How is medical scope enforced?

[deleted555445]

One thing I've always wondered is how scope of practice between board-certified physicians is enforced? Like say I'm a trained general surgeon, but I perform brain surgery. What happens, do I just get sued for malpractice (assuming something goes wrong because I don't have the training to do what I'm doing)? Or can will my board or the board for the scope of the procedure I did come after me? And how is this decided in more borderline cases, like where dermatology and plastic surgery might intersect or vascular surgery and IR?

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[NickNaylor]

1) If you are performing something outside of your scope and something goes wrong, you will almost certainly be held liable for malpractice. Note that malpractice requires some kind of injury, so if you were somehow a world-class surgeon-psychiatrist, this may not actually be an issue.

2) Many insurance companies may be reluctant to reimburse for some services that aren't within your scope. For example, I doubt an internist would be reimbursed for providing psychotherapy services, even if what occurred during an appointment might technically be psychotherapy, as the internist isn't trained to provide psychotherapy services. This isn't an enforcement action per se, but it makes providing services outside of your scope pointless.

3) Your state medical board may have more specific regulations related to scope of practice

 

[mvenus929]

For procedures in particular, a hospital usually won't allow you to do them unless you have a case log history or go through a proctoring experience to show that you are competent in your field.

For non-procedures, it's more about malpractice and liability. As a pediatric subspecialist, I can make a claim that I can do the things a general pediatrician can do, because I had that training. If I try to do things that a nephrologist does (for instance, order dialysis), that is more likely to cause problems. But if I wanted to do psychotherapy, for instance, I could attend some CME course and get some experience and do it--whether or not I'd be reimbursed for it would be questionable.

 

[operaman]

This is usually enforced at the institutional level. You have to request privileges for each procedure you want to do, so you’d be hard pressed to step too far out of your scope. I requested some privileges a bit beyond my scope and I had to submit additional letters from other docs saying I was qualified in addition to case logs.

There’s also the referral issue. Like nobody is referring people to me for things outside my scope of practice. You also have to think about the risk of complications on your referral base. I’m super careful right now as a new doc making sure I have good outcomes. I want a solid 5 years of good outcomes before I even think of pushing the envelope. I have a very low threshold to refer to a sub specialist even if it’s something I think I can manage but may be a bit outside my scope. Reputation is just too important to me and nobody will refer to me if I start having a ton of complications.

 

[MedicineZ0Z]

Depends on institution and what you're doing. Operating? Hospital won't let you do it. More routine hospital procedures or ER procedures? Depends on the place, but many (or perhaps most) are letting you practice within the scope of that job.

 

[guytakingboards]

One thing I've always wondered is how scope of practice between board-certified physicians is enforced? Like say I'm a trained general surgeon, but I perform brain surgery. What happens, do I just get sued for malpractice (assuming something goes wrong because I don't have the training to do what I'm doing)? Or can will my board or the board for the scope of the procedure I did come after me? And how is this decided in more borderline cases, like where dermatology and plastic surgery might intersect or vascular surgery and IR?

Scope of practice can be hammered and narrowed at every possible level. Eg. Individual, hospital/clinic, medical board, licensing board, insurance carrier, payers.

To use your example: if you're a general surgeon and you do brain surgery (and it goes wrong),
-You individually will be sued
-Your malpractice insurance carrier will likely not cover you, as your insurance premium is based on a general surgeon's typical scope of practice. they might also just drop you for doing something so stupid.
-The payer (e.g. what insurance company the patient has) will not reimburse for a procedure not done by a qualified neurosurgeon.
-the hospital system may not allow you to schedule the procedure up front or just strip your regular surgery privileges afterwards.
-the licensing and medical boards may cite you and/or suspend your licenses and certifications for not practicing safely outside the scope of practice.

Basically it's not worth it to stray too far outside your scope of practice because you'll be up **** creek without a paddle.

However, there are plenty of borderline situations in medicine where there is substantial overlap in services. A dialysis catheter can be placed by anyone who can put in a central line. Dialysis AVF work can be done by vascular surgery, IR or interventional nephrology. For the most part, it's pretty clear to those in said fields what constitutes exceeding their scope of practice. IR ain't gonna do an open-AAA repair. Vascular surgery isn't going to embolize the liver.

Furthermore procedure encroachment is a real thing. VIR basically invented and popularized catheter based work. Cardiology immediately took the cardiac work. Vascular surgery took peripheral arterial disease (and lately it seems cardiology is also trying to horn in on cold legs too).

 

[ChordaEpiphany]

Dialysis AVF work can be done by vascular surgery, IR or interventional nephrology. For the most part, it's pretty clear to those in said fields what constitutes exceeding their scope of practice. IR ain't gonna do an open-AAA repair. Vascular surgery isn't going to embolize the liver.

