Scope of practice challenges and a model for team-based care with Michael Suk, MD, JD, MPH, MBA

. 9 MIN READ

AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

Chair-elect to the AMA Board of Trustees Michael Suk, MD, JD, MPH, MBA, joins to discuss the AMA’s position on scope of practice in 2024. Dr. Suk breaks down the difference in training between physicians and other members of the care team and the role each play. Plus, why physicians should lead the care team and barriers to physician-led care. AMA Chief Experience Officer Todd Unger hosts.

Speaker

  • Michael Suk, MD, JD, MPH, MBA, chair-elect, AMA Board of Trustees

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Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about the importance of physician-led care teams with Dr. Michael Suk, chair-elect of the AMA Board of Trustees and an orthopedic surgeon at Geisinger Health System. I'm Todd Unger, AMA's chief experience officer. Dr. Suk, thanks so much for joining us.

Dr. Suk: It's great to be with you. Thanks for having me on.

Unger: Well, we're here to talk about the importance of physician-led care teams, but that's really the solution for what's become a growing problem, which is inappropriate scope of practice expansions. And for those who may be less familiar with scope of practice issues, can you give us a two-sentence rundown of what's at stake here?

Dr. Suk: Sure, sure, happy to do so. I think what you said is really the right way to capture it. It's this issue of scope of practice and inappropriate expansion of that scope of practice, and what we mean by that is when members of the health care team provide care outside of their specific skill set and training. An example of this would be nurse practitioners or physician assistants who practice independently without physician supervision, pharmacists who make diagnoses or optometrists who perform surgery.

What we're concerned about is that this potentially puts patient safety at risk in that there can be confusion in about who's providing the care, the qualifications of the person providing the care, and sometimes people mistakenly believe that this will solve access problems when it comes to health care or ultimately try—as a way to save money. But we now know that several studies have shown that neither of those things are really true.

Unger: And we're going to talk about those in more detail. Is this something that you see affecting your own specialty, this kind of scope of practice expansion?

Dr. Suk: It's interesting. At the system that I work with at Geisinger, I think we really are a model of how a team-based approach that's physician-led really works very well. And so while I know a very many stories out there of independent nurse practitioners or independent physician assistants who have been acting that could potentially place patient safety at risk, I would tell you that I think that we have a system here at Geisinger that works extremely well.

We have physician-led teams. We have very careful supervision of those teams. We actually, even as an academic environment, have created real synergies between physician assistants and nurse practitioners and our residents and students and really helping to shape what we think will be the future relationships of these types of care, ultimately all still being physician-led.

Unger: Let me tell you—let me ask you a couple of questions about that because that kind of team-based approach that you're talking about that's working so well is the model. Can you talk to us a little bit more about the role that PAs play at Geisinger in that team-based model?

Dr. Suk: Sure. In the Orthopedic Department and Musculoskeletal Institute, which I lead, our physician assistants and nurse practitioners really play two roles, both in the clinic setting and an outpatient setting, but they also play an important role as first or second assistants in surgery. This is critical when it comes to creating more efficiency, creating greater access, and ultimately enhancing the quality of care that the surgeon or the physician can provide because it allows that person to be able to do multiple things with great confidence in the team that they have around them.

Unger: Now, the AMA has been advocating for physician-led team-based care, and I think, as you point out, probably, that situation is different across different areas of the country, different specialties. What do you think is at issue here and why is it so important to get to the right balance?

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Dr. Suk: Yeah, I think that, again, it starts with the misconception that creating a greater workforce with lesser training will ultimately lead to greater access and cheaper care. I think that that is a noble cause to pursue, but, in fact, it doesn't end up being as such. We know, for example, that physicians and nurse practitioners and physician assistants gravitate to the same geographic areas, so there's a there's a perception that where there are shortages of physicians, physician assistants or nurse practitioners will fill that gap.

And we know that that has not been shown in the studies that have been done. Nurse practitioners and physician assistants gravitate to the same urban areas that are out there. There are many solutions to that, of course, potentially in order to create those particular geographic deserts more attractive, whether it become a subject of financial incentives or whether it becomes some sort of forgiveness for loans in order to help create a greater physician workforce in those areas.

Unger: So that issue around access to care—that's something that we've dug into here at the AMA, and as you mentioned, the evidence doesn't really support that it does increase that. You mentioned the issues around cost and perceptions that that can lower costs. Can you give us more detail there?

Dr. Suk: Yeah. In fact, what we know from numerous different studies is that those of lesser training tend to order more tests than physicians, and we know that this is through a number of longitudinal studies that have demonstrated this. And as a result, having unnecessary tests results in higher costs for that particular episode of care.

I think physician supervision, I think physician-led teams can ultimately help mitigate that trend, and really, ultimately, it's about teamwork. It's not to say that physician assistants and nurse practitioners play no role within health care. In fact, I think they play a critical role. But at the end of the day, in order to find the right balance, it's our belief that physician-led teams are the way to go.

Unger: Do you think that patients understand those different roles and even the differences between PAs, NPs and physicians?

Dr. Suk: I think that increasingly so that is becoming the case, but I do still think that there is a significant gap in what physicians—or what patients see and the people they encounter and understanding where they're coming from. For example, a physician will go through training—I'll take myself as an example—goes through four years of university, typically. We then go to four years of medical school in orthopedic surgery. We'll do five years of training and oftentimes post-graduate fellowship training for another year.

That adds up to a significant more amount of training than those who are going through physician assistant programs or nurse practitioner programs. For example, a physician assistant program usually runs about two to two and a half years or so, and there's no residency requirement. Physicians are trained in the medical model, but it is intentionally greatly abbreviated. It covers basic science, pharmacology, clinical medicine, behavioral science, but it's purposely set up so that they can continue on-the-job training under the supervision of a physician. Nurse practitioners are along a similar shortened pathway in order to get their training to become nurse practitioners.

At the end of the day, physician assistants, for example, will get about 2,000 hours of supervised clinical practice in their master's level training. By comparison, between medical school clinical rotations and residency training, physicians amass between 12,000 and 16,000 hours of patient care experience, big difference.

Unger: So you've really outlined a number of really important factors to consider. You just covered, really, the training. We talked about access before. We talked about cost. This vision of getting to physician-led team-based care—that's so important. What's in the way of implementing that more broadly, and how do we get rid of those barriers?

Dr. Suk: Yeah, it's a great question, Todd. Among the things that I think are causing some of the barriers are really just a matter of culture. It's a matter of overstating one's desire to be independent. I think getting to team-based care is a matter of both sides looking at the equation. Physicians have to become more accustomed to be able to using and participating and teaming with providers who are not necessarily physicians, and I think that physician assistants and nurse practitioners need to continue to seek out avenues in which to partner with physicians and surgeons going forward.

I think that other barriers include the financial model in that there's not really a great way to comprehensively reimburse for teams. I think our traditional model is focused really on what one individual does and contributes to the care, and I think as we move forward in the future, we're going to be looking at reimbursements for teams rather than individual contributions in that way.

Unger: That's great perspective. Dr. Suk, thank you so much for joining us today. That's it for today's update, and we'll be back soon with another episode. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.

Dr. Suk: Thanks, Todd. Great to be with you.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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