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The AMA Steps Up and Represents.

Discussion in 'Medical Students - DO' started by Old_Mil, Dec 4, 2008.

  1. Old_Mil

    Old_Mil Senior Member
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    For those of you who wonder why I recommend foregoing AOA membership and joining the AMA, it's things like this...

    At its interim meeting held November 8-11, in Orlando, the American Medical Association House of Delegates responded to strategic lobbying efforts by ASA and state sponsoring societies and adopted Resolution 212: State Legislative Response to NBME Practice of Using USMLE Step 3 Physician Licensing Exam Questions for Doctors of Nursing Practice Certification.

    Resolution 212, introduced by ASA and eight co-sponsors was developed in response to an announcement by the National Board of Medical Examiners that it will use content of its USMLE Step 3, Physician Licensing Exam Questions in its certification exam of Doctor of Nursing Practice (DNP).

    The USMLE Step 3 exam provides a final assessment of physicians assuming independent responsibility for delivering general medical care and assesses whether the examinee can apply medical knowledge essential for the unsupervised practice of medicine.

    ASA urged the adoption of the resolution with concern for patient safety and the physician-patient relationship. Significant confusion and harm to patients could result from DNPs misrepresenting themselves to patients as medical doctors, having been certified in a process similar to or the same as the medical licensure of physicians.

    With the adoption of the resolution, the AMA will work to develop and circulate model state legislation that would prohibit NBME from using content from the USMLE Step 3 exam and National Board of Osteopathic Medical Examiners (NBOME) from using content of the COMLEX Step 3 exam in the certification process of non-physician providers.

    You can follow the discussion here:

    http://forums.studentdoctor.net/showthread.php?t=583551

    (in other news, the house of delegates has yet to decide whether allopathic medical students should use roman or arabic numerals in their title when signing their names...)
     
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  3. meister

    meister Senior Member
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    I'm afraid the cat's already out of the bag. The AMA should lobby to force DNP programs to be standardized and elminite ONLINE CLASSES. I mean that **** has to ****ing stop.

    I think using roman numerals is pretty lame, I'd much rather sign M3 than MIII. Not to mention that 1,2,3 and 4 are much easier to distinguish on paper than I, II, III, IV.
     
  4. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    The AOA has has been a very active participant in the AMA's scope of practice partnership.

    http://www.ama-assn.org/ama/pub/category/17840.html

    I keep my AOA membership for practical reasons...I'm a DO and the AOA does step up and assist with state insurance and credentialing issues.
     
  5. jason3278

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    As long as they stop signing "MD Candidate" like I've seen MSUCHMers do, I'm happy.
     
  6. cyclohexanol

    cyclohexanol No, no. Doggie afuera.
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    Wow, that's really douchey...thankfully I haven't seen that yet.
     
  7. DOinMS

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    Unfortunately, it has taken something like this for the medical community to wake up and say, "oh crap we probably need to do something." For years, physicians have stood by while the nursing community has slowly gained territory that was once held only by physicians. How long did physicians really think it was going to take for advanced practice nurses to transition from rounding and writing orders to practicing autonomously? I'm afraid this is going to be a huge problem for the next generation of physicians.
     
  8. DrMidlife

    DrMidlife has an opinion
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    There's reasonable doubt that midlevels have any interest in taking over. In particular, primary care sucks for everybody - not exactly a hot property.

    Not that I disagree with the AMA stance.
     
  9. Taurus

    Taurus Paul Revere of Medicine
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    As it currently stands, nobody really wants primary care. If primary care physicians are having this much trouble getting by, how do you think NP's who get reimbursed 85% of what a physician gets if working solo manage?

    No, the nurses don't want primary care either. What they want is to get reimbursed 100% as a physician and to get into the specialties where the real money is.

    Read my signature and follow the links for more info.
     
  10. BruceBanner

    BruceBanner strongest one there is
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    From the DNP article in Forbes you have linked:

    Really?? The medical knowledge of a physician....with the "added" skills of a nursing professional, as if to imply they are somehow above or beyond the scope of what a physician learns.

    Expert diagnosis and treatment, huh? So some floozy who never went to college and got her RN can go do a <2 year NP, then get her DNP through an ONLINE program---and this equates to expert diagnosis and treatment?? And she gets to be called "doctor"?? :uhno:

    Wow we're really in the wrong field here guys. We could have been 'doctors' without ever having completed a bachelor's degree.


