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What’s All the Fuss about Scope of Practice?

Pssst. I have a secret to tell…

…………………………….Many of the things we do in medicine are not that hard!

Honestly, it does not take 13 years to learn how to do an appendectomy. The fact that we have reserved tasks like this for the highly trained is not about how much we respect the people who have completed the training; it is about how much we respect the people they serve.

Because your body is the most precious thing you possess, it should by sutured by someone who has paid heartily for the privilege of serving you.

My last article, What it Takes to Have a Career In Medicine, attempted to explain the differences in training required for the privilege of participating in the provision of healthcare. There are a variety of roles – each important – and each with its own limitations.

Non-physician providers (i.e. nurse practitioners, CRNAs and physician assistants) represent the fastest growing segment of healthcare professionals. Not long ago these members of the healthcare team were called “physician extenders” or “mid-level providers.” But these terms are no longer an accurate representation of their role as many nurse practitioners and CRNAs practice independently without physician collaboration. (Links connect to maps of practice rights by state.) Physician assistants have yet to secure independent practice rights in any state, but I believe it is only a matter of time.

Non-physician providers are highly trained and capable and are already performing many of the functions of a physician. They know they can do the job. We know they can do the job. But independent practice rights are still being hotly debated in most states.

A long time ago, the differences between osteopathic physicians (DO’s) and allopathic physicians (MD’s) were emphasized and organizations like the American Medical Association tried to limit the practice of osteopathic medicine. The AMA spent nearly 8 million dollars to try to end the practice of osteopathic medicine in the state of California in the 1960’s. (You can read more about that here.) But now D.O.’s and M.D.’s work alongside one another in all 50 states with almost indistinguishable practices and you would be hard-pressed to find a physician anywhere who would argue against this.

Perhaps this is the future of medicine for non-physician providers. Perhaps independent practice rights will continue to expand and PA school, CRNA training and DNP programs will just become different paths to the independent practice of medicine.

And I will not embarrass myself by fighting against it. Because hands down, without question, non-physician providers are capable of taking excellent care of patients. They are already doing it.

But I think all healthcare workers are capable of doing more than they are currently permitted to do. It’s not hard to push medications through an IV, or to set up a nebulizer treatment. It’s pretty easy to reduce fractures and suture lacerations. However, if we value these services, we don’t want them done by someone who stayed at a Holiday Inn Express last night. We want them done by someone who has proven themselves worthy by meeting measured standards through hard work and dedication over time.

I completed a three year emergency medicine residency and was trained to provide care for pediatric patients in the emergency department. However, I have colleagues who chose to specialize in pediatric emergency medicine (PEM). They did a three year pediatrics residency and after that they completed a three year pediatric emergency medicine fellowship (giving them a total of 14 years of education after high school – which is a year longer than most surgeons taking out gall bladders – crazy, I know). They have more than double the training I do in the practice of pediatric emergency medicine.

And this is where it gets tricky. You see, I think I give good care to children in the ED. I think I can treat a case of croup as well as my peds EM trained colleagues. But I can’t get a job as a faculty member in a free-standing, pediatric emergency department. And I’m okay with that. Because it isn’t about me. It’s not because I’m not smart or capable – it’s just because I chose a different (and much shorter) path.

When we talk about scope of practice for healthcare professionals, people often fall into talking about ability – and that is a moot point from my perspective. Medics and corpsmen in the military sometimes have as little as 16 weeks of training, but are often referred to as “Doc” and frequently function as physicians in the field. They put in chest tubes and literally save lives. I’ve worked alongside some of these medics in the hospital and they’re all itching to get their hands bloody again. They know they can do it. They’ve done it. But hospitals are not granting them privileges for these procedures in house.

Is that because they’re not capable?

Or is it because hospital administrators believe that most patients prefer providers with the highest level of education available for these procedures?

Surgical PAs and surgical techs who have assisted with the same cases for years could likely successfully perform them on their own. Increasing their privileges to do procedures independently could potentially decrease the cost of surgery and decrease elective procedure wait times. But no one is talking about a shorter, less-expensive route to independent surgical practice.

Is that because surgery is so difficult?

Or is it because we value it more?

I don’t know, but these are definitely uncomfortable things to talk about – which is why we generally tend to avoid them. Medicine is somewhat unique in this sort of awkwardness. Other professions seem to have clearly established paths to privileges with much less controversy.

Consider pilots…

After years of school, commercial pilots still have to pay their dues on smaller aircraft before they get to fly jumbo jets across the ocean (if ever). Anyone can take flying lessons. But even if I earn my pilot’s license with highest honors and my skills in the cockpit are unrivaled, Delta still isn’t going to put me on the schedule to fly a 747 from JFK to Heathrow. And that isn’t about me or my abilities – it’s only about not completing the course to earn my captain’s stripes.

My husband (who is mostly very humble) would be happy to tell you how he could have done a better job than the last four General Managers of the Detroit Lions. He stays up late drawing up extensive draft strategies and when the draft finally arrives in the Spring – he camps out in front of the TV for an intense 2.5 days.

The truth is, Mickey might be the best choice for the new GM of the Lions. Honestly, he might. But it doesn’t really matter because Mickey didn’t choose a path that would make him a candidate. For better or worse, some other guy (who may not be as smart or passionate or draft-saavy) will become the new GM. And he will have earned the right to make multi-million dollar draft picks – even the kind that make my husband shout, “What the FUDGE?!”

I know some of the nurses I work with have occasionally looked at my orders and thought, “WTF?!” Because while the course I chose has given me the privilege of writing orders – it has not made me infallible or ‘better than’ anyone else. Medicine is a team sport and I am thankful for every time a nurse has caught one of my errors. Physician training doesn’t create perfect providers. But it does produce highly qualified professionals who have been humbled enough by their training to know what a privilege it is to do what they do.

When it comes to limiting the scope of practice of non-physician providers, physicians are often accused of not wanting to “share the spotlight” or “share the wealth.” And I don’t think that’s the core of the resistance. I think it comes from the respect we have for our profession, and an awareness that even after years of preparation, most of us worked our first days as attending physicians with a little fear. The kind of fear that respects risk and understands that even after 11+ years – there is still more to be learned.

For some reason, no one is giving serious consideration to shortening the path to become a physician. We are only creating shorter paths to the privileges of a physician.

Why is that?

The gauntlet of physician training was not created to prove physicians “special” – but to prove them worthy of caring for the most special thing – human life. It was deep and abiding respect for humanity that made the path to practicing medicine so arduous. The length of the course was always more about a reverence for the services provided than their difficulty. So when we talk about scope of practice – it’s not about the merit or skill of the providers – it’s about our values.

So…is the continued expansion of independent privileges a reflection of how much we value people and therefore want them to have improved access to care?

OR is it a reflection that we have devalued non-surgical care?

I don’t know, but I think it is a conversation worth having. And perhaps the wisest way to have it is with the shedding our own white coats and surgical scrubs. Because we will all wear the gown of a patient someday. What will we value then?


Photo credit: XiXinXing/Getty Images

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