There are activities and duties that a person licensed to practice as a health professional is permitted to perform. This is called scope of practice. But while every health professional has an essential role to play in caring for patients, the high-stakes field of medicine demands the leadership that comes with the education, experience and acumen of a fully trained physician. As part of a physician-led team, though, other health professionals can—and do—help deliver safe and high-quality care to patients.
The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.
In this installment, two AMA members took time to discuss what patients need to know about scope of practice and how physicians are trained to lead the health care team. They are:
- Teresa Camp-Rogers, MD, an emergency physician at the South Central Regional Medical Center in Laurel, Mississippi.
- Scott Ferguson, MD, a diagnostic radiologist in West Memphis, Arkansas, and a member of the AMA Board of Trustees.
“At the AMA, we believe in the physician-led care team,” said Dr. Ferguson. “The person with the highest skill level, the most education, the one who is most capable of taking care of that patient and ensuring quality and safety should lead any health care team.”
Nurse practitioners (NPs), physician assistants (PAs) and other health professionals “are all valuable members of the physician-led team, but a physician should always be at the top of that team to ensure that patients get the very best care,” he said. “The AMA’s truth-in-advertising campaign was designed to ensure that when patients go to see a health care provider, that provider is clearly identified—they're an MD, DO; they're a PA, OD or they are an APRN [advanced practice registered nurse].”
“Whatever their credential is, patients need to know who they're seeing, what their level of training is, and it should always be a physician-led team,” Dr. Ferguson said. “We want to ensure that every patient can see the physician … because 95% of patients say they believe that a physician should be involved in their care.”
“A medical doctor has a doctorate in medical training from a four-year medical or osteopathic school, followed by three or more years of residency training,” said Dr. Ferguson. “PAs and APRNs have only a fraction of this education and training. DNPs—doctor of nursing practice—are APRNs with an additional level of training but it is still far less than a physician and can often be obtained through online courses.
“DNPs often refer to themselves as ‘doctors’ and it is confusing and misleading to patients,” he added. “That's why the truth-in-advertising campaign is so important.”
“We have model legislation for ‘truth in advertising’ for passage on the state level to make sure whenever you go in the room or go to a clinic it clearly states the credentials of the health care providers,” Dr. Ferguson said. “Not every state has passed it. Some of those providers have mounted an effective fight against that.
“Different health care professionals come to the legislature, and they say: We want to expand our scope of practice to include this,” said Dr. Ferguson, who testified “in Nebraska where optometrists are seeking the ability to perform eye surgery with a laser.”
“They'll first come and say: We want to remove foreign bodies from the eye,’” he said. “Then they want to prescribe medications or administer injections in the eye. Then they want to perform laser surgery on the eye.”
“The argument they always make, and one that has a strong influence on legislators, is that passing this bill will increase access to care,” said Dr. Ferguson. “However, our data shows clearly that this is a hollow argument, a false promise.”
“We call it creep because they come back year after year, each time seeking a little bit more. The biggest battles in many state legislatures are around the expansion of scope of practice,” he said. “As we like to say, it’s easier to pass legislation than it is to go to medical school.”
“That’s why it’s so important for physicians to be involved. That’s why they need to get to know their legislators early on,” Dr. Ferguson added. “It’s critically important to do that to prevent scope creep, to prevent health care professionals from expanding their legal authority beyond their level of education and training and to ensure the quality and safety of health for our patients.”
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.
“Scope of practice is determined by the state legislature—it sets the parameters around which health care professionals provide care to patients,” said Dr. Ferguson, adding the state lawmakers “can indicate the type of procedures that someone can do or perform, and whether or not they have to work with a physician.”
“As a former member of the state legislature, I’ve dealt with scope-of-practice issues for 25 plus years,” added Dr. Ferguson, who was a member of the Arkansas legislature where he worked on landmark legislation including “any willing provider,” comprehensive children’s insurance programs, vaccination and immunization, and enhanced medical care for pregnant women, newborns and mastectomy patients. “The legislature says who can do surgery, who can prescribe medicine, who can do physical exams, who can work without a physician by their side.”
State regulatory boards may also get involved, he noted.
“Scope of practice is a term that is used to describe the boundaries of each health care professional’s work,” said Dr. Camp-Rogers. “And those boundaries are defined by education, training, certifications and licensing.”
Additionally, “scope of practice can be applied to the political topic of nurse practitioners,” she said. “The questions that come up with scope of practice of nurse practitioners are: What is NP scope, is there truth in what they’re given privileges for, and how do those privileges match up with what their education and certification is in?
“For physicians, scope matches what we are taught. For NPs, it isn’t clear that their scope matches what they are taught in their abbreviated and unstandardized education,” Dr. Camp-Rogers added.
