Dirty Lies, Dirty Airs, Dirty Underwear
The scope creep issue in medicine is a messy mess. A dirty, sordid game of charades that stinks to high Heaven.
I recently read on Twitter a comment by a physician who did not agree with the American Medical Association’s(AMA) hashtag, #StopScopeCreep, which represents their campaign against the infiltration of non-physician practitioners(NPPs) into the practice of medicine. He believed it to be inappropriate and suggested that it could be stated better. Of course he provided no examples, just non-constructive criticism. I am no longer surprised by my virtue-signaling colleagues who are their own worst enemy. Although I am no fan of the AMA, this they got right.
Business and professions codes(BPCs) exist in every state to ensure that various professions remain within their scope and do not perpetrate something or someone they are not. It is particularly relevant in a profession which overlaps with another or those that have different categories of expertise within the same field[ie: paralegals and attorneys, teachers and teacher’s aides, handymen and electricians/plumbers, physicians and nurse practitioners(NPs)/physician assistants(PAs), etc]. It should also be evident that BPCs protect unsuspecting lay people from being deceived or harmed by individuals practicing in a field for which they are neither appropriately trained nor licensed. In other words, BPCs are for the public’s safety. When one “creeps” into another’s scope without the appropriate credentials or training, what else would you call it? The hashtag is apropos and applies to all professions.
What does scope creep look like in medicine? Well, one example is NPs purporting to be “specialists” in areas for which they have received no formal education or training from an accredited body. There are no Urology NPs. There are no Cardiology NPs. There are no Neurology NPs. There are no Neurosurgery NPs. There are no Dermatology NPs. And a new one: Structural Heart NP. Yeah, that doesn’t exist either. The giveaway that this fully-trained NP “specialist” is not qualified is the fact that she needs resources to help with understanding her “specialty”. Nevertheless, she has granted herself an undeserved and non-existent title. See the absurdity?
Folks, there are only NPPs who work in Urology, Cardiology, Neurology, Neurosurgery, etc. There are no legitimate, accredited NPP programs that exist in any of those specialties. Ironically, they do have bodies that certify them in some of those specialties despite not having attended nor received formal training in an accredited program. How is that possible? Money of course–it makes all things possible. There is big money in granting certifications which represent nothing but toilet paper laced in gold ink. Obtain a NP certificate stating one is a “specialist”–no questions are asked nor is vetting mandated. What is even more asinine is that these NPs(and PAs) can then change specialties like one changes dirty underwear, with no one the wiser. And that ability is just as rotten and unethical as the corporate practice of medicine(CPOM). Yet physicians, who are actually trained and licensed to practice medicine, are grilled to the gills and have to produce documentation confirming we have completed a residency and fellowship in those same specialties. You know, so that those hiring us know we are competent. No less than three months of credentialing are required to determine we are not lying and that we did indeed attend accredited programs. God forbid we allow our board certifications to lapse, even after 25 years of practice. Then we are no longer considered worthy to hire or retain. But NPPs, with less training and their freshly “earned” sham s**t online doctorates with questionable “education”, stroll right into whatever department with nary a glance in their direction. In all fairness, PA programs remain competitive and are accredited by one body, the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). However, PAs are not physicians and have no business practicing independently. On the other hand, NP programs, as we know by now, are varied and have inconsistent quality and standards, from competitive programs to entry-level degree mills to programs with 100% acceptance rates. Their schools have two accrediting bodies: the Accreditation Commission on Education in Nursing(ACEN) and the Commission on Collegiate Nursing Education(CCNE). Most of the degree mills are accredited by the CCNE who would accredit an ingrown toenail if it came with a pulse and a checkbook.
