Mary Keary-Scott, a cardiac nurse practitioner, is shown with Army veteran Richard Rocco Turro at the VHA's New York Harbor Healthcare System. Claudie Benjamin, PAO, VA New York Harbor HCS

The Veterans Health Administration is taking heavy fire from doctor groups over a proposal to let nurses with advanced training practice medicine without physician supervision throughout the VHA system—even in states where laws require more oversight.

More than 60 state and national physicians groups have signed a letter to the Department of Veterans Affairs expressing "strong concerns" that the proposed new nursing handbook would "effectively eliminate physician-led team-based care within the VHA system."

Some 40 nursing organizations have countered with letters applauding the proposed changes, which they said "will further facilitate timely delivery of high-quality health care to our nation's service men and women."

The VHA dispute mirrors skirmishes across the nation over the roles nonphysician health providers should play in medical care, with doctors in short supply in some areas and more Americans gaining health insurance. Physician assistants, nurse practitioners and other so-called physician-extenders are increasingly taking on duties once performed solely by doctors, but state scope-of-practice rules differ widely on how much autonomy they have.

The efforts at the VHA—the nation's largest health-care system, with more than 1,700 hospitals, clinics and veterans centers in all 50 states—are being closely watched. The department's overall budget, which is $140 billion this year, has risen 40% since 2009, but the system is struggling to treat a surge of veterans with mental-health issues and to end a backlog of disability claims.

Last month, the VHA issued new guidelines for its 2,200 physician assistants, lifting some restrictions and letting individual PAs and their "collaborating physicians"—previously called "supervising physicians"—determine how much autonomy the PA should have. The American Academy of Physician Assistants hailed the new directive as a "model of flexibility."

The proposed nursing handbook is generating more opposition. As currently drafted, it would recognize the VHA's 6,135 advance-practice registered nurses—including nurse practitioners, nurse anesthetists, nurse midwives and clinical-nurse specialists—as independent practitioners authorized to care for patients without direction or supervision by a doctor. For nurse anesthetists, for instance, that includes administering anesthesia in surgeries, managing acute-pain services and being the lone anesthesia provider in some clinics.

VHA nursing officials say the proposed change follows a 2010 Institute of Medicine recommendation that nurses should practice to the full extent of their education and training. They note advanced-practice RNs, who have master's or doctoral degrees and pass national certification exams, have been operating independently in many VHA facilities and the armed forces for years. The proposed nursing handbook would standardize procedures throughout the system.

The American Society of Anesthesiologists, which represents more than 50,000 physicians, has warned in letters and news conferences that allowing nurse anesthetists to work independently could decrease quality of care at the VHA, where patients are typically in poorer health than the general population. The group says physician anesthesiologists are far better prepared to address emergencies, and it notes that a 2000 study in the journal Anesthesiology found mortality rates are higher for patients who undergo surgery without a physician anesthesiologist.

"When you have a veteran asleep on an operating table, seconds count, and all those years of additional training can make the difference between life and death," said Jane Fitch, the physician group's president and a former nurse anesthetist herself.

The American Association of Nurse Anesthetists says the physicians group is chiefly interested in protecting their jobs. "These are guild-protection arguments, not patient-protection arguments," said Frank Purcell, the association's senior director for federal-government affairs.

The nurse-anesthetist group cites a 2010 study in Health Affairs that found no difference in patient outcomes whether anesthesia was administered by a physician or a nurse anesthetist, with or without supervision. A 2010 analysis in Nursing Economics found that nurse anesthetists working independently are the most cost-effective model for anesthesia delivery.

Physician anesthesiologists ranked sixth in average income among medical specialists in 2013, according to Medscape's annual physician-compensation report. Nurse anesthetists typically make far less than their physician counterparts, their association says. In some surgical settings, anesthesiologists supervise as many as four nurse anesthetists at a time and collect 50% of their fees.

VA Secretary Eric Shinseki—who credits a nurse with saving his foot when physicians wanted to amputate it in Vietnam—defended the proposed change in a letter to lawmakers last fall, saying it "will increase access to care and ensure continuation of the highest quality care for our nation's veterans." But VHA officials say they are still meeting with physician and nursing groups and reviewing the handbook internally.

Meanwhile, some lawmakers have joined the fray. Rep. Andy Harris, a Maryland Republican who is a practicing anesthesiologist and former Navy medical corpsman, has questioned VA officials and urged physicians to express their concern. While nurses can be needed to fill in for doctors in military settings, he says, "this is not wartime."

Write to Melinda Beck at