" It's time to became aware of the AMA Scope of Practice Partnership, which has implications for conventional as well as CAM providers.
AMA Policy D-35.993 Limited Licensure Health Care Provider Training and Certification Standards, provides:
Our AMA, along with the Scope of Practice Partnership and interested Federation partners, will study the qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes, and peer review of the limited licensure health care providers and limited independent practitioners, as identified by the Scope of Practice Partnership, and report back at the 2006 Annual Meeting. (Res. 814, I-05)
This is in line with a wave of AMA resolutions going after the scope of practice issue, including this one:
AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Introduced by: American Society of Anesthesiologists
Subject: Need to Expose and Counter Nurse Doctoral Programs (NDP) Misrepresentation
Referred to: Reference Committee B
(John M. Zerwas, MD, Chair)
Whereas, The patient-physician relationship is the foundation of effective medical care; and
Whereas, Patient trust is a cornerstone of good medical care delivery; and
Whereas, Quality medical care requires appropriate education, skills, training and experience, as recognized and upheld in state laws; and
Whereas, State-based regulation of medicine should be aggressively protected to ensure patient safety and optimal clinical outcomes; and
Whereas, Confusion, injury and a breakdown of quality medical care would result from persons not trained as medical doctors and doctors of osteopathy misrepresenting themselves as "doctors" in clinical settings; and
Whereas, The American Association of Colleges of Nursing plans to convert its advance nurse practice degree from master's programs to "Doctor of Nursing Practice" (DNP) by the year 2015; and
Whereas, Four such "doctoral" nurse anesthesia programs currently are offered in the United States and more are planned; and
Whereas, The Nurse Anesthesia Accreditation Council has mandated doctoral training for all nurse anesthetists by the year 2015; and
Whereas, At least one of the DNP programs is advertising its programs as "similar in concept to practice doctorates in other professions such as medicine (MD), law (JD), and dentistry (DDM)"; and
Whereas, The quality of care rendered by individuals with a nurse doctoral degree is not equivalent to that of a physician (MD or DO); and
Whereas, Nurses and other non-physician providers who hold doctoral degrees and identify themselves to patients as "doctors" will create confusion, jeopardize patient safety and erode the trust inherent in the true patient-physician relationship; and
Whereas, Patients led to believe that they are receiving care from a "doctor," who is not a physician (MD or DO), but who is a DNP may put their health at risk; therefore be it
RESOLVED, That it shall be the policy of our American Medical Association that institutions offering advanced education in the healing arts and professions shall fully and accurately inform applicants and students of the educational programs and degrees offered by an institution and the limitations, if any, on the scope of practice under applicable state law for which the program prepares the student (New HOD Policy); and be it further
RESOLVED, That our AMA work jointly with state attorneys general to identify and prosecute those individuals who misrepresent themselves as physicians to their patients and mislead program applicants as to their future scope of practice (Directive to Take Action); and be it further
RESOLVED, That our AMA pursue all other appropriate legislative, regulatory and legal actions through the Scope of Practice Partnership, as well as actions within hospital staff organizations, to counter misrepresentation by nurse doctoral programs and their students and graduates, particularly in clinical settings. (Directive to Take Action)
For more detailed notes on the Scope of Practice Parternship, see B of T (AMA Board of Trustees) Report 24 - A-06, on Limited Licensure Health Care Provider Training and Certification Standards, which can be found on the American Medical Association website (ama-assn.org/) and is reproduced below. This report is in line with efforts to protect the public from unscrupulous and unqualified practitioners, but also echoes a protectionist history (see Complementary and Alternative Medicine: Legal Boundaries and Regulatory Perspectives, 1998) and the kind of turf battles that have characterized not only medicine, but the health professions in general (Beyond Complementary Medicine, 2000).
The chiropractic community has responded in a wave of protests, including characterization of the AMA Scope of Practice Partnership as "The Next Attempt to "Contain and Eliminate" Chiropractic?" (Dynamic Chiropractic, June 6, 2006, Volume 24, Issue 12, http://www.chiroweb.com/archives/24/12/01.html). Dynamic Chiropractic analogized the AMA Scope of Practice Partnership to the attempt by the AMA to eliminate the chiropractic profession in the Wilk case some years ago. The article charged:
"More than 40 years ago, the American Medical Association (AMA) made its first attempt at destroying the chiropractic profession when it formed the Committee on Quackery in November 1963. Interestingly enough, the committee's original name was the Committee on Chiropractic, but the name was later changed so as to not lend credibility to the chiropractic profession. The primary objective of the Committee on Quackery was to "contain and eliminate" chiropractic as a recognized health care service in the United States. While its efforts were ultimately unsuccessful, its activities are believed to have delayed the full integration of chiropractic into the health care marketplace for several years."
