We Must Stay Vigilant on Scope Creep

SUMMARY: Non-physicians without the same intensive training & education are trying to convince legislators  across the nation that they give equivalent care as do physicians at great potential safety risk to patients.  Scope of practice expansions in the medical world are increasing on a daily basis.  As physicians, we need to be vigilant in our battle against scope creep through advocacy efforts at the local, state and national levels.

Many non-physician health care professionals have pushed to expand their scope of practice to provide care to patients independent from physicians and outside their education and training.  This scope creep is deeply concerning and such expansions threaten patient safety, and despite promises, such expansions have not led to improved access to care in rural areas.

As I am sure many of you have experienced, it can take a multitude of health care professionals to provide optimal care to patients in many situations. We indeed benefit from medical assistants, pharmacists, registered nurses, physician assistants, nurse practitioners, physicians, and the list goes on. However, what we have learned in medicine is that patients benefit when health care professionals work together as a team led by physicians – with all members of the team drawing on their specific strengths based on their unique education and training for the benefit of the patient with physician supervision.

A past-president of the Texas Medical Association was first trained as a nurse anesthetist, a CRNA, before she went back and enrolled in 4 years of medical school and did a several year anesthesia residency. After her intensive residency, she came to realize how little she knew about anesthesia with just a nursing degree.  She said, “I didn’t know (when I was a CRNA) how little I knew (back then).”

I have worked in my own office with a P.A.   But, there is no way that even after spending a year with me after PA training, that I would allow the PA to practice the full scope of facial plastic and reconstructive surgery on my patients.  It took me 6 extra years of training after 4 years of medical school to get to where I am. Certainly, my PA was a great help, but her level of decision-making and expertise were not the same as mine.

Essentially there are two tracks.  The first is comprised by non-physicians who traditionally work as part of a health care team and provide care to patients with physician supervision or collaboration who now seek to expand their scope so they can diagnose, prescribe (including highly addictive opioids) and treat patients without any physician involvement.  Physician Assistants and Advanced Practice Registered Nurses, which includes Nurse Practitioners, Nurse Anesthetists, Nurse Midwives and Clinical Nurse Specialists fall within this track.

Second, you have non-physicians like optometrists, podiatrists, and psychologists who are experts within a specific field of study yet seek to expand their scope of practice outside their education and training.  Do you want, for example, an optometrist who has never been to medical school or done an ophthalmology residency to do your cataract surgery? Optometrists are trained in primary eye care; they are not trained to perform surgery, yet legislation is introduced in multiple states every year that would allow optometrists to perform surgery.

A primary concern with both tracks of these groups is that these non-MD health care professionals do not have the education and training to provide the care sought by the scope expansions they seek.

Physicians complete seven or more years of postgraduate education between medical school and residency programs and 10,000 – 16,000 hours of clinical experience. By comparison, nurse practitioners complete just 2-3 years of post-graduate training and only 500-720 hours of clinical training. And PAs complete 2 years of post-graduate training and just 2,000 hours of clinical practice. But, it’s more than just the difference in the years of education and clinical training, it’s also about the difference in rigor and standardization between medical school/residency and Advanced Practice Registered Nurses (APRN) programs. When I attended medical school, I studied the biological, chemical, pharmacological, and behavioral aspects of the human condition in the classroom and laboratories. This was supplemented by two years of patient care rotations through different specialties, during which I was able to assist licensed physicians in the care of patients. As a medical student, I continued to develop clinical judgment and medical decision-making skills through clinical rotations which allowed me to manage patients in all aspects of medicine. Following graduation, all medical students must then pass a series of examinations to assess their readiness for licensure as a physician.  It’s at this point medical students “match” into a three- to seven-year residency program during which they provide care in a select surgical or medical specialty under the supervision of experienced physician faculty. As a resident, I was not given greater responsibility to care for patients until I gained experience and demonstrated growth in my abilities.