For the record, no physician specialist can proclaim a NP or PA working under him/her a specialist simply because they trained them. Why? Because no physician is an accrediting body in and of him/herself. They are simply a doc in a specialty teaching someone untrained or minimally trained in medicine what they know…without the one in training possessing a solid fundamental medical foundation on which to build. So the training is only as good as the physician, with nowhere near the quality. We know apprenticeships don’t work–if they did there would have been no need for the Flexner Report, and those were actual physicians being apprenticed. So how can a physician then apprentice a NPP, with limited to no medical knowledge, well enough such that they can then be considered a specialist in their own right? THEY CAN’T. They just think they can. No doc exists that is that good. A physician alone also cannot determine the clinical competency of NPPs–because they aren’t nurses or PAs. In addition, there have to be objective, LEGITIMATE exams that evaluate nursing/PA competency; not tests developed subjectively by some random hospital program, department or individual. But that is exactly what is happening today. And it is a vile, farcical practice because it lends validity to the invalid. Yep, NPPs are trained by doctors who send them to function on their own with only notional supervision, allowing them to perform initial consults on patients referred to the specialist by another physician because they require a higher level of care. How is that a higher level of care? IT ISN’T.
The irony is that for NPs, every state Nursing Act mandates they remain within their scopes of practice. IT’S THE LAW. It is the responsibility of each state’s Board of Registered Nursing(BRN) to enforce those laws that apply to NPs. Even in FPA states like Arizona. Physicians have no authority to supersede that law.
The controversy over scope creep has escalated because it is wrong and docs are sick of witnessing and repairing the damage while taking the fall for those “practicing” bad medicine. But what exactly does anyone expect to happen when those with minimal to no training in medicine are permitted to practice it independently? Exemplary, exceptional care? When will enough be enough? Physicians, NPs and PAs were never meant to be one and the same. Never. This forcing a square peg into a round hole is not in the best interest of patients–it is unconscionable and potentially illegal. There are indeed NPPs who could give two s**ts about violating scope of practice laws because they expect no repercussions because there will almost always be some physician or hospital system who will be sued on their behalf. In addition, the CPOM, backed by the putrid Cartel of private equity, provides the perfect platform for them to continue their deceit unencumbered. Since most employers and physicians don’t know or understand NPP SOP, particularly for NPs, they just believe what they are told. They verify nothing nor are they compelled to do so. Or worse, they just don’t ask because they don’t want to know. Their only motivation is profits. That ignorance and greed enables NPPs to engage in unethical practices while docs, as usual, own the majority of the liability, whether they are aware or not.
Here’s the deal folks, it is not ok to break the law. “Scope creep” is a perfect term for the intentional sleazy, slimy, insidious, immoral and illegal behavior to perpetrate a profession in which one is not qualified. It needs to end. The American Association of Nurse Practitioners(AANP), the American Academy of Physician Assistants(AAPA) and the American Association of Nurse Anesthetists(AANA) initiated the enmity when they decided their care was equivalent to physicians while denigrating our education in an attempt to elevate their positions–purely inspired by greed and a misperceived prestige. Because physicians are notoriously passive and non-vocal, these offenders expected no reaction to their objectionable actions. They were wrong. They woke a sleeping bear. Additionally, they demand respect while they give none. NPPs insist they want to work in teams when their actions indicate otherwise. Full Practice Authority(FPA) and Optimal Team Practice(OTP) are completely antithetical to the team model. And thus began the battle to protect patients. Instead of improving their education or just going to medical school and completing a residency, predatory NPPs guffawed and humped their way over to legislators, individuals typically uninformed and uneducated about health care in general, to assist them in legally perpetuating the fraud. They then had the audacity to expect physicians to become duplicitous in these reprehensible acts and accused them of being unsupportive when they weren’t. This nonsense is preposterous and as nasty as soiled underwear which, along with FPA, OTP, PE and the CPOM, needs to be thrown into the wash. With double bleach. Then burned to ashes. The stench will be unbearable, I know. My hope is that over time, when the Cartel and Pimps get booted from our domain, the funk will dissipate and the residual ashes will be swept out of the House of Medicine. That time won’t come soon enough.