    Scary stuff, man. As far as I'm concerned, DNP's are still MIDLEVELS, period. Midlevel providers provide care based on PROTOCOL and what they are told rather than on an exhaustive knowledge of pathophysiology built on an advanced scientific foundation and many thousands of hours of training.
     
  11. Jamers

    Jamers Sexy Man
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    Wow, I never realized it was this bad. I knew they were trying to move in on our territory but never this much. Yeah, they need to be stopped. Online degrees in the health care field are just insane. I don't know how we let this happen.
     
  12. meister

    meister Senior Member
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    It's too late, I'm already setting my sights on moving to another country if **** gets really bad. Mexico would be pretty sweet, you could live like a king on the coast.
     
  13. Taurus

    Taurus Paul Revere of Medicine
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    I believe every physician needs to be aware of the DNP issue and recognize it for what it is -- blatant power grab by the nurses to practice medicine without having to go through medical school and residency. To add further insult, these DNP's think that they are equivalent to physicians even though they have less than 1000 hours of clinical training and many programs are online. As you can see, it's not about competency, but rather about the power, prestige, and money from being able to walk around and call yourself a "doctor". First, the DNP's will want to get into primary care. Second, it will be the specialties like derm, GI, cards. Primary care is just a way for them to put their foot in the door before they rush in to dig for some gold.

    Every physician, whether they be MD, DO, or FMG, needs to unite under this common cause to prevent nurses from trying to take over medicine. It's bad for medicine, it's bad for patient care, and it's misleading for patients to believe that DNP's who introduce themselves as "doctors" are physicians. I'm glad to see that the AMA has taken this issue seriously. So should you!

    You can read more on allnurses.com how DNP's view themselves compared to MD/DO's.
     
  14. DOinMS

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    I'm glad to see that there are people like Old_Mil, BruceBanner, and Taurus who refuse to keep their heads in the sand. If someone thinks DNPs would graciously stop with primary care, then that person is completely out of their minds. Stopping this momentum that nurses have established is going to be up to our generation of physicians as the current generation has let us down - big time. Give me a break, if a physician is so lazy and useless that he/she will send an NP to make rounds, then that physician should do us all a favor and change careers.

    Lastly, I love the piece that suggests DNPs have everything a physician has plus some. Problem is, most people are probably naive enough to believe that.
     
  15. theraball

    theraball Panned
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    Tempest in a teapot. There's a huge shortage of primary care docs and few are choosing that field, so DNP's and NP's and PA's are merely filling a tiny part of a large void. Just train well and work hard and you'll have a great career and don't worry so much about people encroaching on your turf, especially when it's not turf you even care about.

    And for those who look down on nurses, like the guy above with the "floozy" comment--well it's people like that who have contributed to the problem, driving nurses out of the profession and creating a huge shortage.

    Everyone in the health professions should be treated with respect.
     
  16. Taurus

    Taurus Paul Revere of Medicine
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    The issue is not about respect. It's about letting the patient make informed decisions. The nurses have shown repeatedly that they use propaganda that practically borders on fraud to achieve their goals. They deny they practice medicine, for one thing, even though they diagnose and treat. They claim to practice "advanced nursing" and that's how they achieve independence and avoided being under the regulation of boards of medicine. They put out crap studies trying to show equivalency and then they use this "evidence" to go to the politicians to loosen the laws. They have done this repeatedly with CRNA propaganda. Now they think that they can do this with DNP's. Don't you think it's misleading for a DNP in a long white coat to introduce themselves as "doctor" and perform the traditional duties as a physician? Did you like Mundinger's proclamations that DNP's have the knowledge of physicians but are better because they're nurses also?

    The AMA is interested in just making sure the public is not duped by the lies spun by the nurses. Shouldn't one of our goals be transparency and truth in advertising? How else can patients make informed decisions if they are mislead by the qualifications of the provider?
     
  17. JaggerPlate

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    Anyone who doubts that this DNP thing can be a HUGE problem for everyone should read up on what happened/is happening with the CRNA situation (check out the gas forums).
     