Furthermore procedure encroachment is a real thing. VIR basically invented and popularized catheter based work. Cardiology immediately took the cardiac work. Vascular surgery took peripheral arterial disease (and lately it seems cardiology is also trying to horn in on cold legs too).

It really seems like the specialties with the best representation are winning these scope battles. I think the vascular surg vs. IR vs. interventional nephrology really illustrates this. Nephrology died a long time ago, and adding procedures could have revitalized the specialty and reimbursement. They were an obvious choice (or at least as obvious as cards breaking into cath work), but clearly they didn't have the resources or leadership to stick up for themselves. Vascular surgery is a small specialty and its members are too busy to advocate. IR has allies with radiology and managed to eat into this space despite maybe being the least "obvious" specialty to take on that work.

Really it makes less sense for IR to do dialysis access compared to vascular surgery, and in many hospitals the vascular surgeons are upset about it. At the end of the day, scope seems to be about who can advocate for themselves.

 

[deleted555445]

Thanks everyone for the great responses!

 

[guytakingboards]

It really seems like the specialties with the best representation are winning these scope battles. I think the vascular surg vs. IR vs. interventional nephrology really illustrates this. Nephrology died a long time ago, and adding procedures could have revitalized the specialty and reimbursement. They were an obvious choice (or at least as obvious as cards breaking into cath work), but clearly they didn't have the resources or leadership to stick up for themselves. Vascular surgery is a small specialty and its members are too busy to advocate. IR has allies with radiology and managed to eat into this space despite maybe being the least "obvious" specialty to take on that work.

Really it makes less sense for IR to do dialysis access compared to vascular surgery, and in many hospitals the vascular surgeons are upset about it. At the end of the day, scope seems to be about who can advocate for themselves.

Interesting perspective.

As a radiologist, I can say from our perspective that the key thing that drives those procedures is who owns and manages the patient. (Spoiler alert: that ain't radiology). Vascular surgery has an inherent one-up on IR in peripheral arterial work because they can see the patient longitudinally in clinic and manage the full spectrum of disease from the initial statin prescription to the BKA. That's how cardiology 'stole' cardiac caths from radiology; they just stopped referring out. Radiology traditionally has just been the hired gun doing whatever intervention someone else ordered. The IR society recognizes that and has made a push to be a more traditional clinical specialty with clinic time and longitudinal follow-up but there's a long way to go.

From the radiology perspective, whatever procedure work we get tends to the less-desirable, lower RVU work that other specialties don't want to do. If given the choice between an Ax-fem bypass or a dialysis fistula declot, the vascular surgeon is gonna take the more complex/fun/compensating ax-fem bypass every time. We radiologists often see ourselves as crap procedure dumping ground. LP's, tough percutaneous nephrostomies, etc... And its because we don't control the patients that we have to do those crap procedures to stay busy.

And I'd strongly disagree vascular surgery is better suited than IR for basic dialysis catheter placement. A) its not rocket science B) i've rotated with both vascular surgeons and IR's and didn't notice a particular difference in care or outcomes.

 

[mvenus929]

Interesting perspective.

As a radiologist, I can say from our perspective that the key thing that drives those procedures is who owns and manages the patient. (Spoiler alert: that ain't radiology). Vascular surgery has an inherent one-up on IR in peripheral arterial work because they can see the patient longitudinally in clinic and manage the full spectrum of disease from the initial statin prescription to the BKA. That's how cardiology 'stole' cardiac caths from radiology; they just stopped referring out. Radiology traditionally has just been the hired gun doing whatever intervention someone else ordered. The IR society recognizes that and has made a push to be a more traditional clinical specialty with clinic time and longitudinal follow-up but there's a long way to go.

From the radiology perspective, whatever procedure work we get tends to the less-desirable, lower RVU work that other specialties don't want to do. If given the choice between an Ax-fem bypass or a dialysis fistula declot, the vascular surgeon is gonna take the more complex/fun/compensating ax-fem bypass every time. We radiologists often see ourselves as crap procedure dumping ground. LP's, tough percutaneous nephrostomies, etc... And its because we don't control the patients that we have to do those crap procedures to stay busy.

And I'd strongly disagree vascular surgery is better suited than IR for basic dialysis catheter placement. A) its not rocket science B) i've rotated with both vascular surgeons and IR's and didn't notice a particular difference in care or outcomes.

As an example outside of a procedure-based specialty... it is within endocrine's scope to deal with calcium issues. But it's also within the scope of nephrologists (who deal with the kidney stones). At my primary institution, someone in nephrology became really interested in calcium issues several years ago and no one in endocrine put up a fight, and now all the referrals go to nephrology except for once in a blue moon when the underlying issue is hypoparathyroidism. Even Vitamin D deficient rickets often gets triaged to nephrology.

