Scope of Practice

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This is an older article but one that bears highlighting.    In State Considers Changing Non-Physicians Scope of Practice:

  • California lawmakers are considering expanding the scope of practice for non-physicians in an effort to address a shortage of doctors to treat individuals who will gain health insurance coverage under the Affordable Care Act.
  • Sen. Ed Hernandez (D-West Covina) — chair of the Senate Health Committee — plans to offer legislation that would allow physician assistants to treat more patients and nurse practitioners to establish independent practices. It also would allow pharmacists and optometrists to act as primary care providers and diagnose and manage certain chronic conditions. Hernandez questioned what good expanding health care coverage is if patients “are going to have a health insurance card but no access to doctors.”

I am not going to beat the same dead horse about my feelings on competing (instead of collaborating) with midlevels.  The point here in this piece is how politicians can use information and spin it any way they want.   The fact that Hernandez, a democrat who I guarantee pushed for Obamacare, now questions what good is it if there are no access to doctors?  Are you kidding me?  Unfortunately, Mr. Hernandez, life is not like the movie Field of Dreams.   You know, build it and they will come.  But, I believe he knew this all along.  And the goal was to expand the scope of midlevels all along.   And the AMA and AAFP and many of us doctors were suckers to believe otherwise.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  7 comments for “Scope of Practice

  1. Bridget Reidy
    December 16, 2013 at 3:24 am

    Of course some meds would be safe for a pharmacist to prescribe, but who is going to diagnose? Are all red eyes conjunctivitis? If you think asking a patient if they have asthma or a patient having been given an inhaler before is a good way to find out they have asthma, you know nothing about the complexity of good primary care. Safe meds for conditions there is no risk of getting the diagnosis wrong should be over the counter, where the patient has only themselves to blame if they find out they wasted their money on something they didn’t need. I see no reason why someone who doesn’t diagnose should prescribe. And knowing the side effects of a medication doesn’t make you able to tell someone else to stop a medication either; determining a symptom is a side effect and not a disease or a red herring also requires the ability to take an excellent history and diagnose.
    I don’t know any reason not to have pharmacists dose coumadin, but I always wonder why they are so eager to perform this unreimbursable service. Is it a foot in the door kind of thing, or do they have a lot of spare time on their hands? Like any service, if it needs doing it should be paid.
    There is no shortage of primary care to do things that pay well, like antibiotics for viruses, which I’m afraid is a lot of what these midlevels are doing. If we all stopped treating colds and otitis, give back pain to the chiropractors and message therapists and PT’s, and use opiates and benzos only when necessary, do only the prevention that’s proven, and quit trying to get lipids to target, I think we’d find lots of time to do what is needed. All we need is a payment system that rewards us for doing that. If we charted only what was necessary and/or got rid of EMR’s, we could double our productivity. Maybe if the EMR didn’t have a “med list” that wasn’t anything like what the patient takes the nurses would go back to obtaining a real med list for us. Gee maybe we could have a team of people to fulfil all the requirements of the “insurance company centered medical home” and just have the doctors practice medicine. Maybe midlevels could be in the team, and we could guide them in doing the simpler and/or more repetitive stuff and patient education, and we could help them keep abreast of the science, and maybe even have some supervisory authority to encourage them to use it. Wasn’t that supposed to be the idea?
    I don’t mean to blame all midlevels or even some. Too often they actually learned this stuff from MD’s. But I still think if we MD’s took (or were allowed to take?) our supervisory role more seriously, eventually they’d get it from being exposed to good ones at some point.

    • Doug Farrago
      December 16, 2013 at 8:48 am

      Brilliant

  2. Ray
    December 10, 2013 at 6:21 pm

    Disagree Ellen, to say that pharmacists and mid levels are better than nothing is pathetic. The “standard of care” is what all physicians are measured against in a court of law and public opinion. Point being is that there is a standard. The administration, 3rd party payers, and organized medicine need to step up to the plate and support the training and more importantly the compensation of primary care physicians. As medicine has become more and more specialty driven, the number of medical students entering primary care has diminished. I train medical students in my primary care office. I ask each and every one why or why not primary care? They always state that their students loans prevent them from entering what they think is a vital piece of the health care system. Re-imbursement, and salary are the main drivers of the specialty selection process. They graduate after 7-10 years of medical training (post undergraduate BS degrees), with upwards of $300-400,000 in student loans. It is a no brainer. Primary care makes no economic sense. Unfortunately, without primary care doctors you are settling for an inferior product with long term consequences for our patients, the health care system and our economy.

    • JRDO
      December 10, 2013 at 10:18 pm

      “It is a no brainier, primary care makes no economic sense”. I think that supports Ellen’s position. The authors of Authentic Medicine appropriately are physician advocates as apparently are most of the commenters. Unfortunately sometimes being a patient advocate, as Ellen is seemingly trying to be, is at odds with physician interests. Realistically, primary care is likely to remain an unattractive choice for many medical students for all the reasons you mention. I would rather have my family member’s Coumadin and hypertension be monitored by a PCP, but if that is not possible I would prefer an independent mid-level provider to no monitoring at all. Btw, it is a bit off topic, but what do you think of primary care docs who increase revenues by employing mid-level providers rather than adding another doc to the practice? Also, have you ever been involved in a malpractice case that went to court? “Standard of care” is a joke- it is best defined as what a lawyer can get the jurors to believe. There is no authoritative holy book or consensus as to what the “standard of care” is for legal purposes.

  3. Pat
    December 10, 2013 at 9:11 am

    Hernandez, Obama, Gingrich, the killer AMA/AAFP’s et al always take the same approach – just tell people what they need, pass what you want no matter how nonsensical, and the targets and tools of your wisdom will simply buck up and adapt to your new guidance. That’s exactly what this ass is saying.

  4. Ellen Luse RPh
    December 10, 2013 at 6:03 am

    In areas of the country where the closest physician is 50+ miles away, pharmacists have monitored diabetes and anticoagulant therapy for some years. We’re quite capable of that as long as the diagnosing physician and the patient are in agreement. In fact, it has been shown that the more accessible we are, the better the patients do. Why not make use of that capability to lighten the load of today’s harried physicians and improve patient care?

    • Sir-Lance-a-Lot
      December 11, 2013 at 2:04 pm

      I agree with you, Ms. Luse, to the extent that every category of medical care provider should be allowed to do what he was trained to do. I should not have to ask the RN to check the patient’s other meds and allergies before giving a shot. They should be able to do this, consider the information, and tell me if something doesn’t seem right. Similarly, they should be able to tell the patient what to do for his constipation without me writing a list, or administer a vaccination, after determining that it’s not contraindicated, without a specific order. Pharmacists should be able to give the patient amoxicillin tablets instead of capsules, if that’s what the patient wants, without calling me, and should be able to look at a patient’s med list and suggest a rational replacement for a BP med that’s giving them problems. I also think they should be able to prescribe a few meds themselves, such as an albuterol or ipratropium inhaler, or maybe gent. gtts for conjunctivitis, or Diflucan for a yeast infection. I’d rather not see them managing complex diseases, such as DM and HTN, as you need real visits and exams to do those correctly, and bad things could slip through the cracks.

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