  18. DOinMS

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    Unfortunately, my point about naive individuals has been made more quickly than I anticipated. Let me preface my next comments by saying that I am not a kid fresh out of undergrad. Instead, I have several years of healthcare experience with nurses (of all levels), physicians, PAs, etc, etc. Having said that, I think I have a pretty good grasp on "reality healthcare." I hesitate to even bring up the economics of this situation, but for the individual who thinks that to simply "train well and work hard" is enough, it must be done. What is going to happen when healthcare organizations can hire a DNP with the same scope of practice as a physician for less money? THE SAME THING THAT HAS HAPPENDED IN ANESTHESIA!!!! I have plenty of respect for nurses who do their job well and within their scope of practice, but I have no respect for a group trying to practice autonomous medicine via the back door because they chose not to or couldn't get into medical school.
     
  19. BruceBanner

    BruceBanner strongest one there is
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    This is really the crux of this whole issue, in my opinion. JaggerPlate made a key correlation--the CRNA issue(s) in anesthesia.

    This has nothing to do with a 'lack of respect' for nurses. I think it's safe to say that most physicians have the utmost respect for their supportive team as long as they know their roles and are competent at said roles.

    BUT--there has been a rash of these "pseudo-doctor" programs popping up in recent years, and while no one is saying that their existence per se is bad, those with professional authority (physicans, the AMA, the AOA, etc) need to put the motherf'ing smack down on accessory health professionals trying to take the BACK DOOR into autonomous medical practice...because that's what it is. Did you read that article, theraball? The one written by the dean of nursing programs at Columbia? If that doesnt send a "we're not only just as good, we're better" message, then I dont know what does. The public needs to be acutely aware that DNP's are NOT doctors, period.

    I knew a girl from college who went to DPT school, and I had a similar discussion with her. She was probably one of the more reasonable folks who go into these programs (by reasonable I mean she wasnt pretending to be a doctor), but even she had questionable ideas about where her authority would stop and begin. Of course someone in that profession is going to defend their title and rights tooth and nail, but it's what they are teaching these students that makes them come out with these distorted ideas of authority they have. Now granted this was a DPT program, but I think the illustration hold for DNPs as well.

    The argument I have made, and will always make for this issue, is that it is misleading. Not only to the public, but also other practitioners who arent up to speed on the implications of this whole "doctor nurse" sham. One of the things people are so fond of saying here is "the general public has no clue what the difference between an MD and DO is." Well, guess what? They probably dont know what the hell a DNP is either, and if they happen to be receiving care from a DNP who introduces themselves as 'doctor', they are going to believe they are being treated by a physician, which will only further fortify DNPs self-placed position as 'professional equals'.
     
  20. theraball

    theraball Panned
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    What is going to happen when a DNP with a similar scope of practice to a primary care doc can be hired for less money? They will be hired for less money. So what? There's a huge shortage of primary care docs. There's a need for more midlevels because docs aren't going into family practice. Claiming, baselessly, that this is a disastrous situation doesn't make it so. Nor does it help your case to call people "naive" just because they disagree with you.
     
  21. Taurus

    Taurus Paul Revere of Medicine
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    A DNP fresh out of school can't replace a primary care physician, not because they don't want to but because they are unable to. Read through the course offerings of a DNP and their classes on stats, research, leadership and then keep in mind that most of them are online and that they have less than 1000 hours of clinical training. 1000 hours is less than 6 months of being on the floors. That's why all NP's, including the ones who get DNP's, need to work under a physician for years before they can adequately work independently. A FP, pediatrician, or IM doc just graduated from residency can work independently immediately because they each have over 17000 hours of clinical training under their belts.

    These are the details that patients need to know. I'm fine with free market and competition, but the patients need to be given all the facts before making informed decisions.
     
  22. size_tens

    size_tens Senior Member
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    At least financially, anesthesiologists are doing very well at the present. In fact many are hiring CRNA's into their groups and turning handsome profits from them. I am not opposed to the idea of DNP's. As long as NP's receive adequate training I think it's ok for them to expand the scope of their duties to meet their capabilities. IMO we need to focus on optimizing patient care as the #1 priority and not worry so much about protecting our pocketbooks.
     
  23. Instatewaiter

    Instatewaiter But... there's a troponin
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    Look at the disparity in training between DNP and MD, especially clinical training, and that should tell you all you need to know about patient care.
     
  24. Spleen

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    To illustrate the differences between the groups there should be a rally point around the title physician (rather than doctor) and explaining what that is and means to patient standards. The doctor title is a lost war. Every one can be a doctor for all I care (and apparently is). But few are physicians. Every state restricts its use to MD/DO/MBBS/MBCh etc. Some (depending on the state) permit DPM, DDS/DMD, DC, ND to also legally use the title physician.

