In your words

Scope of practice expansion: Patient safety sacrificed for greater access

There are no shortcuts to educating highly skilled, competent, and qualified physicians.

Editor’s note: This story was originally published by KevinMD.com and has been edited for The DO. It has been reposted here with permission. This is an opinion piece; the views expressed are the author’s own and do not necessarily represent the views of The DO or the AOA.

When a patient seeks the care of a professional, they expect that person to be well-trained, experienced, and constantly continuing their education.

As an ophthalmologist, I completed a four-year undergraduate program at Virginia Commonwealth University, four years of medical school training at The University of North Texas Health Science Center, a one-year rotating internship, and a three-year residency program in ophthalmology at Tulsa Regional Medical Center.

After becoming a physician, I studied for, and passed, a rigorous didactic exam followed by an oral exam. Finally, once I submitted my first year of surgical cases for review and approval, I became board certified in ophthalmology. Participating in the requisite continuing education process enables me to remain on the cutting edge, and best serve the needs of my patients.

The years of hard work necessary to become a physician are well worth it. With the exceptions of my marriage and my two wonderful children, serving and helping patients as a practicing physician is my life’s greatest privilege.

The job of a physician is to provide the highest quality care to patients while fostering a relationship based on trust. There are serious consequences for the health of our patients if that standard is eroded and compromised by well-intentioned, but misguided, interest groups and politicians.

Our health care system is a complex tapestry of players who have specific roles in patient care. Regrettably, the federal government and many state governments are attempting to “fix” the already complicated and overly burdensome system beyond reasonable and safe limits, and they are considering some outlandish possibilities.

Life-or-death legislation

An idea being discussed here in Virginia is giving pharmacists the ability to practice medicine. One can see the thinking: Why can’t a pharmacist just give someone a flu test and Tamiflu if a patient suspects that they have contracted the influenza virus? While this is a great sales pitch for pharmacists seeking a new revenue stream, any physician would find such a question absurd. When legislators ask, “What’s the big deal?” it is no exaggeration to say “life itself!”

According to the Journal of the American Academy of Pediatrics, “rapid influenza tests had an overall sensitivity of 63 percent.” That means that patients may get a false negative reading 37% of the time. According to the CDC, “the positive and negative predictive values vary considerably depending upon the prevalence of influenza … in the patient population being tested.”

While it isn’t obvious to politicians, testing and diagnosis of the flu are complicated. A physician is trained to look beyond a test result at the other presenting symptoms and a patient’s history. A physician is trained to draw on their broad base of knowledge of other mimicking diseases and co-morbidities of the patient. A pharmacist may just see the negative test result and feel justified in withholding treatment. This is a potentially life-threatening oversight.

In addition, when a patient has the flu or other illness, it often is their point of entry to the primary care physician. Too many patients put off health care until they are sick, meaning that patients who come into a doctor’s office for a possible minor ailment may also have been living with hypertension, asthma or other untreated chronic illnesses. A pharmacist is not trained to diagnose or treat these conditions.

Limiting patients’ access and point of entry to a primary care physician by increasing the scope of practice for nonphysician clinicians reduces the opportunity to diagnose and treat those often unknown, and potentially life-threatening, diseases.

More battles to come

Battles involving scope of practice are going to increase as more and more legislators look for health care answers. All it takes is one interest group to convince a legislator that diagnosing a disease is easy, or performing a procedure is simple.

Here in Virginia, for example, optometrists brazenly pushed a bill that would permit them to perform any ocular surgery except those requiring lasers or those that would require general anesthesia. The mood of our legislators that year was to do all things that would increase patient access to care. We never even had a debate on the committee floor; instead, the General Assembly asked for a bill that optometrists and ophthalmologists could “live” with.

Fortunately, we minimized the damage by restricting that far-reaching bill to the injection of a chalazion with a steroid only. While this was a ‘win’ for Virginia health care, there was never any consideration of what the patients could “live with.”

Optometrists are seeking to elevate themselves to the status of an eye physician and surgeon. They, however, want to skip medical school and the years of training required to become a board-certified eye physician and surgeon. They are focused on attaining that status through the political process and turning a blind eye to the health and safety of patients.

I suggest that if the privilege of practicing medicine, appropriately earned after years of rigorous medical school and residency training, is eroded by the passage of myopic expansion of scope legislation, every patient will be at risk. There are no shortcuts to educating highly skilled, competent, and qualified physicians.

Advocating for patients

Physicians must stand up for patient safety and advocate on behalf of patients. Specialty and state medical societies can help. Your legislators are listening to stakeholders at their doorstep. To be a part of the solution, you must remember to step outside the polarizing and political arguments and simply stay true to patient care and safety.

