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:
- https://twitter.com/AmerMedicalAssn/status/1322342527287070722
- 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
- https://authenticmedicine.com/2020/09/fruitology-in-california-the-doctor-is-out/
- https://authenticmedicine.com/2020/09/liar-liar-pants-on-fire -joint-statement-on-the-role-of-advanced-practice-registered-nurses/
The AMA tried to suppress the scope of practice of DOs before too. They also don’t help the physician shortage with their power to accredit (or limit) accreditation to medical schools. Lastly, “mid-level” is a completely misleading, made-up term used in attempt to degrade NPs and PAs. The evidence does not back up the AMAs claim that NPs and PAs are not as safe as physicians. In fact, the evidence shows that NPs and PAs give comparable care (whether you like it or not) with comparable and sometimes better outcomes than physicians. I’m not asking to do brain surgery here, but I’d like to help more people have access to timely, quality health care.
Wrong. Read all the articles here on this site. Those studies are bogus.
Thank you!
Over the 43 years since I received my BSPT (Bach.Sci./Physical Therapy) degree, mission creep has been on the agenda. The BSPT has branched out into PTAs, MSPT clinical with extra training in a subspecialty, MSPT where you get a degree in something like chem or bio first, then the traditional BSPT curricula, and now it’s hard to find a school that lets you out with anything other than a DPT. I know some DPTs who have more knowledge and expertise in addressing specific parts of the body than I did, but I also know a lot who don’t know as much as a BSPT who has been out working in the field for 30 years. In my retirement I’ve done transcription for various PT clinics, and there’s only been one or two PTs I transcribed that knew how to pronounce most drug names.
When I worked as a PT I didn’t want the responsibility of ruling out the kidneys being responsible for the back pain a patient experienced. I wanted an MD/DO to diagnose the condition, any comorbidities and then refer the patient to me if indicated.
Very true.
I am a Physician Assistant for 44 years now. I love what I do and I enjoy being part of a team.Me and my Supervising Physician. So much to learn so much to do. I will keep fighting my fellow PA’s who push for mission creep. Many have no experience as RN,lab tech xray tech, EMT or Paramedic. Just school. Takes them 3 to 5 years of SUPERVISED work with increasing levels of responsibility to become Good PA’s. That is my observation and many get very scared about it.Most interesting to watch. It is what I expected would happen as is the “mission creep”. Keep fighting for the right.
Thanks Dr Duprey! Excellent post and oh, so true – unfortunately.
Workers comp is especially funny (and I do not accept their insurance anyway- the only way they get in is if employer pays my usual fee and i do not file any paperwork other than a superbill which they can keep as a receipt). In the spirit of efficiency (cost cutting) all patients are pre-screened by an NP at a clinic they have a contract with. Any of you guys out there who would go to an NP for anything much less an eye injury???? Heck I have seen patients who have seen a real ER physician in the ER and unfortunately the doc got in over his head.
A lot of this “mission creep” is promoted by insurance companies because mid-levels are agreeable to working for discounted fees. Again the funny thing is if they bill the insurance companies, they are paid by CPT……and CPT does not care about quality of service or experience of provider.
You are a little low on your range of trading hours. Many surgical specialists have greater than 40,000 hours of training including cardiac surgeons, plastic surgeons, and neurosurgeons.
As a surgical specialist I trained in the ’80s with four years of medical school and seven years of residency I put in greater than 40,000 hours of training. I get competition from specialties with far less and relevant training that take a weekend course and claim they are as good. I get competition from people with fake boards that somehow confuse the public and actually claim they are better because some of my training was reconstructive. Now we are seeing nurses that can afford tuition for a nurse practitioner program with no pre-qualifications or academic ability also compete. These people have literally 2% of the training I have and claim they are equivalent. We are back to medicine of 1890 and the buyer beware.
I am a DNP student in my 5th and final year. I have been an RN in Oncology and Psychiatry for 6+ years (I also have a BA in psychology). I am required to have a minimum of 1500 hours of clinical experience in the schooling program and will likely finish with over 2000 hours; my years of experience as an RN should not be discounted, as many PA and Med students go into their programs without any clinical experience whatsoever. I am not invalidating the concerns and expertise of the medical profession, however, clinical experience in all settings can be essential in understanding the myriad of ways that illness and dysfunction manifests from person to person (and should be considered in this argument).