“That's why medical schools exist. That's why medical boards exist. It's to ensure the training that a physician receives is standardized across the country,” said Dr. Ferguson. “You have to do so many surgeries of a particular type to be certified. You have to read so many X-rays of a particular type. You have to meet the standards that are set by the” Accreditation Council for Graduate Medical Education. This is “something that's lacking in some other health care professionals—that standardization to ensure that you are qualified to take care of patients, qualified to do surgery, to put patients to sleep, to remove foreign bodies from the eye, to see a patient independently, to diagnose and treat,” he said.
“Patients are looking for quality. They come to us and they're looking for care. They generally have a problem that they want fixed,” said Dr. Ferguson. “A scope-of-practice expansion may mean they see someone with lesser training, less able to take care of their problems.”
“Scope of practice is important because of the impact that practicing outside of your scope has on public health and safety,” said Dr. Camp-Rogers. “For example, I am trained, and board certified, in emergency medicine. The limits of my scope are the emergency department.
“It would be unsafe for me to go practice in the operating room because that’s outside of my scope,” she added. “And if I did end up working in an operating room, because of previous, unvalidated experiences, I should be questioned. Someone should speak up and say: Where is the objective evidence that there is competency in that field?”
“This example is analogous to anyone working outside of their training. You can look like you have enough experience, wear the right clothes, if you ask the right questions, and you do it in the right order and say the right things,” Dr. Camp-Rogers explained. “But what’s underneath that is some substantial gaps in knowledge and process that could compromise patient safety.
“It is unsafe for anyone to practice outside their scope because they don’t have standardized training or experience to guarantee safety,” she added.
NPs, PAs and other health professionals pursuing scope-of-practice expansions often argue that doing so will make it easier for patients to get care.
“What’s interesting is that in the states where it has been passed, it has not been associated with improved access to care,” Dr. Camp-Rogers said. “One interesting fact about Mississippi is that even though we don’t have full practice authority, we do have one of the highest concentrations of nurse practitioners in the United States.”
“According to Bureau of Labor Statistics Data from 2020, three of the top ten cities for highest concentration of NPs nationwide are located in Mississippi,” she noted. “This national data conflicts with what the NP lobby is promoting. Full practice authority is not needed to work in a rural state. NPs are here, in droves, thriving.”
“Our AMA has a scope of practice partnership that we doubled the funding for this past year, ” said Dr. Ferguson. “Part of our resources include a geomapping tool. They go to every state in the country, and they say: OK, where do the physicians practice? Where are the nurse practitioners, the PAs, the optometrists?" “We have the data to combat this argument in every state. You'll hear them say: This is to increase care in the rural areas,” he said, noting “they don't go to the rural areas. They practice in the same places that physicians practice.” “People in rural areas deserve the same level of care as people who live in big cities,” said Dr. Ferguson. “We don't need to lower the standard of care just because they're in a rural area.”
“Telehealth is one of the real positive things that came out of COVID,” said Dr. Ferguson. “Telemedicine and the ability to see patients where they are and to do follow up in those areas, that's one of the things that's really going to help us in rural areas.”
“Telehealth is actually important because it’s changed the conversation on the impact of nurse practitioners on access to health care in rural areas,” said Dr. Camp-Rogers. “It has changed it in some ways because you don’t physically have to set up shop in the rural area to reach the patients who live there.”
“It has also created some new conversations with regard to scope of practice and it has been interesting to see how that plays out,” she said. “Telehealth has changed the dynamic in favor of the physician-led team and has taken away a little bit of the steam from the nurse practitioner argument about access to rural health care.”
Nurse practitioners and other health professionals are “integral to our team. We could not function without them. They are strong and they save lives,” said Dr. Camp-Rogers. “They are supposed to be part of the health care team, and they should be here.”
“They are essential to our health care team. They just need to be working with a physician at the top overseeing and coordinating the care that is given, not allowing them to practice independently with no oversight,” said Dr. Ferguson. “And we need to ensure patients know who is providing their care by passing strong Truth in Advertising laws.
“We think the quality and health of our patients is too important to play games with,” he added.
“The way that we do get involved and engaged in the battles that we win is because of our patients,” said Dr. Ferguson. “We need to have patients be our advocates when the time comes, when these battles are fought.” “It's with patient advocacy and with us being more involved in the political process—as distasteful as that may be for some,” he said. “Patient care and safety is going to suffer if we don't make a stand and engage our patients, engage the legislatures to understand the difference in the training, the education, and the quality of care that our patients seek and deserve.”
Table of Contents
- Physicians must lead the care teams
- Why transparency matters
- It’s called “scope creep” for a reason
- Each state is different
- It is defined by your education
- Public health and safety are affected
- Expanding scope doesn’t boost care access
- Telehealth changed the conversation
- Everyone plays a role on the team
- Patients can be advocates too