BMDA Position On Advanced Practice Nurses
Noting they have ”enormous respect for Bermuda’s nurses and the critical role they play in our healthcare system,” the Bermuda Medical Doctors Association said they do not “support independent Advanced Practice Nurses [APNs] medical practice or independent prescribing in Bermuda.”
Bermuda Medical Doctors Association [BMDA] President Dr. Kyjuan Brown said, “The Bermuda Medical Doctors Association [BMDA] wishes to respond to recent commentary suggesting that our position regarding independent practice by Advanced Practice Nurses [APNs] is insulting to Bermuda’s nurses. That was neither our intention nor our message.
“The BMDA has enormous respect for Bermuda’s nurses and the critical role they play in our healthcare system. We recognise their education, experience, dedication and contribution to patient care. This is not a debate about whether nurses are valuable, intelligent or highly trained. They unquestionably are.
“The issue is whether Bermuda should grant APNs independent authority to diagnose, manage and prescribe without physician oversight, and whether Bermuda has demonstrated a healthcare need requiring that change.
The Training Is Different — That Is a Fact, Not an Insult
“Physicians and APNs are both highly educated healthcare professionals, but their preparation for independent clinical practice is fundamentally different.
“A physician completes medical school followed by years of structured, supervised postgraduate medical training. In the United States, Family Medicine residency alone is a minimum of three years after medical school. In the UK, doctors entering General Practice complete two Foundation years followed by three years of GP specialty training.
“The BMDA’s position paper identified approximately 500–1,000 supervised advanced clinical hours for APN training compared with approximately 10,000–16,000 supervised clinical hours through physician medical education and postgraduate training.
“Put into understandable terms, using a 40-hour clinical week:
“500–1,000 hours = approximately 3–6 months of full-time-equivalent supervised clinical training.
“10,000–16,000 hours = approximately 5–8 years of full-time-equivalent supervised clinical training.
“Actual requirements vary by programme and jurisdiction, but the magnitude of the difference is clear.
“Medical education and residency specifically prepare physicians for differential diagnosis, pharmacology, interpretation of investigations, prescribing, complex and undifferentiated illness, and recognition of uncommon or life-threatening disease.
“This does not make nurses less intelligent, accomplished or valuable. It means the professions are trained differently and for different roles. Respecting nurses does not require us to pretend these training pathways are equivalent. They are not.
“When independent diagnosis and prescribing are being considered, that distinction is directly relevant to patient safety.
Why the United States, Canada and UK Are Different
“It is correct that APNs and other advanced practitioners are widely used in the United States, Canada and United Kingdom. But context matters.
“These countries have faced significant physician shortages, underserved communities and difficulties accessing timely primary care. In Canada, for example, 5.7 million adults were reported as not having a regular healthcare provider in 2024, despite approximately 119 family physicians per 100,000 population.
“In such circumstances, an all-hands-on-deck approach is understandable. When there are insufficient physicians to meet demand, appropriately trained advanced practitioners can help fill an access gap.
“But Bermuda must make healthcare policy based on Bermuda’s needs.
“What Problem Are We Solving in Bermuda?
“Current Bermuda registration data show 46 physicians with Full Registration in General Practice and another 20 in Family Medicine — 66 primary-care physicians serving approximately 60,000 residents.
“That is approximately 110 GP/Family physicians per 100,000 residents in Canada , or 1 GP/Family Physicians for every 909 residents in Bermuda.
“The BMDA therefore asks a straightforward question:
“What healthcare-access problem are we trying to solve?
“If Bermudians cannot find primary-care physicians, if parts of the island are medically underserved, or if patients face unacceptable waits for routine primary care, then the data demonstrating that shortage should be presented publicly.
“If a shortage exists, let us identify it and work collaboratively with Government and our nursing colleagues to solve it.
“But Bermuda should not automatically import a workforce solution developed in much larger countries facing fundamentally different population, geographical and healthcare-access challenges without first demonstrating that the same problem exists here.
Physician-Led Does Not Mean Nurse-Subordinate
“Physician-led medical care does not mean nurses are beneath doctors.
“Healthcare is multidisciplinary. Nurses, physicians, pharmacists and allied health professionals bring essential but different expertise to patient care. The BMDA supports nurses and APNs working to the full extent of their education, competencies and regulated scope.
“But collaboration does not require equivalence of training, and working to the full extent of one’s training is not the same as assuming the independent scope of another profession.
Our Position Remains Clear
“We regret that our position has been interpreted as disrespectful to nurses. However, disagreement about scope of practice is not disrespect for a profession.
“The BMDA remains willing to work collaboratively with the Bermuda Nurses Association, Government and other healthcare stakeholders. If evidence demonstrates a genuine gap in primary-care access, we should examine it together and determine the appropriate solution for Bermuda.
“Until such a need is demonstrated, the BMDA does not support independent APN medical practice or independent prescribing in Bermuda.
“Respect our nurses. Value their expertise. Use their skills. Strengthen collaboration. But do not confuse collaboration with equivalence of training, and do not fundamentally change Bermuda’s model of medical care without first demonstrating a healthcare need requiring that change.”
The author says that the reason they have APNs in Canada is because the lack of GPs means they need an all-hands-on-deck approach. Then he gives some ratios of GPs per population, as follows:
“That is approximately 110 GP/Family physicians per 100,000 residents in Canada, or 1 GP/Family Physicians for every 909 residents in Bermuda.”
These are almost exactly the same: 1.1 per 1,000 population. So Bermuda has basically the same shortage of GPs that Canada has, per the author’s figures. And it therefore *does* make sense to look to a country like Canada to identify solutions, such as these advanced nurses.