I'm Not a Doctor

A second opinion on the challenges and opportunities facing today's physicians.

Blog: Stirring the pot in the scope-of-practice debate

10:15 am, Sep. 26

Predictably, the doctor-nurse scope-of-practice turf battle reignited after the American Academy of Family Physicians issued a report that said, essentially, nurse practitioners and other healthcare professionals play vital roles in team-based care that's provided under the patient-centered medical home practice model—but the team needs to be led by a physician.

The American Academy of Nurse Practitioners, in response, issued a statement declaring the AAFP to be "misdirected and out of step with today's environment."

The extra education physicians receive is at the heart of the debate, but Tamara Zurakowski, a practice associate professor at the University of Pennsylvania School of Nursing, said in response to the AANP's reaction: "A nuclear physicist knows a great deal more about the production of electrical energy than a licensed electrician does, but when I need the wiring in my house fixed, I don't hire a physicist."

Though it was the AAFP that fired the initial salvo—and then took the heat for doing so—it should be noted that the AAFP news release included words of support from the presidents of the American Academy of Pediatrics and the American Medical Association and the executive director of the American Osteopathic Organization.

"The AMA and AAFP recognize that the physician-led team approach to care is key to ensuring that patients receive high-quality, cost-effective care, and most Americans agree," Dr. Jeremy Lazarus, president of the AMA, said in the AAFP release.

But while the doctors have a unified front that the medical home must be physician-led, none of the groups that certify practices as medical homes have physician leadership as a requirement for recognizing an organization's medical home-ness.

The National Committee for Quality Assurance, the Accreditation Association for Ambulatory Health Care, the Joint Commission and URAC all say an organization can provide the attributes of a medical home—such as care coordination and enhanced patient communication—without the presence of a physician.

"We remain neutral," said Marsha Wallander, associate director for accreditation services for the AAAHC. She added that—as long as the organization's state allows it—a physician-less medical operation is eligible for AAAHC medical-home accreditation. The answer was the same from the other organizations.

While the AAFP and the AANP were arguing, on Sept. 22, California Gov. Jerry Brown signed into law a bill (PDF) that allows registered nurses to dispense and administer hormonal contraceptives and permits RNs to dispense drugs and devices upon an order from a certified nurse-midwife, a nurse practitioner or a physician assistant.

"With his signature, the governor also took action to address provider shortages statewide by allowing RNs to work to the full extent of their scope and training," Julie Rabinovitz, California Family Health Council president and CEO, said in a news release. "This is especially important in our changing healthcare landscape."

I get the feeling that the debate on scope-of-practice issues is not going to cool off soon and is, in fact, just warming up.

Follow Andis Robeznieks on Twitter: @MHARobeznieks.


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