    Do your part and don't hire or train them. Don't encourage others and spread the word.

    All we have done is given the green light to a two tiered system. It used to be that when ever you saw a clinician, regardless of your finances, you could expect a standard, a level of quality that was the physician. Now you can't. And can you guess where the financial issue is going to divide out who sees which clinician? Yup. People with money will see a physician, and those with less will likely have to see a DNP/NP. We have reduced the quality of our nation's medical care. We have taken a step backwards.
     
  25. meister

    meister Senior Member
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    Hey Spleen FYI: the word physician is under attack as well. ODs are known as "optometric physicians" in some states. NDs are a joke and are "naturopathic physicians." DCs are "chiropractic physicians." All of these professions are just power grabbing and stealing the word, I mean it is pretty goddamn obvious. We should be lobbying for restriction of physician as a final stand, as it's pretty much the only thing that still means MD short of "medical doctor."

    At this point "medical doctor" is the only way you can identify yourself 100%. Too bad it sounds even more pretentious than "physician." I'm going to continue using "doctor" and **** the NPs of the world. I mean people with bachelors degrees are called "doctor" in the UK (MBBS and MBChB), want to know why? Because they're ****ing doctors, that's why. It has nothing to do with the degree.
     
  26. Taurus

    Taurus Paul Revere of Medicine
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    Don't think for a second that the DNP's are going to be happy in the lower tier. There's less money and more crap to deal with at that level. It's called primary care in this country. The DNP's will first establish themselves in the lower tier and begin to infiltrate the upper tier because that's where the lifestyle and money are at.

    That's why I call for the unification of the physician groups. There should be no ambiguity about a degree. DO's should campaign to have their degree converted to MD's because that's the degree most recognizable.
     
  27. mig26x

    mig26x Senior Member
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    And this is why we need to contact the AMA, ABIM, ACP, FSBM and all others about this joke of DNP's becoming primary care providers.

    Online courses!! No residency!! You got to be kidding me!!!
     
  28. Ki45toryu

    Ki45toryu In this corner...
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    Thats not really a fair statement...I've met several ND's that are very capable family practice docs.
     
  29. JaggerPlate

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    Can they write scripts??? No one should be a PC if they can't write a script.
     
  30. J-Rad

    Physician Moderator Emeritus 15+ Year Member

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    Bravo for the AMA; they are correct in making this case. Why is it that I should not join the AOA because of this?

    What?!? You don't think that the AOA is some kind of monstrosity out take lives and destroy every DO's free will with their cranial mind-control techniques? Haven't you ever Googled "cranial, osteopathy, mind control, and the Illuminati"?!? Don't bury your head in the sand!!! Still was a Freemason you know!:cool:

    Jeezus. Stop the madness. People need to quit trying to merge these two separate and unequal issues. The DNP scope of practice issue is real and is of importance. The whole freakin' DO name change $h1# is pre-med and med stud stupidity. The problem is midlevels being mistaken for physician-doctors, not the other way around. Anyone is free to spend as much time on any meaningless distraction-such as the "Name Change"-as they wish (goodness knows, that's why a lot of us are her on this website:)), but why waste time when there are real issues?

     
  31. J-Rad

    Physician Moderator Emeritus 15+ Year Member

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    Depends on what state they're in. Arizona has pretty loose restrictions on their scope of practice. http://www.naturowatch.org/licensure/laws.shtml
     
  32. JaggerPlate

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  33. rkaz

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    Yes, in Arizona, naturopaths can work as PCPs. Currently there are general 1-2 year residencies available at some N.D. schools (although due to lack of supply, residencies are not required for N.D.s). Arizona also allows N.D.s to use the degree NMD, which stands for 'naturopathic medical doctor'.

    Naturopaths are also planning on creating residencies in dermatology, oncology, and pediatrics - at least, that was what I was told a few years ago when I visted an accredited naturopathic school firsthand to learn more about the program. So N.D.s will also move from primary care into the specialties.
     
    #32 rkaz, Mar 11, 2009
    Last edited: Mar 14, 2009
  34. rkaz

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  35. JaggerPlate

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    Whewww .... I don't want to go into medicine anymoreeeeeeeeeeeeeeee.
     
