AMA graphic.
Wearing a stethoscope is OK even if the scoper is not a doctor. But do they really know how to use one? The same applies to white coats.
AMA:
Physicians and non physicians: What are the differences:
Nonphysician providers such as nurse practitioners and physician assistants are an essential part of the physician-led care team and can help health care organizations and physician practices deliver high-quality care.
But it is easier than ever for patients and the public to get confused about who does what in health care, and mixed up about what distinguishes the training and skill of physicians from those of other health professionals.
That is especially the case given the relentless efforts to expand the scope of practice for non-physician providers—dubbed “scope creep.” Such legislative or regulatory changes would inappropriately permit nonphysician providers to deliver care without doctor supervision, which can increase patient safety risks and health care costs.
AMA: Dermatology, emergency medicine and anesthesia are just three specialty areas in which undermining physician-led care is endangering patient safety.
Feb 15, 2024
AMA: Attempts to inappropriately expand scope of practice for non-physician providers are taking root well beyond the clinic walls of internists and family physicians. Now specialists are hiring more “mid-levels.”
Nurse practitioners (NPs) and physician assistants (PAs) seek more independence in practicing in emergency departments, dermatology clinics, anesthesiology departments and beyond.
Blogfinger: I have been alarmed by the way that doctors are being shoved to the side by corporate efficiency experts who want to substitute “mid-level” healthcare providers for physicians so as to reduce the cost of services. *I have seen such providers impersonating doctors by giving patients the impression that they are the same as doctors. And hospitals and office practices are complicit in this sort of deception. Such providers may not explain to patients about their actual level of training. Their identifying name tags may be purposely unclear.
AMA:
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 non-physicians 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 non-physician 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.
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: AMA
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.
Blogfinger. Some of you might be seduced by the idea that a “mid-level” can do what a doctor can. At times it is so for some obvious, non- acute situations, but the real concern is about a patient whose true diagnosis is not obvious and when the wrong diagnosis by a “mid-level” leads to the wrong pursuit of the truth and then ultimately to patient worsening or even death. And the excess use of tests by mid-levels drives up the cost of healthcare, not down.
These “mid-levels” pursue care using triage algorithms. (cut and paste methods) that they learn.
They never acquire the insightful experience that fully trained physicians receive over years of training. Doctors develop a way of thinking and performing that cannot be reduced to “cut and paste” instructions. They learn to envision differential diagnoses that guide them deeper into clinical problems.
I saw a case* recently where a man came to the Jersey Shore ER with knee pain and swelling. A “doctor” came in wearing a white coat. He did not explain at first that he was a physician assistant. He did not know that I, standing by, was a real physician. He was pleasant, but he failed to review the patient’s medications (which were key in this case) and past history, and he failed to ask critical questions required for a correct diagnosis. He also performed a superficial and sloppy physical exam.
He mishandled the case by failing to properly assess the patient. And he wasted time and money by ordering a useless X-ray.
The patient was saved by a specialist’s attention in the ER.
Increasing the scope of practice for mid-levels is a movement that is being energized by shortages of physicians and nurses. The motive is to have more doctors and nurses, but accepting an alternative that is less skilled will cause a decline in quality.
It takes years to develop a med school whereas mid-levels get “trained” at all sorts of facilities. Med schools only turn out 100-200 doctors each year.
Hackensack-Meridian has a recently opened medical school, but I have no information about them. They used to be affiliated with Seton Hall University but evidently that is over.
LIONEL HAMPTON “A Foggy Day.”