More posts to come on the likely federalization of the scope of practice and "unlicensed practice of medicine" issue.
At the 2005 American Medical Association (AMA) Interim Meeting, the House of Delegates (HOD) adopted as amended Resolution 814 entitled "Limited Licensure Health Care Provider Training and Certification Standards." Resolution 814 calls on the AMA, along with the Scope of Practice Partnership (SOPP) and interested Federation partners, to study the qualifications, education, academic requirements, licensure, certification, independent governance, ethical standards, disciplinary processes, and peer review of the limited licensure health care providers and limited independent practitioners, as identified by the SOPP.
Testimony before the Reference Committee and HOD was generally supportive of this resolution. Testimony also indicated that the SOPP Steering Committee had identified a study similar to the one called for in Resolution 814 as one of its first priorities, once the SOPP had officially come into existence. The Reference Committee concurred with the testimony presented that the issue raised in Resolution 814 was one to be addressed as soon as possible. As a result, the Reference Committee recommended that the initial resolve be modified to reflect the involvement of the SOPP in conducting the study called for in Resolution 814. However, the Reference Committee, noting the extensive nature of Resolution 814's study, indicated that it "under[stood] that a report back at the 2006 Annual Meeting may only be a preliminary update on the Partnership's progress on this issue." The HOD voted, therefore, to have the AMA report back at the A-06.
RELEVANT AMA POLICY
The AMA has extensive policy related to scope of practice issues. A sampling of AMA policies most relevant to Resolution 814 are as follows:
· E-3.03 - Allied Health Professionals (AMA Policy Database). E-3.03 states that "[p]hysicians often practice in concert with allied health professionals such as, but not limited to, optometrists, nurse anesthetists, nurse midwives, and physician assistants in the course of delivering appropriate medical care to their patients. In doing so, physicians should be guided by the following principles: (1) It is ethical for a physician to work in consultation with or employ allied health professionals, as long as they are appropriately trained and duly licensed to perform the activities being requested. (2) Physicians have an ethical obligation to the patients for whom they are responsible to ensure that medical and surgical conditions are appropriately evaluated and treated. (3) Physicians may teach in recognized schools for the allied health professionals for the purpose of improving the quality of their education. The scope of teaching may embrace subjects which are within the legitimate scope of the allied health profession and which are designed to prepare students to engage in the practice of the profession within the limits prescribed by law. (4) It is inappropriate to substitute the services of an allied health professional for those of a physician when the allied health professional is not appropriately trained and duly licensed to provide the medical services being requested. (I, V, VII) Issued December 1997.
· H-35.985 - AMA Role in Allied Health Education and Accreditation. H-35.985 calls on the AMA to ". . . reaffirm its commitment to promoting quality in allied health education. (CME Rep. E, I-86; Amended by Sunset Report, I-96).
· H-35.996 - Status and Utilization of New or Expanding Health Professionals in Hospitals. H-35.996 provides "(1) The services of certain new health professionals, as well as those professionals assuming an expanded medical service role, may be made available for patient care within the limits of their skills and the scope of their authorized practice. The occupations concerned are those whose patient care activities involve medical diagnosis and treatment to such an extent that they meet the three criteria specified below: (a) As authorized by the medical staff, they function in a newly expanded medical support role to the physician in the provision of patient care. (b) They participate in the management of patients under the direct supervision or direction of a member of the medical staff who is responsible for the patient's care. (c) They make entries on patients' records, including progress notes, only to the extent established by the medical staff. Thus this statement covers regulation of such categories as the new physician-support occupations generically termed physician's assistants, and those allied health professionals and nurses functioning in an expanded medical support role. It is not intended to cover regulation of nurses and allied health professionals performing their regular and customary roles, nor nurse practitioners functioning within the legal definition of nursing. (2) The hospital governing authority should depend primarily on the medical staff to recommend the extent of functions which may be delegated to, and services which may be provided by, members of these emerging or expanding health professions. To carry out this obligation, the following procedures should be established in medical staff bylaws: (a) Application for use of such professionals by medical staff members must be processed through the credentials committee or other medical staff channels in the same manner as applications for medical staff membership and privileges. (b) The functions delegated to and the services provided by such personnel should be considered and specified by the medical staff in each instance, and should be based upon the individual's professional training, experience, and demonstrated competency, and upon the physician's capability and competence to supervise such an assistant. (c) In those cases involving use by the physician of established health professionals functioning in an expanded medical support role, the organized medical staff should work closely with members of the appropriate discipline now employed in an administrative capacity by the hospital (for example, the director of nursing services) in delineating such functions. (BOT Rep. G, A-73; Reaffirmed: CLRPD Rep. C, A-89; Reaffirmed: Sunset Report, A-00).
