Health Care Advocacy Early On Can Have A Great Impact

Getting Involved in Health Care Advocacy Early On Can Have Great Impact

I realized there were significant problems in health care delivery as a medical student at the University of Cincinnati College of Medicine. Socioeconomic determinants of health, compounded by rising health care costs, and inadequate care for the underserved, were not addressed in the curriculum for medical students in most schools. 

So, I jumped at the opportunity when I learned that my medical school had a unique program where students could get involved in taking care of patients in underserved areas of the local community. I also joined the Student American Medical Association (SAMA) because it had established a program called MECO (Medical Education and Community Orientation), where students could do an elective in primary care in non-urban communities away from the super-specialized academic medical center.

My involvement in medical education started while still a medical student. I lobbied for and initiated the first comprehensive course on human sexuality for the medical school, which the OB/GYN and Psychiatry departments embraced. I was beginning to see the role I could play in improving our health care system and medical education.

When I was a junior in medical school, I was named president of SAMA and was asked to do an interview for a national Blue Cross Publication. In the interview, I lamented the low 4.8 percent level of African-Americans in U.S. medical schools and felt the enrollment of all minority students should appropriately reflect the actual population of the country. I talked about the difficulties that minority groups had in getting into medical school, including inadequate support and encouragement in the pre-requisites necessary for admission, an insufficient number of role models, and inadequate support for minority students once admitted to medical school.

Shortly thereafter, I realized that in order to do the job well as National President to represent all of the medical students in the United States, I needed to take a year off from medical school. During my presidency, SAMA’s Minority Group Affairs Committee undertook a national program to improve and prepare minority students from high school onward to prepare for entry into the medical profession. We also worked through our representation on the National Board of Medical Examiners and the Association of American Medical Colleges, to see that the medical college admission test didn’t discriminate against anyone because of the type of questions asked.

At the same time, the then-president of the American Medical Association (AMA) formed an AMA Commission on the Cost of Health Care, recognizing that physicians, as purchasing agents for their patients’ health care needs, knew little about the actual cost of tests, supplies, and hospital charges that patients had to pay. As SAMA president at the national level, I organized grassroots efforts to inform physicians-in-training of their obligations in this area and push hospitals to be transparent in their charges. (And it took recent legislation to make this a law.)

This was the stimulus for a book that I later wrote as a surgical resident, along with another Baylor resident, that the AMA published on Medical Cost Containment. I will never forget the pushback I got after the publication came out as I had given many lectures at local hospitals. One hospital administrator called me directly and asked me to stop talking about fair pricing and transparency. I should have been intimidated but instead told him that we had full support from the then-president of the American Hospital Association to do so. It was then that I learned that when you know you are championing a just cause, you will meet resistance, but action and progress can, and must continue.


I was hooked on being involved in health care advocacy, the AMA, and  being a practicing physician. I knew that being involved in organized medicine at the local, state and national level, as well as providing the highest quality patient care as a physician helps bring better health care to all patients.

I applaud all medical students, physicians in training and young physicians in their involvement and strong efforts to improve our healthcare and educational systems and to provide care to all. I encourage others who are not currently involved to get involved. Healthcare advocacy is critical and has such a significant impact for patients.

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!

Texas Bluebonnet Award Given To Dr Kridel

Texas Bluebonnet Award Given to Dr Kridel For Contributions to Community Health

Dr Kridel given Texas Bluebonnet Award

Texas Bluebonnet Award Given to Dr Kridel

At a ceremony in Corpus Christi at the Omni Hotel on April 25th, the Texas Academy of Nutrition and Dietetics Foundation presented Dr. Russell Kridel with the prestigious Texas Bluebonnet Award.

Dr. Kridel received the award for his contributions to health care, including his efforts to reduce obesity throughout the Shut Out Sugar campaign developed during his tenure as President of the Harris County Medical Society.

Dr. Kridel created the HCMS Personal Responsibility Committee dedicated to helping address the obesity epidemic. The committee provides physicians across all specialties with tools to communicate the importance of diet and nutrition to their patients to prevent obesity, diabetes and other diseases, with emphasis on sugar sweetened beverages. Through Dr. Kridel’s leadership, the committee developed a brochure called “Shut Out Sugar” for physicians and health providers.  The brochure clearly outlines simple and easy steps people can take to reduce consumption of sugar-sweetened beverages to improve their health. He also participates in key roles at the state and national level on health care issues that positively promote the role of diet and nutrition in the ever-changing landscape of health care.

TX Academy of Nutrition and Dietetics

Texas Academy President, Carol Bradley, PhD, RDN, LD presented the Texas Bluebonnet Award to Dr. Kridel along with Jennifer Cash, MS, RDN, LD, the Texas Academy Nominating Chair.

Dr. Kridel also received the local Houston Academy of Nutrition and Dietetics Foundation Bluebonnet Award in 2013.