The standing definition of “scope of practice” is “the activities that an individual healthcare practitioner is permitted to perform within a specific profession, based on appropriate education, training, and experience.” In general that is still true, however, defining scope of practice for any given specialty is widely variable. Like nearly everything else in healthcare today, the sands are shifting under scope of practice and it’s becoming a hotbed of debate. Here’s what’s going on, and the key differences between physicians and advanced level practitioners.
Define Scope of Practice? Not So Fast.
The Journal of the American Board of Family Medicine tried to define scope of practice and couldn’t. “Key to considering the scope of practice of family physicians is the question of just what are we doing right now and how this varies by region and by physician characteristics such as age cohort and sex. Given the numbers of family physicians across the United States and the variation in practice across regions, tracking trends is very difficult.” In other words, there is no standard scope of practice.
The Federation of State Medical Boards uses the definition we opened with, adding, “Scope of practice is established by the practice act of the specific practitioner’s board, and the rules adopted pursuant to that act.” Beyond that, the federation tosses the question back to the states. “State Medical Practice Acts define what constitutes the practice of medicine in that state. Generally, the definition of the practice of medicine is consistent among the states though particular details do vary.”
It seems that defining scope of practice is like getting a toddler to stand still. It is also a highly charged issue. Physicians and their associations are becoming increasingly concerned with encroachment of practice and a dilution of physician oversight. They are taking action to protect it.
According to the Federation of State Medical Boards there are many factors impacting physician scope of practice, including “fluctuations in the health care workforce and specific health care specialties; geographic and economic disparities in access to healthcare services; economic incentives for physicians (M.D., D.O.) and other health care practitioners; and consumer demand.” The American Medical Association (AMA) is highly concerned as well, and isn’t waiting for the issue to sort itself out. It has created the Scope of Practice Partnership (SOPP) in collaboration with the American Osteopathic Association (AOA), national medical societies, state medical associations and state osteopathic medical associations. The AMA says that SOPP “focuses the resources of organized medicine to oppose scope of practice expansions by non-physician providers that threaten the health and safety of patients” in order to “protect patients whose well-being may be threatened by health care practitioners who lack the education, training or experience to perform procedures for which they seek licensure or recognition.” In other words, advanced level practitioners like nurse practitioners and physician assistants.
The Federation of State Medical Boards wants state policy makers to oversee non-physician providers, with patient safety as the goal. “All discussions about changes in scope of practice should begin with a basic understanding of the definition of the practice of medicine and recognition that the education received by physicians differs in scope and duration from other health care professionals. Non-physician practitioners may seek authorization to provide services that are included in the definition of the practice of medicine under existing state law. Patient safety and accountability should be the most important factors in establishing expectations and limitations associated with scope of practice changes.
Is it possible to define the scope of practice for any provider?
Like physicians, scope of practice for advanced level practitioners is varies by state. However, there is some guidance for the 270,000 nurse practitioners (NP) and 131,000 physician assistants (PA) in the United States.
Nurse Practitioner Scope of Practice
A nurse practitioner’s clinical practice can include:
- Ordering, performing, supervising and interpreting diagnostic and laboratory tests
- Diagnose and management of acute and chronic disease
- Treatments including prescribing medications
- Coordination of care and patient education
They may serve patients in a wide range of demographics, in specialties that includes children and families, women and adults, the elderly and those needing mental health services.
In terms of accountability, the American Association of Nurse Practitioners states in its scope of practice:
“Each NP is accountable to patients, the nursing profession, and the state board of nursing. NPs are expected to practice consistent with an ethical code of conduct, national certification, evidence-based principles, and current practice standards.”
Physician Assistant Scope of Practice
The physician assistants’ scope of practice is similarly broad. According to the American Academy of Physician Assistants (AAPA) a PA is qualified to:
- Take medical histories
- Perform physical examinations
- Order and interpret laboratory tests
- Diagnose illness
- Develop and manage treatment plans for patients
- Prescribe medications
- Assist in surgery
Physician assistants must follow specific regulations when setting up practice namely. According to the AAPA, “Licensed healthcare facilities (hospitals, nursing homes, surgical centers and others) have a role in determining the scope of practice for PAs in their institutions. In order to provide patient care services within an institution, PAs request clinical privileges. These privileges must be approved by the medical staff, and ultimately, the institution’s governing body. This process defines a scope of practice that each individual is qualified to provide within that organization. Institutions assess PA requests for privileges, including verification of professional credentials (graduation, licensure, and certification) and documentation of additional relevant training, previous privileges and/or procedure logs, CME, or skills assessment under direct observation.”
So there you have it; the differences between physicians and advanced level practitioners in all their messy, undefined glory. The various pieces and parts of this issue will remain hotly debated and dynamic in the years to come. If you have questions about scope of practice for your profession, check with your state’s medical boards. That seems to be the only place where everyone agrees on the rules of the road.