· H-160.949 - Practicing Medicine by Non-Physicians. H-160.949 states that "[o]ur AMA: (1) urges all people, including physicians and patients, to consider the consequences of any health care plan that places any patient care at risk by substitution of a non-physician in the diagnosis, treatment, education, direction and medical procedures where clear-cut documentation of assured quality has not been carried out, and where such alters the traditional pattern of practice in which the physician directs and supervises the care given; (2) continues to work with constituent societies to educate the public regarding the differences in the scopes of practice and education of physicians and non-physician health care workers; (3) continues to actively oppose legislation allowing non-physician groups to engage in the practice of medicine without physician (MD, DO) training or appropriate physician (MD, DO) supervision; (4) continues to encourage state medical societies to oppose state legislation allowing non-physician groups to engage in the practice of medicine without physician (MD, DO) training or appropriate physician (MD, DO) supervision; and (5) through legislative and regulatory efforts, vigorously support and advocate for the requirement of appropriate physician supervision of non-physician clinical staff in all areas of medicine. (Res. 317, I-94; Modified by Res. 501, A-97; Appended: Res. 321, I-98; Reaffirmation A-99; Appended: Res. 240, Reaffirmed: Res. 708 and Reaffirmation A-00; Reaffirmed: CME Rep. 1, I-00)."
· H-275.976 - Boundaries of Practice for Health Professionals. H-275.976 provides "(1) The health professional who coordinates an individual's health care has health professional who coordinates an individual's health care has an ethical responsibility to ensure that the services required by an individual patient are provided by a professional whose basic competence and current performance are suited to render those services safely and effectively. In addition, patients also have a responsibility for maintaining coordination and continuity of their own health care. (2) As a supplement to strengthen state licensure of health professionals, standard-setting and self-regulatory competency assurance programs should be conducted by health professions associations, certifying and accrediting agencies, and health care facilities. (BOT Rep. NN, A-87; Reaffirmed: Sunset Report, I-97).
SCOPE OF PRACTICE PARTNERSHIP
The Scope of Practice Partnership (SOPP) was created by a coalition comprised of the AMA, six national medical specialty societies (American Academy of Ophthalmology, American Academy of Orthopaedic Surgeons, American Academy of Otolaryngology - Head and Neck Surgery, American Psychiatric Association, American Society of Anesthesiologists, and American Society of Plastic Surgeons) and six state medical associations (California Medical Association, Colorado Medical Society, Maine Medical Association, Massachusetts Medical Society, New Mexico Medical Society, and Texas Medical Association). Members of this coalition (referred to as the "SOPP Steering Committee") agreed that it was necessary to concentrate the resources of organized medicine to oppose scope of practice expansions by allied health professionals that threaten the health and safety of the public. The SOPP Steering Committee agreed that this would best be accomplished through a wide-range of efforts, including a combination of legislative, regulatory and judicial advocacy, as well as programs of information, research and education. Moreover, the SOPP Steering Committee was committed to creating a true partnership that operated by consensus and functioned in a cooperative and coordinated manner.
The SOPP Steering Committee has met either in person or via conference call quarterly for the last two years. During this time, it developed various core documents that serve as the foundation for the SOPP. Three main principles that the SOPP Steering Committee agreed to are as follows:
· Oversight: A Steering Committee currently composed of six state medical association representatives, six national medical specialty society representatives, and one AMA representative will oversee the activity of the SOPP.
· Membership: Input from all state medical associations and national medical specialty societies will be vital to the viability of the SOPP. The SOPP and its Steering Committee will be open for participation by any state medical association and/or national medical specialty society represented in the AMA HOD. The greater the number of members, the greater the resources (both financial and in-kind) the SOPP will have to advance its advocacy efforts.
· Funding: SOPP project funding will be derived solely from the annual dues collected from all medical societies participating in the SOPP. In other words, the amount of dues raised in any given year will dictate the SOPP's level of involvement in scope of practice initiatives.
