Hey Creep: Patients Deserve Care Led by Physicians

So, who hasn’t seen the recent tweet by the American Medical Association (AMA) (1)? So, is it “scope creep” whereby the creep is a shady person, and those who want increased scope are creeps? Or is it “scope creep” analogous to role appropriation of one discipline encroaching on another discipline? I’ve written many blogs on the notion of disciplines crossing lanes into other disciplines and disciplines trying to fill shortages in other disciplines. It’s getting frustrating. But as a former member of the nursing profession, I found it to be a systemic problem within the field of nursing. From my experiences as a RN then NP, I’ve seen it at all levels within the nursing profession. It’s well known in the nursing profession that nursing has an identity crisis at all levels. The following doesn’t apply to all members of the following nursing levels, but some nonetheless. This is “scope creep” and where it starts in nursing: Some certified nursing assistants (CNAs) believe they can do everything a licensed practical nurse (LPN) can do. Some LPNs believes they can do everything an associate’s degree (ASN) RN can do. Some ASN RNs believes they are equal to the bachelor of science (BSN) RN. Some BSNs believe they are as educated and equal as the master of science (MSN) RN. See that right there? RN’s can be RNs with an ASN, BSN, or MSN. I always found this odd. Then some RN’s themselves believe they are equal to the nurse practitioners (NP). It makes sense that it follows in suit that there are those NPs who believe themselves on par with physicians. Especially the ones with the doctor of nursing practice (DNP) degree. It’s been bred into the discipline. With the DNP NP, they have run out of higher-level nursing personnel to emulate, so it makes sense that the projection is onto physicians. This is “scope creep.”

            When I was in the military, there was an expression called “mission creep.” No, military personnel are not creeps! Mission creep is defined as “a gradual shift in objectives during the course of a military campaign, often resulting in an unplanned long-term commitment.” Mission creep is the gradual or incremental expansion of an intervention, project or mission, beyond its original scope, focus or goals, a ratchet effect spawned by initial success. Thus “scope creep” seems to be the gradual shift of scope of practice of one discipline through legislation into another discipline scope of practice. Well, why wouldn’t physicians be upset? I mean others are trying to break into our house without asking, and we get criticized when we become upset. Then when we push back, we are subject to vitriol, doxing, called names, accused of fear mongering, accused of being high and mighty, and the wrath. Interesting that because in psychology 101, I learned that the extent of emotional responses, for example to a tweet like this, can be correlated to the extent of truth in the thing being purported. In other words, the anger and defensiveness being seen in the comments section correlates to the truth of the picture. There is “scope creep!”

            I have nothing against mid-level providers. Heck, I use to be one. Enjoyed my time as an NP. Enjoyed being on some of the best physician-led teams as I believe it should be and was meant to be. I had the rare privilege of being an inpatient NP on a unit where there was a physician residency, and every day was learning, research, and expertise. I was in awe, and this is what inspired me to go to medical school. Why wouldn’t I enjoy and savor the collaborative, expertise, and/or supervisory relationship with someone with a higher level of education in the discipline I was ‘creeping’ in to? The tweet references an AMA position paper (2).  The paper states “Patients deserve care led by physicians—the most highly educated, trained and skilled health professionals.” To this, I agree. The paper also states “A persuasive argument in scope-of-practice battles has been the differences in education and training. Physicians complete between 10,000 and 16,000 hours of clinical education and training—four years in medical school and another three to seven years of residency training. By comparison, NPs, for example, complete between 500–720 hours of clinical training during two or three years of graduate-level education.” But think about it, apples and oranges. Why wouldn’t when I was an orange doing the work of an apple not accept the apple’s expertise and collaboration? Only a fool would try to be an apple, do the work of an apple as an orange with training in orange theory and not accept the apple’s lead and expertise? I’ve blogged about this concept of fruit before (3). Somewhere there is a quote, I can’t remember from who, but goes something like this “do not correct a fool or he will hate you. Correct a wise man and he will appreciate you.”

Health care is a team effort, and all members of the team play a vital part, but logic dictates that the captain of the ship is the one with the most expertise. I’ve blogged about this before too (4). I can assure you, I am not anti-midlevel provider, I’m just pro-truth and pro education. Being teachable is a mark of wisdom. But hey, don’t listen to me. What do I know? Listen to Mother Teresa “keep the corners of your mouth tuned up. Speak in a low, persuasive tone. Listen; be teachable. Laugh at good stories and learn to tell them… for as long as you are green, you can grow.” Now I’m sure the hate will spew in response to this blog. But don’t hate me. I’m just a messenger. Here’s the facts:

References:

  1. https://twitter.com/AmerMedicalAssn/status/1322342527287070722
  2. https://www.ama-assn.org/practice-management/payment-delivery-models/scope-practice-how-ama-fights-patient-safety?utm_source=twitter&utm_medium=social_ama&utm_term=4031857228&utm_campaign=Advocacy&utm_effort=FBB009
  3. https://authenticmedicine.com/2020/09/fruitology-in-california-the-doctor-is-out/
  4. https://authenticmedicine.com/2020/09/liar-liar-pants-on-fire -joint-statement-on-the-role-of-advanced-practice-registered-nurses/

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