In this vicious fight against scope creep, I leave you with this quote:
“You must never be fearful about what you are doing when it is right.”–Rosa Parks
I had a good professional relationship with the N.P. who collaborated with me. When the practice started talking about using them as “practice extenders” eons ago some docs were o.k. with it, some weren’t . I was easy going and like, “What the hay.” I had one and she was with me for 22 years. She retired before me as she was older and I still get a homemade fruitcake her mother bakes every year! Her biography was a wild ride and she said she saw me work when she was a student though I don’t remember it. Told me later that’s when she decided she wanted to work with me.
The thing about it is the so-called “easy cases” were shunted to the N.P.’s which you know taking care of sore throats and ear aches is not rocket science. It left the more difficult medical problems ie. takes more time to deal with, to the doctors. So instead of having “easy cases” interspersed with hard ones, the docs had all hard medical problems to deal with.
Well, I didn’t complain and just went on with it. My N.P. shared two exam rooms next to mine and would grab me whenever she had a problem. In fact whenever she came after me I thought to myself, “Oh crap, now I know I’ll have to really think!”
In our practice, the N.P.’s had a supervising doc and didn’t have hospital privileges. Worked o.k. for us.
Now I do remember that the surgeons had R.N.s that worked closely with them and scoped out their patients before they made rounds. The surgeon would dictate to them their progress note and their nurse would hand write it into the chart!!! Later with computerized dictation, the surgeon had to do their own notes!
Using N.P.s as physician extenders is what it should be about as I describe above. Giving them independent practice privileges, well the malpractice attorneys will put the kibosh on that soon enough. The “independent” N.P.s will have to get their own malpractice insurance as their mistakes can’t be smashed onto a supervising physician.
One can say it’s hard to screw up with an office practice but we’ll see!
Kurt
As an American physician, I have great interest in technology, science, and its societal ebb and flow. We seem to be entering a cultural period similar to the post-Roman dark ages in several areas of analogy.
It puzzled me how the inevitable progress of technology could not only slow, but reverse, so that useful things are forgotten, and the apparently relentless path of methodological progress might slide backwards.
A very readable book by Joseph Teeter of Utah State University, The Collapse of Complex Societies (New Studies in Archaeology) which was published thirty years ago, remains current, and fascinating, “clarifying the processes of disintegration by detailed studies of the Roman, Mayan and Chacoan collapses.” Jared Diamond also offered the more readable Collapse: How Societies Choose to Fail or Succeed
Cultural taphonomy, then, is analogous to the pathologist’s charge – to see what mortal interruption in social processes lead to the civilization’s demise. These two cited authors explain their theories with much more richness than I can.
American culture has replaced the question of how we can make the future brighter, for the anticipation that whatever leadership we choose to follow will grant us great things in the future. We simply need to agree to make America great again, and those who know how will do so. This seems to be a common thread in declining societies, a slide from the maturity of adulthood into the impetuousness of childhood.
There is no longer any wish to make healthcare improve in the future; instead, we see a deep mistrust whether Leader Fauci and the magic factories of Pfiser, Merck etc., have our best interests at heart.
Provision of good medical care is near the apex of the pyramid of civilization. If we can no longer support the actions needed to operate the basics of a civilized society, it’s no wonder that we cannot handle problems at the apex. It is usually at such times that we see the degradation of the more complex elements, substituting a cheaper, inferior substitute for the previous, and claiming that nothing has changed.
Rarely if ever does a complex society fall from a bolt from above, an asteroid or earthquake blasting it to smithereens. Far more frequently, societies have fallen from well-documented changes that are recognized as potentially devastating to the society, ones that are discussed and analyzed, and about which nothing is done. Teeter’s description of the Mayans comes to mind.
21st American society cannot even act on the clear threats to basic function. In such an environment, medicine is a canary in the coal mine. Any study of third-world healthcare will see many foreboding analogies to the United States, with one exception – the third world is aggressively struggling for a better future. We are allowing national retail pharmacies to become the new clinics and hospitals of the future for us and our children.
Scope creep is merely the tide coming in over the wreckage.