AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. June 2004, Volume 6, Number 6.

Policy Forum

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Scope of Practice--Twenty-First Century

Many nonphysician health care practitioners are looking to expand their scope of practice.

Grant La Farge, MD

Would allowing an optometrist to perform laser surgery improve access to eye care for needy patients? Would permitting PhD psychologists to prescribe Prozac or other psychotropic drugs to patients with mental illnesses be safe?

These 2 questions, and many like them, are being asked of medical societies and boards and legislatures with increasing frequency all over America. Nonphysician practitioners such as acupuncturists, chiropractors, and nurses are seeking to expand the scope of their professional practices beyond the boundaries of what they have traditionally been taught and what they have been clinically trained to do well.

What are the incentives? Medical boards and legislatures frequently are told that expanding nonphysicians' scope of practice into the realms of allopathic or osteopathic medicine will "improve care for needy patients," especially in medically underserved areas, both rural and urban. Nonphysician practitioners also make the case that legislative approval for extended services will likely lead to increased reimbursement from payors like Medicare and Blue Cross. This, they argue, benefits those who can only afford care that is reimbursed. Yet, behind these noble-sounding reasons may lie more subtle motives of increased professional prestige and power.

How are legislators to know whether a request for expanding a particular scope of practice into the realm of medical diagnosis and treatment is safe or justifiable? Their many fields of expertise do not usually include an intimate knowledge of the details and subtleties of medical education, clinical training, professional examination and certification, the rigorous requirements for licensure, and the administration of discipline. Those are the time-honored concerns of professional practice boards.

Legislatures Must Form Health Care Practices Committees

Yet all too often legislatures are confronted—without much warning—with requests for extended scope of practice, requests that are replete with anecdotal success stories and promises of increased access to safer medical care resulting from the proposed change. They hear, "There aren't enough doctors to take care of the needy and uninsured so we, who outnumber the doctors in this state, will get special training and then be able to take good care of your constituents." Too often omitted in the ensuing debate are the specific details of the didactic education and the clinical training that would be required in order to assure both competence and safety for the public in the performance of the newly acquired, expanded scope of practice.

During this past year, a special committee of the national Federation of State Medical Boards has been considering how to expand scope of practice safely while at the same time improving access to care and assuring professional competence. The committee was made up of knowledgeable members from many professions: physicians and nonphysician practitioners and informed public members, aided by the federation's staff.

The outcome of the committee's effort has been a formal report containing a set of recommendations for professional practice boards and state legislatures. It categorizes and lists the many considerations necessary to arrive at a rational, sensible, and safe method for amending a professional practice act. The report's carefully crafted questions and recommended actions address the reasons for the requested change as well as the effect such actions would have on access to care and safety for the public. The fiscal impact of the change on existing practitioners currently performing the same medical or osteopathic service is factored in, as is the cost to the health care system at both state and national levels.

Fundamental to any consideration for such a change is the concept that specific, detailed questions and actions must be decided upon by each profession and discussed jointly with other professions to forge the final set of recommendations. Additionally, the federation report strongly urges that each state legislature should create—or should have already created—a Health Care Practices Committee that would include members of each affected profession, experts in the relevant fields of practice, and knowledgeable public members with expertise in health care. All must work together to seek answers. The major questions are detailed in the federation's report.

Critical Elements for Expanding Scope

The critical elements that must be addressed in detail before formulating a recommendation for an increased scope of practice include: didactic education, supervised clinical training (like a residency), professional examination and certification by a specialty board, requirements for licensure, public information and education about newly "re-scoped" practitioners, and complaints and discipline procedures.

Two very important concepts have been embedded in the report of the federation's special Scope of Practice Committee. First, the process of determining whether the requested increase in scope of practice is warranted must be one in which all of the affected parties—the physician and nonphysician practitioner boards, and knowledgeable public experts—participate jointly. The process must truly be a cooperative one; one in which such a representative group may be able to arrive at a final, agreed-upon, rational, sensible proposal and recommendation for the legislature to consider.

The second important principle is a new one, and it is slowly entering into the practice of medicine in this country. This principle grew out of the gradual transformation of the attitudes toward interprofessional relationships that has taken place over the past 2 or 3 decades. First, there were medicine and nursing. Then, with the growth of the "allied" health professions came the concept of alternative medicine. At first, allopathic medicine's response to this development was one of "we-they," "either-or." Then, as more and more patients sought care from nonphysician practitioners, the term complementary medicine appeared: each profession may be valuable and more than one may have useful roles in the patient's care. Yet, the professions did not always work together well. More recently, the concept of integrative medicine became the desired approach: the physicians and nonphysician practitioners can and should work together for patient benefit. Yet communication often was still marginal. Now, especially with the federation's Scope of Practice recommendation, the relationship is to become collaborative practice, with that collaboration being mandatory for the well-being and safety of the patient.

The era of totally independent practice, without interpractitioner collaboration, is rapidly fading away; too many conflicts and hazards for the patient exist to allow a "separate but equal" approach to continue. Truly integrated practice is here, with improved access and assured competency and safety. It is now our task as professionals to assure that the integration is increasingly sound and effective.

Grant La Farge, MD, a cardiologist, serves as secretary-treasurer of the New Mexico Board of Medical Examiners. He also advises the Federation of State Medical Boards and is the federation's liaison with the American Medical Association as a member of the federation's special committee on scope of practice. He has taught at Harvard Medical School as associate clinical professor of pediatrics and as clinical professor in pediatrics (cardiology) at University of New Mexico, Santa Fe.

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