AMA News Wire
How scope creep is pushing beyond primary care
Feb 15, 2024
Attempts to inappropriately expand scope of practice for nonphysician providers are taking root well beyond the clinic walls of internists and family physicians. Specialists, too, are seeing nurse practitioners (NPs) and physician assistants (PAs) seek more independence in practicing in emergency departments, dermatology clinics, anesthesiology departments and beyond.
In fact, recent AMA survey data shows that scope of practice tops the list of 2024 legislative priorities for state and specialty medical associations surveyed, with 86% ranking it at the top of their legislative priority list.
Expanding nonphysician providers’ scope of practice can make patients less safe. That is especially so when health professionals present themselves in a way that makes it difficult for patients to understand their role or training, experts said during a panel discussion at the 2024 AMA State Advocacy Summit.
Cost-cutting measures have driven a large amount of the growth in nurse practitioners and physician assistants in emergency medicine, despite research showing that these nonphysicians often deliver costlier care when practicing outside the physician-led care team.
“The initial use case for NPs and PAs was for the lower acuity patients that we were seeing. Patients that would come in and be triaged as low acuity, the NPs and PAs would be seeing those patients in partnership with a physician,” said Alison Haddock, MD, president-elect of the American College of Emergency Physicians.
“But that's grown and grown over the past 10 or 20 years to the point where there are emergency departments that are staffed solely by nurse practitioners or physician assistants. That is a big problem that we're seeing in emergency medicine.”
And the expansion is expected to continue to grow in many specialties.
"This replacement of physicians is a result of health care policy advocated by nonphysician practitioner leadership, and I think we're only going to see a continued trend unless something changes," said family physician Rebekah Bernard, MD, whose latest book is Imposter Doctors: Patients at Risk.
Fighting scope creep is a critical component of the AMA Recovery Plan for America’s Physicians.
Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals. The AMA vigorously defends the practice of medicine against scope of practice expansions that threaten patient safety.
Patient safety risks
Last year, the AMA played a role in helping defeat more than 100 bills in state legislatures that threatened patient safety by inappropriately expanding nonphysician providers’ scope of practice.
There are already noteworthy cases of how scope expansion and poor or no oversight of nurse practitioners and physician assistants is causing patient harm.
A study published in JAMA Dermatology showed that physicians diagnosed melanoma in situ more frequently than physician assistants, said Alexander S. Gross, MD, incoming member of the American Academy of Dermatology’s board of directors.
“Melanoma in situ has a negligible risk of metastasizing,” Dr. Gross noted. “However, if you don't make that diagnosis early and the melanoma in situ progresses to an invasive melanoma, even at the lowest stages for invasive melanoma the risk of metastasis goes way up. This, I think, is an important example of how the use of midlevel practitioners is actually affecting patient care and possibly outcomes.”
Dr. Gross also pointed to the $20 billion medical spa industry in which patients are getting medical treatments with no physician on site and sometimes no physician even involved in the facility’s management.
Some results: at least three patients in New Mexico acquired HIV after receiving a vampire facial, a platelet-rich plasma treatment. A Texas patient who went to a medical spa for an intravenous hydration treatment and was given total parenteral nutrition as part of it went into cardiac arrest and died. There was no anesthesiologist on site.
“You're really taking your life in your hands, literally and figuratively, when you go to these places. You don't know who's providing the treatments. They may or may not be licensed, and it's very, very sad and frightening,” Dr. Gross said.
There are similar stories from the emergency department, including the tragic story of Alexus Ochoa-Dockins. In addition, a Michigan health system replaced its established anesthesiologists with a contract management group that emphasized its ratio of certified registered nurse anesthetists (CRNAs). A week after initiating the plan, a 51-year-old man went in for a colonoscopy and died. A nurse anesthetist managed the anesthesia, with no anesthesiologist there. When things went wrong, the nurse anesthetist couldn’t replace the breathing tube.
“By the time an anesthesiologist arrived it was too late, and Richard Curbelo died,” said Dr. Bernard. “It has to stop, because not only are we physicians, but I always remind everyone, we're patients. If you're not a patient now, you're going to be one, and when you look up from that gurney, you'll hope and pray that there will be a physician there, and that might not be the case.”
Dr. Gross said that such examples point to the importance of physician-led care and proper supervision.
He said the fight to stop scope creep is “a battle to make sure that patients get appropriate care,” he said. “I have physician assistants who work with me. … But I have one office that I go to and I'm always there or available.”