Yes, medical school is expensive, takes only the most qualified applicants, and takes a long time to complete, but it is through this process that one becomes proficient in caring for patients and proficient in forming complex diagnoses and treatment plans. Nurse practitioner and other APRN programs do not have a similar time-tested method. Nurse practitioner programs can be completed partially or completely online and students can be required to find their own preceptor for clinical training.  There is very little standardization.

Unfortunately, however, when state legislators enact legislation allowing scope expansions, allowing APRNs or PAs to practice independently from physicians, this essentially removes physicians from the care team, and it applies to all NPs, including new graduates – who may have completed an entirely online NP program and only 500 hours of clinical training in a family physician office. Yet, this same NP could be hired after graduation to practice in an emergency department, without any physician oversight. Yes, that can happen in some states. That is scary for patients who need expertise to diagnose and treat their emergency condition whether it be a heart attack, pneumonia, or multiple lacerations or broken bones.

Ensuring access to health care has been a top priority for the medical community as a whole. Access to health care is also deeply entrenched in multiple AMA’s policies and advocacy. It’s a multi-faceted issue, with no single solution. Yet, access to care is the primary reason cited by non-physician health care professionals to support their scope expansions.

Back in 2013 the AMA created maps for each state illustrating exactly where physicians and non-physicians were practicing.  There are now more than 4,500 maps showing the practice locations of physicians by specialty and various non-physicians. These maps very clearly illustrate that non-physicians tend to practice in the same areas of the state as physicians.  This occurs irrespective of state scope of practice laws. For example, there are some states where nurse practitioners can practice without physician supervision or collaboration – even in these states NPs have not moved into rural areas of the state.  Yet, in states like Georgia, which require NPs to practice pursuant to a protocol agreement with physician supervision and delegation, there has been a substantial increase in the number of NPs in the state since 2013 and they are scattered throughout the state, including rural areas.  These findings have also been confirmed in state workforce studies and a graduate nurse demonstration project conducted by the Centers for Medicare and Medicaid Services.

There’s a myth that nurse practitioners will decrease health care costs.  In fact, multiple studies have shown expanding the scope of practice of nurse practitioners my increase the cost of care, due to inappropriate prescribing, unnecessary referrals to specialists and unnecessary orders for diagnostic imaging services such as x-rays. Not only does this end up increasing the cost of care, but it is also worse for patients as care is delayed, unnecessary antibiotics are prescribed, and unnecessary tests are performed.  Many authors of the studies concluded that, if nurse practitioners worked within a health care team with physicians, the care provided by the nurse practitioner would improve.

But, at the same time that they claim they will reduce health care costs, NP’s also actively lobby for pay parity with physicians. So, in the end, independent nurse practitioners will end up costing the health care system much MORE not less.

For a long time, physician assistants had been strong allies of the physician-led team-based model of care. In 2018, however, this all changed when their national organization adopted model legislation supporting independent practice of physician assistants, which allows them to practice medicine without any physician involvement.  Recently the same organization adopted policy to change their title to “physician associate” which no doubt confuses the public into thinking the PA is a physician.  Such association actions will not change the name PAs can legally call themselves in each state as that is regulated by state boards of medicine and state legislatures.

Finally, it’s important to note, this is a top legislative priority for the AMA which as formed the Scope of Practice Partnership. The AMA works closely with state medical associations across the country and national specialty societies to oppose legislation at the federal and state levels that would inappropriately expand the scope of practice of non-physicians. These are tough battles.  And when the AMA wins, these non-physicians turn around and gear up for next year because they will lobby to get the same legislation under future consideration.

Scope expansions typically occur incrementally, so even when we lose, we need to prepare for the next attempt for further expansion. We cannot let up on the pressure to keep Scope Creep high on the list of priorities at the AMA, as well as at our state and local levels.  This effects all physicians, whether or not they are a member of the AMA and has critical ramifications for our patients.

We need to stay vigilant about scope creep!