB-gyn from Corpus Christi who oversees certified nurse midwives, noted they can graduate “having participated in few as 30 to 40 deliveries. To put this into perspective, I performed over 400 deliveries and 100 cesarean sections in my first year of training as an OB-gyn resident.”
Physician testifiers cautioned that diluting Texas’ physician-led standards risks increased health care costs and poorer quality of care, challenging nurse claims that SB 3055 is a safe, “no-cost solution” to Texas’ rural access shortages.
Drs. Callas and Silva and Senator Schwertner elaborated with studies and articles from the Hattiesburg Clinic in Mississippi, the Department of Veterans Affairs, and Bloomberg showing how independent nurse practitioners and training gaps result in higher prescribing, testing, referral, and hospitalization rates, and poorer performance on quality measurement – all of which can lead to greater patient safety risks and health care costs.
Ned Snyder, MD, a plastic surgeon in Austin, added that in Florida – which in 2019 allowed for nurse independent practice just in primary care – most nurses have flocked away from rural areas to more lucrative med spas, echoing data from scope researcher and Ft. Myers, Fla., family physician Rebekah Bernard, MD, author of Imposter Doctors: Patients at Risk.
Physicians also disputed nurse claims that Texas’ supervisory and delegation structure is an “outdated checkbox.”
Dr. Callas, Temple internist Jimmy Widmer, MD, and Tyler emergency physician Lane Schnell, MD, were among those who explained their current collaboration and quality assurance protocols go above and beyond what were intended to be minimums in current state law, which, in and of itself, is not limited to chart reviews.
Dr. Widmer said he has protocols for “before, during, and after” care delivery, and “not a day goes by, my [nurse] and I don’t communicate about patient care.”
Even during the hearing, Dr. Callas testified he was in communication with the nurses he oversees on four different occasions that day.
Physicians also combatted nurse claims that delegation and supervision fees are a major barrier to APRNs practicing in rural areas, with physicians like Drs. Callas, Widmer, and Silva testifying they are among the majority – 80% according to a 2019 National Journal of Nursing Regulation survey in supervisory states – who do not charge such fees.
Brad Holland, MD, who works in a critical access hospital in Waco, also referenced American Medical Association data demonstrating even in states with APRN independence, nurses don’t gravitate toward rural areas for the same reasons physicians largely are unable to practice there: economic viability.
New solutions
Rather than compromising patient safety for the sake of a quick fix, physicians pointed to an immediate solution on the table and advancing through the legislature: Senate Bill 2695 by Sen. Lois Kolkhorst, chair of the Senate Health and Human Services Committee.
The latest version of SB 2695 – which passed the full Senate almost unanimously the same day SB 3055 was heard – would:
- Establish the Rural Admission Medical Program – or RAMP – to provide financial and academic support to encourage students from rural areas to pursue medical school and practice in rural communities after graduation. Qualified students would be guaranteed admission to a participating state medical school. The program mirrors Texas’ Joint Admission Medical Program – or JAMP – for economically disadvantaged undergraduate students.
- Create a rural APRN delegation and supervision program at Texas A&M University System Health Science Center College of Medicine, under which the college contracts with or otherwise retains physicians to enter into delegation and supervision agreements with certain APRNs practicing in rural areas.
Within the rural APRN delegation and supervision program, in counties with a population of 30,000 or less:
- Delegation and supervision agreements would be limited to primary care, women’s health, and mental health;
- No fees could be charged for those agreements;
- Texas A&M may collaborate with other rural schools.
Statewide, SB 2695 would require the Texas Medical Board to track the number of delegation and supervision agreements, fee amounts, and where those APRNs practice. Physicians would have to review at least 5% of charts pertaining to those agreements.
TMA also supports the creation of public nurse profiles on the Board of Nursing website with their education, training, and practice location under House Bill 3614 by Rep. Katrina Pierson and Rep. Tom Oliverson, MD, pending in committee.
Senator Kolkhorst said SB 2695 was the result of a “cumulative effort for quite some time,” involving multiple stakeholders, including TMA.
“This is striking a balance” and “allows us to collect data here in Texas to get a better idea of how we are reaching these medically underserved areas,” she said.
Senator Campbell also endorsed SB 2695, saying it “strengthens” Texas’ existing physician-led framework and gets physicians to rural areas without “just trying to fill the need with someone that’s not qualified.”
TMA also supports measures within the proposed state budget that boost graduate medical education, physician loan repayment and rural training programs, and physician Medicaid and telemedicine payment.
Physician testifiers agreed especially in rural areas, more supervision is needed, not less, given the variety and complexity of medical problems that tend to arise within those populations.
Nor do patients want any less, according to a February 2025 survey Deborah Fuller, MD, referenced showing 63% of statewide voters and 61% of rural voters oppose the notion of nurses practicing medicine without physician supervision.
Especially in distant rural areas, physicians are the first call – and often the only call – when emergencies happen and often respond without a full team of specialists behind them, said TMA President-Elect Jayesh Shah, MD, who began his career in rural Uvalde.
“In these settings, there is no margin for error – and no shortcut to competence,” Dr. Shah testified in a voice that boomed throughout the Senate chamber. “Our rural communities deserve not just care; they deserve the best care. … Every Texan – rural or urban – deserves a doctor, not a shortcut.”