Preventing doctors from practicing at the top of their license

The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.” Often, you’ll hear people advocate that every health care worker should “practice at the top of their license.” What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time. Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart. This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

(Just for fun, I sent an email one day to the head of environmental services at my hospital, asking if the cleaning crew could attach a new suction canister to the anesthesia machine after they remove the dirty one from the previous case. The answer was no. His reasoning was that this would delay the workflow of the cleaning crew.)

Then I checked the circuit on the anesthesia machine, assembled syringes and needles, and drew up medications for the case. To each syringe, I attached a stick-on label with the name of the medication, and wrote by hand on each label the date, the time, and my initials. These tasks, as you might guess, don’t require an MD degree either. A pharmacy can issue pre-filled syringes, and clever machines can generate labels with automatic date and time stamps.

It was now 7 a.m., and I moved on to the preoperative area to meet my first patient. I introduced myself, and started to interview her. Then I noticed that no one had started her IV yet. I asked the patient’s nurse if he would set up the IV fluid, which had already been ordered via the electronic medical record. “If I have time,” he replied.

The nurse, in fairness, was busy with his own tasks — few of which required a nursing degree. He was doing clerical data entry in the computer, recording answers to a host of questions such as whether or not the patient had stairs in her home. In between, he was answering the phone, as there is no desk clerk to pick up the phone or check for incoming faxes.

So I got hold of a liter bag of IV fluid, attached sterile tubing to it, and flushed the air out of the tubing. Then I did my first clinical care of the day, inserting an IV catheter into a vein in the patient’s hand. For the record, IV starts are well within the scope of nursing practice and don’t require a physician.

Finally, at 7:07, I began my clinical assessment of the patient’s readiness for anesthesia, which was the first activity that approached working at the top of my license. Multiply the 22 minutes I had already spent doing lower-level tasks by hundreds of cases per year per physician, and you’ll start to see what a colossal waste of resources is occurring every day.

Not just at my hospital but also at hospitals nationwide, administrators have pared back support staff in an effort to cut costs. Their reasoning appears to be that lower-level support staff can’t do more advanced tasks, but their work can be “rolled into” what physicians and nurses do. A nurse, so this thinking goes, can easily answer a telephone during idle moments, though most nurses I know would laugh bitterly at the idea that idle moments occur very often. A physician can type on a computer keyboard and enter data while doing a patient’s physical exam, regardless of how much extra time this takes compared to dictating the same information. Don’t think about how much the need to focus on the computer screen detracts from the doctor’s personal interaction and eye contact with the patient.

Bureaucrats and administrators advocate “practicing at the top of the license” as a not-too-subtle way of enabling health care workers with lower-cost skills to replace physicians. An alarming example of this is the Veterans Health Administration’s recent attempt to change VA rules so that advanced practice nurses could work without any physician supervision at all. Vigorous opposition from veterans’ advocates has stymied this initiative so far, but it could rise again.

These same bureaucrats and administrators eliminate lower-paid personnel — desk clerks, transport orderlies, and dictation typists, for instance — to trim their budgets, with no regard for how much they prevent physicians and nurses from truly practicing at the top of their licenses. Someone still has to do the tasks that were previously done by those employees, and that someone, too often, is a physician or nurse.

The next time you wonder where your health care dollars are going, remember this: Your physicians and nurses would like to spend more time taking care of you. But they may be too busy doing other things.

Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA.  She blogs at A Penned Point

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  • Dr. Drake Ramoray

    I don’t believe this author understands the context in which “top of their license” is typically used. It has very little to do with ancillary staff, janitors, or transcriptionists etc. and has everything to do with “simple” cases or patients vs. “complex” cases or patients. It is a phrase used to encourage the use of CRNA’s or PA’s/NP’s in place of physicians in an effort to reduce costs. I am baffled as to how given the current battle with non-MD providers performing anesthesia this hasn’t been mentioned in your article.

    Furthremore, while NP’s and PA’s may wish to always perform at the “top of their license.” Physicians (at least outpatient primary care docs and endocrinolgists) do not want to practice medicine this way. The phrase is code for giving me nothing but the hard complicated patients after they have become difficult or complicated without establishing a relationship beforehand. I get no break, no chance to make a difference in the early stages of a disease process, establish no rapport with patients before they become complicated, and get paid less to boot since I can see many more simple cases in the time it takes to see one complicated patient. I haven’t even touched on what this would do to physicians within the scope of a pay for performance system.

    In order to address the challenges in our evolving healthcare system, one must understand the terminology and the intentions of those who use these terms. While doctors are certainly spending more time on non-clinical work (and this is indeed a problem), and I am not trying to start a NP/PA vs. MD fight on this site; this article fails to address or understand the issue of “top of their license”, the context in which it is typically used, and its impact on the practice of medicine and how it relates to our changing healthcare environment.