Many legislators simply do not know what they do not know. It is our job to inform them! It is up us to inform legislators of the unintended consequence of legislating medical and surgical privilege and enable them to put the safety of their constituents, and our patients, first.

As we say here in Virginia, if you are not at the table, you and your patients will be on the menu.

Related reading:

Chart: Doctors top health care providers in education and training

4 recent scope of practice wins for DOs in Indiana, Hawaii and New Hampshire

27 comments

    1. Pharmacy students today are trained to treat and diagnose every disease state the author used as examples. I noticed my asthma patient needed an ICS/LABA inhaler instead of just a LABA for asthma, as per the guidelines and her increased symptoms. Told her to go to doc and see what they put here on. It was my exact suggestion. Could have done it right at the pharmacy instead of the doctors office, where she waited 2 hours.

      Stop fighting progress. Help your patients.

      1. How did you know that she had asthma at your visit? What if she had a space occupying mass on one side that made her wheeze? Or atypical pneumonia? Allergic reaction? Panic attack? Stick to refilling the scripts or go to medical school and learn to address all the differential diagnoses and how to sort them out. Your argument that you can refill a prescriptions on your own is based on a Physicians having made that diagnosis for you at that particular time. Addressing a patient in a tunnel vision will make you miss a potentially harmful event.

      2. I don’t see pharmacist wearing stethoscopes…! Why Smitty..?
        Are you really trained in that…?
        Wouldn’t putting medicines in a dispensing machine be better than waiting all day to get your prescription at the pharmacy…stop fighting progress..!

      3. The problem here is not that you’re trying to treat the patients without good training regarding one possible solution to medical problems (prescriptions), but trying to treat them without the training or opportunity to take a good history … and …why would it matter… do a physical exam…and by the way… make a real differential diagnosis. And by the way, consider non pharmaceutical treatments. Medicating DOES NOT equal practicing medicine.

  1. Diagnosis of more common disease states is straightforward, and your flu example may be easiest of all. I cannot tell you how many patients are inappropriately prescribed Tamiflu by physicians who “know what they’re doing”.

    The idea of pharmacists practicing medicine only makes sense as we are the medication experts. We have 8 semesters of pharmcotherapy compared to your one semester. We read the same guidelines as you, too. Who would you rather have prescribing? Physicains are great diagnosticians, but pharmacists know which medications work best for which disease. More so than any other medical profession.

    Grow up. You are fightimg this to preserve your paycheck, and you hide it under the guise of “patient safety”. So much of the country is classified as medically underserved and a scope of practice expansion would only help patients. Or maybe you “learned” physicians can just keep prescribing levaquin for a sore throat. Great stewardship yall practice!

    For the general public: physicians are vital to your health, this is true. But the reality is that pharmacy students today are graduating with increasing knowledge of treating more simple diseases. Would you like to wait 2 hours for getting a sore throat looked at? I wouldnt. I could go to my local pharmacy if the AMA stopped restricting what my pharmacists can practice. Remember, they did the same thing with immunizations.

    1. Smitty, I know you’re here just to antagonize and your mind wont be changed so this is for the other people who are reading your misguided comments. You clearly don’t see the difference between your training and that of a physician. It is not all about the drugs like it is for your profession. There are dozens of serious illnesses that present as flu like symptoms and would come back negative on a flu screen, but are in need of medical attention. So by providing half-baked interventions we are in fact doing a disservice to our patients. Is this the case with every single patient, obviously not. How, though, would you decide which patient needs more thorough care and what training did you receive to make you competent in making that decision?

      The beauty of this is that is ok you don’t have the skill set to make these determinations because there are rigorously trained people who do! To pretend that you are well enough equipped to move beyond your scope is dangerous and irresponsible. Just because someone is medically underserved or poor does not mean they deserve to have subpar care. We should be figuring out ways to get everyone the level of care they require not lowering the bar saying something is better than nothing.

    2. But the reality is most pharmacists don’t have a clue when it comes to most disease processes, the appropriate signs and symptoms and how to treat them. Stop fighting that fact under the guise of your paycheck and patient wait time.

  2. This does not relate to pharmacists, but I am recovering from open heart surgery 2 weeks ago. I went to urgent care twice for dyspnea. Since my sats were 90%, I was diagnosed with allergies. All the while the PA bragged that he did not need a dr there. I finally went to the ER and was diagnosed w critical aortic stenosis due to bicuspid valve and pulmonary hypertension. Was told that I would have died within 2 weeks w/o treatment. Don’t get me wrong. I train PAs and NPs and think they serve a very valuable role. They just should be supervised. They need to learn to think outside of the box!!