  36. mig26x

    mig26x Senior Member
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    Did you saw the poster that says that he thinks nurses dont need expertise/knowledge in Dx digestive disease to be experts in endoscopies??? WOW!!! what are these nurses smoking/drinking or consuming?!!! How the hell are you going to be good at something if you dont know what the hell you are looking for. So they are going to obtain a biopsy of everything that looks "unusual", I would love to see the rates of complications if thats the case.
     
  37. Haole

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    There is a sickness in this country. Everyone wants something for nothing. No longer do people want to work hard to enjoy the fruit of labor. Instead they use politics and propaganda to get what they demand, as if that honor was rightfully theirs.

    I agree that we must be proactive to do what we can to slow the progress of those who seek to encroach upon the privilege we are all working with due diligence to achieve.
     
  38. JaggerPlate

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    nuff said. :thumbup:
     
  39. mig26x

    mig26x Senior Member
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    perfectly said!!!
     
  40. Bleurberry

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    I just joined both, too. Hope you're well, drusso. Thanks for your PM&R input in the past.
     
  41. Taurus

    Taurus Paul Revere of Medicine
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    :thumbup:

    Here's an excellent recent article on this topic.

    Scope of practice expansions fuel legal battles

    Physicians combat legislative and regulatory actions they say infringe on the practice of medicine and endanger patient safety.

    By Amy Lynn Sorrel, AMNews staff. Posted March 9, 2009.

    Physicians are going to court to fight what they call an onslaught of scope of practice expansions by a growing number of allied health professionals.

    Increasingly, the medical profession is mounting legal challenges against state boards and others on issues such as nurse anesthetists performing interventional pain management and podiatrists being allowed to treat ankles as well as feet.

    "There is this overall push by allied health professionals to try to increase their scope of practice, and what's landing people in the courts is when they actually meander outside of their scope into areas considered the practice of medicine," said Timothy Miller, the Federation of State Medical Boards' senior director of government relations and policy.

    Miller said he has noticed a slight uptick in such legal battles as more allied health professionals seek change, often by turning to their state legislatures or regulatory boards. The disputes come as nonphysicians nationwide are pushing for more than 100 bills related to scope of practice, according to American Medical Association research.

    But in many cases physicians warn that allied professionals are overstepping their bounds without appropriate medical expertise. That puts patients at risk, said AMA Board of Trustees Chair Joseph M. Heyman, MD. The Litigation Center of the American Medical Association and State Medical Societies has supported physicians in many recent scope legal battles.
    More than 100 bills in state legislatures relate to scope of practice.

    "Nonphysician health care providers serve a vital role on a physician-led health care delivery team," Dr. Heyman said in a statement. "However, the health and safety of patients is threatened when health care providers are permitted to perform patient care services that are beyond their level of education and training."

    Rather than go to medical school, "the easiest way to [achieve scope expansions] is to go to the Capitol," said Jeffrey Howell, general counsel to the Missouri State Medical Assn.

    That's what happened in 2007, when certified professional midwives in Missouri succeeded in passing a state law allowing them to practice independently, he said. The MSMA, along with several other state physician groups, waged a constitutional challenge, but the Missouri Supreme Court in 2008 ruled that the medical organizations did not have standing to sue.
    Using other tactics

    When legislative avenues fail, allied health professions increasingly seek expansions through their regulatory boards, physicians said.

    The Texas Medical Assn. is engaged in legal disputes with the state's podiatrists, chiropractors, and marriage and family therapists, whose boards adopted regulations to include surgical, diagnostic and other services that physicians say tread into the practice of medicine.
    Some physical therapists are using the courts to gain direct access to patients.

    The Louisiana State Board of Nursing has asked the state Supreme Court to uphold a board rule allowing certified registered nurse anesthetists to perform interventional pain management procedures. State anesthesiologists challenged the regulation, and an appeals court in December 2008 found it violated state laws governing medical practice. The Louisiana State Medical Society is monitoring the case.

    Nonphysician boards contend that they are within their regulatory authority. But physicians say the moves are illegal.

    "A state agency is a creature of statute, so it cannot do more than what the statute says," said TMA General Counsel Rocky Wilcox. "These state agencies in Texas and in other states, as well, are attempting to expand their scope without getting the legislature's approval."

    When it comes to regulatory actions, physicians' and medical boards' first line of defense typically is to pursue an administrative objection, the FSMB's Miller said. "But if there isn't an agreement and the interpretation of that [nonphysician] board allows an increase in scope, then really the only recourse is the courts."