· Consensus: The SOPP Steering Committee has identified consensus decision-making as one of its fundamental operating principles. This is a process that attempts to recognize and account for the differing, legitimate interests of all of its members and maximizes opportunities to resolve differences and reach agreement.
The AMA also sought a detailed and exhaustive legal review of the SOPP by its Office of General Counsel (OGC). This was done in order to ensure that the creation of the SOPP was not in violation of any existing antitrust, truth in advertising, election, or lobbying laws. Understandably, this was a very extensive review. Ultimately, the AMA OGC approved of the underlying principles governing the SOPP. Furthermore, per AMA OGC's insistence, all members of the SOPP will be required to sign a Statement of Legal Compliance, which ensures that all participating medical societies are committed to conducting all activities of the SOPP in compliance with all applicable federal, state, and local laws. The Statement of Legal Compliance reiterates that at all times, the SOPP will have as its goal the protection of the health and safety of patients whose well-being may be threatened by health care practitioners who lack education, training or experience to perform procedures for which they seek licensure.
From its inception, the SOPP Steering Committee has envisioned that the SOPP's involvement in scope of practice "campaigns" would be multi-dimensional. The members of the SOPP Steering Committee had the foresight to see that the SOPP would become involved not only in the individual state legislative, regulatory, and judicial advocacy, but also in programs of information, research and education. From the very start, the SOPP Steering Committee's discussions focused on two "top priority" research projects. Both studies would be extensive and therefore, benefited from the formation of the SOPP and the concentration of the Federation's resources. The first of these studies would focus on discrediting access to care arguments repeatedly made by various allied health professionals when seeking to expand their respective scope of practice, particularly in rural states. The second study, and arguably the more extensive of the two, would concentrate on completing educational/training/licensure comparisons of specific allied health professions and the medical profession. Obviously the second study aligns perfectly with Resolution 814.
Official Roll-Out of SOPP
The SOPP was officially rolled out at the AMA Advocacy Resource Center's (ARC) 2006 State Legislative Strategy Conference in January. Up to that point in time, the SOPP had been favorably received by the Federation and was enthusiastically embraced by the attendees of the conference. During this meeting, AMA staff sought input from the conference attendees regarding a proposed draft 2006 SOPP Work Plan. This work plan provided a series of action steps which operationalized the SOPP. One of these steps included the need for the SOPP Steering Committee to identify SOPP projects for 2006. The work plan included the following ideas for possible SOPP projects: (1) education/training/ certification/licensure/ethical standards/disciplinary processes/peer review/etc. comparisons between the medical profession and specific allied health professions (per Resolution 814); (2) discrediting access to care arguments made by various allied health professionals, particularly in rural areas of a state; (3) creating maps that identify the locations of physicians, by specialty, to be used to counter claims that physicians do not exist in certain areas of a given state; and (4) same as (1) but for the medical profession and specific complementary/alternative medicine professions. It is notable that the draft SOPP Work Plan clearly identifies (1) as its "top priority" for SOPP projects in 2006.
Since the 2006 State Legislative Strategy Conference, ARC staff has sent letters to the executive directors of all state medical associations and national medical specialty societies recognized by the AMA HOD. These letters included, as attachments, the SOPP's core documents, as well as the Statement of Legal Compliance for all medical societies to sign and an invoice for annual dues for all national medical specialty societies and the AMA to process. ARC staff is currently fielding any questions associated with these memos and processing all dues that are sent by the Federation.
Furthermore, the SOPP Steering Committee considered the draft SOPP Work Plan at its face-to-face meeting on March 13, 2006. The priority for this meeting was determining the amount of annual dues raised and based on that, identifying SOPP 2006 projects. Shortly after the SOPP Steering Committee meeting, the ARC team added a new full-time legislative attorney who was hired to focus their attention on scope of practice issues. This is an exciting addition to the ARC team and signifies the AMA's continued commitment to addressing scope of practice issues in an effective, collaborative and cooperative manner with its Federation partners.
The AMA will continue to play an active role as a convener and consensus builder between state medical associations and national medical specialty societies with respect to scope of practice issues. In this role, the AMA will continue to support the SOPP and be an active member of its Steering Committee. Moreover, ARC staff will continue to monitor and track scope of practice developments at the state level, expand its Scope of Practice Campaign when deemed necessary, and work with affected state medical associations and national medical specialty societies, at their request, to oppose allied health professions that seek to expand their scope of practice in a manner that threatens the health and safety of the public. The Federation has been energized by the development of the SOPP and the AMA will continue its work in bringing organized medicine together to fight these scope of practice battles."