  3. It is too simplistic to say majority of physicians will oppose this legislation vs non-clinician pharmacists that will support it. The fact is Dr Everhart is right, we must never compromise the doctor-patient contact/relationship for expedience. A doctor’s training and expertise is incalculable, but most important the humane compassionate approach in treating a patient is the basis of the art of the practice and the catalyst for healing. Otherwise, we can have computer algorithms treating and prescribing for patients.
    Yes, doctors do over prescribe antibiotics but by far majority of antibiotic consumption that leads to resistance is passed through the meet and poultry we consume.
    How many lives are saved every day with incidental findings discovered on a routine or non-related exam? A good clinician also knows his limits and the limits of his training and non-physicians may not even understand those limits due to the lack of formal training. We must never erode the physician patient relationship.

  4. Hey Smitty, you sound like a frustrated pharmacist. You didn’t mention all the pharmacology physicians learn while they are interns, residents and fellows—“real life” pharmacology applications, knowledge and judgement calls Involved in treating actual patients. This is actually learned by taking care of patients on the wards, clinics and hospitals. Medicine is more than just pharmacokinetics and pharmacodynamics. It is truly an art—a good physician knows how to look and interpret the “whole picture”—the pharmacology, physiology, anatomy, and microbiology pertinent issues that need to be addressed to properly diagnosis and treat a patient, all in the name of healing.
    A comprehensive education consisting of didactic and then real life scenarios as a medical student, intern, resident and fellow help to make a competent physician. Board certification is the “icing on the cake”!
    Not taking anything away from the different education of a pharmacist but be careful what you say…..the pharmacy techs do make a strong case that “they can do what you do so why shouldn’t they get paid what you get paid”. From my understanding, they actually perform most of the same duties that pharmacists perform.

  5. In the same token, why not have pharm techs who have been around the pharmacist have an expanded scope of practice? They’ve seen first hand what the pharmacist does and has likely done many of the same things. Why shouldn’t they be allowed to bill and practice independently? Why can’t the paralegal, after 6 months (aka 1000 hours), start practicing law? Why can’t the flight attendant who has been working on the plane for 4 years just become the pilot? Medicine seems to be the only place where everyone else wants a piece but doesn’t want to get the necessary training to do it, and to do it safely.

  6. I wholeheartedly agree with this piece. The author is correct. We need to put the NPs and PAs and midlevels back in their places. In my residency program, the PAs and NPs run the ICU while the attendings sit in the back room reading charts. This is a blasphemy. I as a resident physician asked the attending to teach me how to do procedures and the attendings told me that they don’t do procedures any more and that the midlevels do all the critical care. What blasphemy! Giving the least knowledgeable least experienced midlevels the most critical patients while they sit in the back room and supervise the care of our sickest patients. The NP in the ICU did not know what alcoholic cirrhosis was and I had to spend 15 minutes educating her about that.

    It is disastrous that now NP programs can be done online in 8 months. NPs and PACs now are terrible and they come from schools that want to push them out as quickly as possible. NPs enter the hospitals never having worked a day in the hospital, and are told to manage critical patients. The NP PA s in my hospital tell me they basically just go on uptodate and do whatever it says on there and hope it works.

    In our clinic, the PAs order EKG tests and pregnancy tests on every patient regardless of clinical gestault. They are following guidelines and driving up the cost of medicine.

    The midlevel scenario is a true and epic disaster. They should never have existed. Nurses and others who want to be physicians should go to medical school.

    1. Hi Mark,

      I am also a resident and also frustrated with this same issue.

      I’m in my final year of occupational medicine and just had an awesome training with ortho/sports medicine doc. We saw many ridiculous consults from midlevels who even an intern can do. Most don’t know how to do basic MSK physical exam. At the end, they just refer and refer.

      Unfortunately, this is a sad thing that becomes reality because of expediency and money. They are cheaper than physicians and will unfortunately replace us in some settings like primary care and urgent care.

      The notion that their organizations advocate for more NPs and PAs to alleviate primary care shortage is bogus. Most of them dislike primary care and end up doing specialized care after one or two month training such as ophtho, hemeonc, etc. Whats more concerning is more and more are going in the antiaging medicine route.

      Independent and smaller clinics are now looking into midlevels as well for the same reason, money!

  7. I was (and still am) a registered pharmacist (old BSP and add-on PharmD) who went to osteopathic medical school and now am a pulmonologist/intensivist. So I can attest to both standpoints.