    Some physical therapists are using the courts to gain direct access to patients. The Washington Supreme Court will decide whether state licensure and anti-kickback laws prohibit orthopedic practices from hiring physical therapists and profiting from their services.

    Physicians maintain that patients still have a choice and the collaboration is legal. Such cooperation has helped make care more efficient, and without it, "continuity of care would disappear," said Tim Layton, Washington State Medical Assn. general counsel. The organization, as well as the American Academy of Orthopaedic Surgeons, filed friend-of-the-court briefs in the case.

    Layton noted that in 2006, physical therapists won a similar case in South Carolina.

    The American Physical Therapy Assn. contends that a conflict of interest interferes with patient care decisions when physicians own physical therapy services. The association is monitoring the Washington case.
    Access and quality

    But allied health professionals don't see such moves as expanding their scope of practice; they say they are within their realm of expertise and authority. Scope changes also can help address access to care, said Len Finnocchio, DrPH, a senior program officer at the California Health Care Foundation.

    "These battles are not going away, and the challenge for professions is to accept that we are going to have overlapping scopes in some practices," he said. "We should be using every resource to its optimum to provide health care to everyone possible at the lowest cost possible. And it boils down to: If a professional can demonstrate they have the judgment, competence and skill to provide certain services, they should be able to do that."

    For example, Louisiana is the only state that does not consider certain pain management services to be within the scope of practice of nurse anesthetists, despite uniform national educational standards, said Mitchell H. Tobin, senior director of state government affairs for the American Assn. of Nurse Anesthetists. The AANA filed a friend-of-the-court brief in the Louisiana case.

    "With an aging population and, by all reports, an underserved population suffering from chronic pain, to say this is an area exclusively carved out for doctors could have a catastrophic impact on patients and the care they receive," Tobin said.

    Courts typically evaluate public policy considerations, such as quality and access to care, when interpreting scope laws and rules, the FSMB's Miller said. But expansions should not compromise patient safety, he said. "Access to bad care doesn't really help access to care."

    Scope trials

    Scope of practice expansions increasingly are landing in the courts. Here are a few recent cases:

    Columbia Physical Therapy v. Benton Franklin Orthopedic Associates Washington Supreme Court, pending
    Issue: Whether state licensure and anti-kickback laws prohibit orthopedic surgery practices from employing physical therapists. Oral arguments have not yet been scheduled.

    Texas Orthopaedic Assn. v. Texas State Board of Podiatric Medical Examiners Texas Supreme Court, pending
    Issue: Whether a podiatric board regulation expands on a state law restricting podiatrists' scope of practice to the foot. An appeals court rejected the rule, which defined the foot to include the ankle. An appeal by the podiatric board to the state Supreme Court is on hold while the board rewrites its rules.

    Texas Medical Assn. v. Texas State Board of Examiners of Marriage and Family Therapists Travis County District Court, pending
    Issue: Whether a regulation allowing marriage and family therapists to diagnose patients infringes on the practice of psychiatry. The TMA sued the board in December 2008.

    Spine Diagnostics Center of Baton Rouge Inc. v. Louisiana State Board of Nursing Louisiana Supreme Court, 1st Circuit, pending
    Issue: Whether a nursing board rule allowing nurse anesthetists to perform interventional pain management procedures is valid. The appeals court struck down the regulation, and the nursing board appealed to the state Supreme Court.

    Missouri State Medical Assn. v. State of Missouri Missouri Supreme Court, 2008
    Issue: Whether a state law allowing certified professional midwives to practice independently is constitutional. The high court ruled that the state medical society did not have standing to sue, leaving the law intact. The court did not address the constitutional issue.

    Pushing for change

    Allied professionals continue to pursue legislation in a wide range of scope of practice issues this year. The following is a sample of some state measures under consideration.

    Licensure/regulation of lay/nurse midwives: Idaho, Illinois, Indiana, Iowa, Nebraska, New Mexico, Oregon, South Dakota, Virginia, Wyoming

    Independent practice/regulation of nurse anesthetists: Illinois, Montana, New York, Oklahoma

    Treatment authority of podiatrists to include the ankle: New York, South Carolina, Tennessee, District of Columbia

    Independent practice/prescribing authority of physical therapists: Texas, Washington

    Diagnosing/prescribing authority of chiropractors: New Mexico, Oregon

    Source: American Medical Association​
     
  42. Bleurberry

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