The biggest turf war under the Capitol dome right now is not between Republicans and Democrats - it's between doctors and nurses.

A several-year battle between the medical community's two largest professions is coming to a head in legislative committees, and the outcome could affect access to health care, especially in rural Colorado.

At issue is the independence of advanced practice nurses, a subset of registered nurses who have advanced degrees and, in some cases, prescriptive powers. Some of these nurses operate their own medical practices, much like doctors, and a number cater to low- income or rural populations that have limited access to primary- care doctors.

To have the power to prescribe medicine, however, nurses now must sign a collaborative agreement with a physician who claims some degree of oversight. But both sides say this 14-year- old practice is causing problems.

On the nurses' side, they say that physicians are demanding too much.

Colorado Nurses Association Executive Director Fran Ricker related the story of one rural nurse whose collaborating physician died and was told by another that he would sign her agreement only for a $30,000 fee.

CNA government affairs director Tay Kopanos said another nurse left the state because doctors would sign on with her only if she gave up her practice and her Medicaid patients and became part of their staffs.

"It is a bit of a turf war," Ricker said. "These are groups openly competing for clients and services . . . These issues are about economics."

Patient safety

But Colorado Medical Society officials say the issue is patient safety.

Physicians are required to undergo tens of thousands more hours of training, and only recently have qualifications to become an advanced practice nurse become more stringent, Colorado Springs neonatologist Dr. Sue Townsend said.

Studies have shown that care is delivered more economically and effectively if done through a medical team rather than a single individual like an independent nurse, said Dr. Alex Slucky, an Englewood anesthesiologist.

And while APNs argue that a widened scope of powers is needed for them to serve rural areas, maps of physician and APN offices show that the two professions serve the same areas, he said.

"I'm OK with nurses having the dominant role in helping to defining the aspect of their training that would then clarify scope of practice, but it has to be more concrete and specific to what their training entails," said Dr. Luke Casias, a primary-care doctor in rural Mancos. "In medicine and in nursing, when things get vague, something gets missed and patients suffer."

Gov. Bill Ritter signed several laws last year to require more equal treatment between doctors and nurses. But the Senate already has passed one measure this year to roll one of those laws back - a bill that bans advanced practice nurses from committing someone to drug or alcohol treatment against their will without a doctor's approval.

Nurses and doctors have been meeting to find a compromise on the collaborative agreements and believe they have found an answer that they soon will ask the legislature to accept. It would require APNs to do 1,800 hours of supervised mentorship and training with a physician before they get independent prescriptive authority.