    I must say, before starting my medical career, I too thought that pharmacists should be able to prescribe. After years of medical training, my perspectives have changed and looking back, pharmacists lack many diagnostic skills needed for DIAGNOSING (but not necessarily prescribing).

    Additionally, forcing all pharmacy schools to go PharmD after 2004 has really watered down the curricula and now pharmacy residencies are being required for commensurate education.

    That being said, pharmacology is definitely a weak point at many medical schools, and appears downright atrocious with nurse practitioner training.

    A collaborative approach opposed to individual scopes of practice is the best approach to the treatment of a patient.

    Just my opinion.

    1. Nathan Samsa, I am also a RPh and DO.

      No doubt, the Pharmacist knows more about medications and Pharmacology than a DO/MD.

      BUT, what is lacking in Pharmacy school, is diagnostic skills.

      On the other hand, I would much rather have Pharmacists being more involved in rural and under served areas than any NP, PA.

  8. Funny how so many want to practice medicine without going to medical school. Why should they take absorb the cost and have you extended overhead not to mention the long and grueling training? If you want to be a physician go to medical school and get the training. Just because your focused study in pharmacy gives you an upper hand on what Physicians might know in pharmacy doesn’t mean you have a working knowledge of what it takes to integrate all aspects of patient care. Patient care is more than just and expertise in Pharmacology.

  9. Bravo! Well stated. This could be expanded to all aspects of medical care beyond Ophthalmology. Recently SAMHSA passed a bill allowing “Nurse Specialialists”, CRNAs and nurse midwives to prescribe buprenorphine (Suboxone) to treat addiction! They already allow midlevels to prescribe it and I have personally seen that go horribly wrong. This field is so unique that the DEA even requires physicians to obtain a special license to prescribe it. Yet now they want to allow “providers” with no experience in addiction treatment to prescribe it. Essentially everyone except perhaps the cleaning lady can now prescribe buprenorphine! Who is in control of modern medicine???

  10. When I was interested in the medical field years ago, I initially wanted to be a PA. However, I decided I wanted to be a physician so I can go as far as possible with my education and have the largest scope of practice. I didn’t want to spend my entire career working under a physician. Once I decided I wanted to be a physician, a few people talked me into being a NP or PA (which of course I said no). I understand that advanced practice providers are common and some prefer the path because it’s less time in school, less debt, and allows one to practice sooner.

    I agree with the last poster that patients should decide who they want to see. I have a fantastic psych DNP who has been better than most of my previous MD psychiatrists. She is amazing because she cares about me as a person and doesn’t push meds. Several years ago, I saw a PA at a primary care practice who was better than the MD. While I am open to seeing PAs/NPs for primary care or psychiatry, I prefer to see physicians for other specialties. Several months ago, I had a poor experience with a GI NP who contradicted the MD’s suggestions and was not aggressive in her treatment. What was worse was that she was easier to get appointments with than the MDs. Fortunately, I switched to a small GI practice with no NPs/PAs present so all my care is with the doctor.

    1. Part of the problem is that mid levels were created—NP’s, PA’s and CRNA’s to be an “extension” of the physician, not a replacement. The education is different—nurses’ educations are much less stringent than a physician’s— entry requirements are much lower than for medical school. Pharmacy school requirements have also dropped considerably over the years because of many new pharmacy schools opening and seats need to be filled and paid for! Basically, if someone wants to be a doctor, go to medical school. If you want to be a nurse, go to nursing school. Nurses are educated by other nurses. CRNA’s are educated by other CRNA’s (nurses), not doctors—the depth and expectations are much, much different! They don’t do a residency or fellowship. Pharmacists have less practical pharmacology knowledge that physicians because they don’t see, diagnose and treat patients—they read about the drugs in textbooks and then take an exam. Also, nurses and pharmacists do not have MOCA like doctors.
      It seems that many want to “put down” doctors—they are grumpy, angry, mean and disinterested—-at least in some of the articles that I have read. What about the older, burned out nurses who are clock-punchers and can barely make it through an 8 hour shift without bitterly gossiping and complaining about patients? Or the angry pharmacists who complain that their district/regional managers want them to “give more flu shots” and push other treatments in order to “make the pharmacy’s quota”?

      1. Dr. Charles, great points. As someone who wants to be a primary care physician, I worry that I may be replaced by NPs and PAs. :(

  11. Lets not forget all those “Grandfathered” DO’s who have not had to continuously take the
    Re certification exams.

    Whats driving so much independence for NP’s and PA’s and other mid levels is the burnout of the current generation of DO’s who have to do much more OCC, and Re certification than the
    “Grandfathered” DO’s

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