In my clinic, which is about an hour away from the primary institution, there are no nephrologists around. There are also no obesity medicine specialists. Or GI (for failure to thrive). So while during fellowship, I didn't learn a ton about those disorders, they make up a decent amount of my practice now, so I am learning as I go. My scope of practice is quite different than my colleagues at the main institution because of these referral patterns.

 

[OptionOffense]

For the life of me, I dont know how Anesthesiologists got roped into doing intubations around the hospital and in code situations. Why cant the Emergency Physicians take control of that realm?

 

[MedicineZ0Z]

For the life of me, I dont know how Anesthesiologists got roped into doing intubations around the hospital and in code situations. Why cant the Emergency Physicians take control of that realm?

If they're called for back up, that's reasonable. I mean what happens if you miss, just let the patient go even if someone else could maybe get it?

 

[ChordaEpiphany]

And I'd strongly disagree vascular surgery is better suited than IR for basic dialysis catheter placement. A) its not rocket science B) i've rotated with both vascular surgeons and IR's and didn't notice a particular difference in care or outcomes.

Well, I'll defer to you on that. I always come from the assumption that most things in medicine aren't rocket science, but that scope is ideally is determined by who will mess it up less frequently and how bad the consequences are for messing up, much like the argument for CRNAs/NPs vs actual physicians.

I have no idea where those numbers lie for vascular surg vs. IR other than some musings from a nephrology attending I know personally who was tasked with mediating an ongoing battle in the hospital between these groups. Ultimately the attending took the side of the vascular surgeons even though they had a closer working relationship with IR. However, I also assume the skill difference between vascular surg and IR for dialysis catheter placement is far smaller, if present at all, compared to the gaping chasm between MD and NP or anesthesiologist vs. CRNA.

 

[mcat_taker]

For the life of me, I dont know how Anesthesiologists got roped into doing intubations around the hospital and in code situations. Why cant the Emergency Physicians take control of that realm?

Because the emergency physicians don't leave the emergency dept. Duh.

 

[NITRAS]

Because the emergency physicians don't leave the emergency dept. Duh.

When I was a resident (at a community hospital), I called the ED to supervise me to intubate when my ICU staff wasn’t here.
I once called him at 0820 because my icu staff was taking his sweet time coming in. (The ED doc was not happy).

I techincally was suppose to call anesthesia for complicated airway issues, but only ran into that like once or twice.

Point is, some places operate differently. Sometimes the emergency airway guy is the ED doctor.

 

[CliveStaples]

Ay my hospital, it's EM that responds to codes for airway, not anesthesia.

 

[jambro]

How does inappropriate midlevel scope factor into this? I've never understood how it seems like there's no rhyme or reason to what they do or don't do in different systems

 

[mvenus929]

How does inappropriate midlevel scope factor into this? I've never understood how it seems like there's no rhyme or reason to what they do or don't do in different systems

It's very hospital dependent. The credentialing committee for each hospital sets the scope allowed by NPs and PAs. We aren't in an independent practice state, so there are requirements for signing off on charts and proving ongoing ability to perform procedures (largely IVs and central lines).

Of course, in independent practice states, midlevels can set up their own practice and just not accept insurance--and they're held to a different malpractice standard than physicians. In those states where they can't have independent practice, they can still set up a cash only practice, but they have a physician back-up that can be sued for malpractice as well.

 

[Marcus Brody]

Hospital privileges. And threat of a lack thereof.

 

[OptionOffense]

Ay my hospital, it's EM that responds to codes for airway, not anesthesia.

Thats the way it should be. I dont know how in the **** anesthesiologists got roped into responding to code blues when thast the ER doc's job

 

[VA Hopeful Dr]

Thats the way it should be. I dont know how in the **** anesthesiologists got roped into responding to code blues when thast the ER doc's job

Because anesthesiologists have long billed themselves as the airway experts

 

[Wordead]

Thats the way it should be. I dont know how in the **** anesthesiologists got roped into responding to code blues when thast the ER doc's job

Well when you have most of your staffing done by NPs and PAs and most of the attendings are fresh grads that can barely intubate transorally much less fiberoptic anesthesia is much safer.

I would 1000% rather have any of my anesthesiologists and most of the time CRNAs at an airway than any of the ED guys.

Obviously this is hospital dependent.

 

[OptionOffense]

Well when you have most of your staffing done by NPs and PAs and most of the attendings are fresh grads that can barely intubate transorally much less fiberoptic anesthesia is much safer.

I would 1000% rather have any of my anesthesiologists and most of the time CRNAs at an airway than any of the ED guys.

Obviously this is hospital dependent.

then they should get good at it