Opportunistic Infection: How to expand the APP role in a crisis

So, this article pops up on social media recently (1).  It is disappointing that my former profession is using this coronavirus pandemic crisis to manipulate into expanded roles that may be out of bounds of their education and scope of practice. 

Before the pandemic crisis, evaluation visits by the advanced practice provider (APP) would have been reviewed on the same day by the supervising physician through an in-person encounter with the patient.

This is the quintessential Physician-led healthcare team with which I have practiced as a former APP and that I agree with. This is what the role of the APP was intended. The article then goes on to reference a healthcare organization changing the protocol to where “the attending physician can fulfill a requirement for seeing the patient within 24 hours during rounds the following day.” This is actually in keeping with the Physician-led healthcare teams model provided the physician is available. Although some of my colleagues will debate the appropriateness of this change. The only difference I can see so far is the timeline with which the attending physician sees the patient. I’ve actually practiced under this model too and it works fairly well. 

            Where I have a problem with the article (not the article itself, but the content) is where the manipulation starts:

These protocols point toward future conversations about the limits to APPs’ scope of practice, and whether more expansive approaches could be widely adopted once the current crisis is over, say advocates for the APPs’ role.

            It reminds me of the phrase “give an inch and they will take a mile.” This is where I draw a parallel to the opportunistic infections. The opportunists will stop at nothing until full practice authority (FPA) is attained for all APPs. Even when I was an APP, I was all for Physician-led healthcare teams. Having seen firsthand the difference in education, depth and breadth of teaching content, and licensing (physician) vs certification exams (APP), I can’t in good conscious advocate FPA for APPs as a good thing. On the contrary, a Physician-led healthcare team works better. It kept me sharper, safer, and more cautious to be accountable to someone who had more expertise and experience than me. The militant members of my former profession will now likely stand up and shout obscenities and attack me for saying this: I knew my lane and stayed in it. 

            The article unknowingly provided an example of why there needs to be Physician-led teams. If I presented a patient with respiratory symptoms and suspected COVID without a respiratory physical exam as an APP, a med student, or now as an MD, I’d be negligent and excoriated:

“listening for lung sounds with a stethoscope has not been shown to alter treatment for these patients. Once a chest X-ray shows structural changes in a patient’s lung, all lung exams are going to sound bad.”

            To be fair, the article point on the above quote was to limit the amount of in person contact with a suspected COVID patient, but any physician would be held to a different standard. Even if the person is suspected COVID, the differential diagnoses on shortness of breath and fever is very long. But this still doesn’t stop the opportunists:

“the experience with the COVID crisis could help to advance the conversation about the appropriate role for APPs and their scope of practice in hospital medicine, once the current crisis has passed. “People were used to always doing things a certain way. This experience, hopefully, will get us to the point where attending physicians have more comfort with the APP’s ability to act autonomously,”

            More comfort??  I’ll leave it right there. 

References:

  1. https://www.mdedge.com/chestphysician/article/222031/coronavirus-updates/how-expand-app-role-crisis?channel=63993&utm_campaign=NewsBrief&utm_source=hs_email&utm_medium=email&utm_content=88026497&_hsenc=p2ANqtz-_oaJz6khi-c6kRo7cvGuEQwXV_kySfkS9b2Z7OglbrrVt2PT-T-oHMZIqMSzAoFAsXzTveuyYa96zAi72bRoSVzi_-ng&_hsmi=88026648

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Robert Duprey MD

Robert is a 2nd career physician (MD); a combat Veteran with the US Army; a former psychiatric nurse practitioner; an independent researcher; a medical writer; and now having passed USMLE Steps 1, 2CK, 2CS, and 3, is a residency applicant.

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1 Response

  1. Jesse L Belville Jr,PA-C says:

    Thank you,thank you. Dr.Duprey,MD
    I advocate for PA-C’s to be PA-C’s with supervision by a Physician. Same for NP’s. MD or DO supervision the health care team.. APP’s there to take care of routine cases, so the MD or DO can handle the more complicated people in his or hers practice..
    I practiced independently in a remote site for a time, still do at times in rural Health but I ALWAYS have an MD/DO to call or immediate referral too if needed. If in doubt I refer. I err on side of caution to protect my patient,MD,facility and me.
    If I wanted independence I would have gone to Medical School,not PA school.. If
    you want independence go to MED school. Become an MD,not a PhD,
    Tremendous difference in training, focus and outcomes.. Course big EGO’s in all areas but a few years in practice with knock that out of you. If it does not get out of practice and go do research. You will hurt someone as well as yourself and the profession we all love.
    I am a PA-C for 44 years,still practicing,still having FUN and under supervision.

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