    • NPPCP

      Exactly Dr. Drake. Perfect clarification. And as far as the VA debacle, Karen should note that all of this happened with APNs squarely under the “supervision” of physicians. I wouldn’t be mentioning that too much Karen. Physicians are in charge of the VA (see congressional hearings over the last few days). So the buck stops with them and the administrators – and many of them ARE the administrators. Things would not be any worse with APNs being allowed to practice at the “top of their license” to free time up to see more patients.

      • NPPCP

        And thanks for pitching in and doing things you really don’t have to do when you get to work Karen. That is kind of you.

      • Dr. Drake Ramoray

        While your points about the VA are valid, and certainly raises the question of what “supervision” means, suggesting that you can do better than the VA is not exactly a logo I would want to put on a T-shirt.

        • NPPCP

          No – definitely not suggesting that. Just saying to Karen that “she” HAS been in charge there and HAS been supervising APNs and her beloved CRNAs. How has that worked out for you? Obviously, as she already knows, NPs at the VA practice with “token supervision” and the concept is a farce.

          • Dr. Drake Ramoray

            “Things would not be any worse with APNs being allowed to practice at the “top of their license” to free time up to see more patients.”
            While most of the current issue has been regarding access to care, it is well known that the care provided at the VA is inferior. Yes the physicians are in charge and as you point out their supervision is a farce. But why does that mean the care (not the wait times and secret lists) will improve if the NPs are unsupervised if its already bad while “supervised?” If the current supervision is a farce wouldn’t that show that the NPs don’t do well unsupervised because they aren’t really supervised in the first place?

            I am really trying hard not to make this a PA vs. NP post but poor care with the existence of supervision in name only is not a strong case for the absence of supervision but more supervision. There are far better examples you can use as evidence of your position than that of the VA.

            I am not as opposed to NPs providing care independently as some of my colleagues, but touting the VA and it’s ineptness only makes a case for less beuracracy and the dangers of government run medicine (not the same as single payer), and in my opinion contribute in a meaningful way to the dialogue of NP’s practicing independently and providing quality care in many states.

          • NPPCP

            I completely understand your point and agree completely. This is more about the author understanding that there are two sides to every story. When it comes to APNs she is a mouthpiece for MDAs and it gets weary. The black and white point is (for Karen) – Don’t mention the VA and APNs as YOU are in charge there. We are your tools as you wish we are. If there is a fault, it is administrators, many of them being physicians. No other point meant Dr. Drake.

    • buzzkillerjsmith

      Bingo. Working at the top of one’s license at all times is like keeping the tachometer continuously in the red zone. Also Dr. S. does misunderstand the term.

      Also, having us fool around with tasks that others could do makes economic sense to our overlords when we have to do those things on our own time for no extra pay. Diabolically clever on their part.

  • azmd

    These are all valid concerns, but as others have pointed out, “practicing at the top of your license” is more of an economic construct involving having mid-level practitioners siphon off all the easy cases so that MDs are forced to see only the sickest patients. Basically, it’s a way of rationing healthcare.
    If the administrators can force you to do clerical, nursing and janitorial work in addition to managing those difficult patients, they get bonus points.
    Why our professional organizations are rushing to climb on board with this concept is a complete mystery to me.

    • NPPCP

      I could not agree more. I manage what we would all consider very complex patients – very little “easy” stuff. That is not what I am concerned about. It is allowing everyone to practice at their demonstrated level of competence. But, to your point, yes, NPs could only see so many thousands of sore throats before their motor burns up and MDs could only see so many hundreds of multi-system patients before they catch fire and incinerate. The “top of your license” article here is just more prodding and nagging. It has nothing to do with the real world we are all talking about.

  • Kristy Sokoloski

    It’s not just the AAFP that thinks this thought. A number of other organizations, and people of the lay public think so too.

  • DeceasedMD1

    I’m afraid her point gets lost because she is using the term “top of the license”, out of text but i think the idea is solid issue with Corpmed giving menial tasks to clinicians when that use to be admin work.

  • betsynicoletti

    I don’t know about “top of your license” but I do know that there are assessments, decisions and interventions that only a physician can make. And, that we burden the physician with a multitude of tasks that someone else could do.

  • DD Cross (MD)

    Rationing, misdirection, and dollars for drones. How will you convince young folks to buy into high deductible plans with plenty of out-of-pocket expense to see a non-physician provider? How will this ‘New Era” incentivize folks to buy into a system that steers them away from physician care in a: “Your problems aren’t serious enough to see the doctor,” manner? How long will Americans tolerate a system that devalues their medical complaints or conditions by establishing non-physician provider protocols for more money than they spend for week’s worth of groceries? This looks like a formula for sicker, uninsured patients AVOIDING standing in line to see the physician “extender,” because our culture has branded, cherished, and revered, MDs. The current, as well as past generations have come to “accept no substitutes,” when they’re not well. Affordable Care Act? Good luck with devaluing physicians?

  • DD Cross (MD)

    Rationing, misdirection, and dollars for drones. How will you convince young folks to buy into high deductible plans with plenty of out-of-pocket expense to see a non-physician providers? How will this ‘New Era” incentivize folks to buy into a system that steers them away from physician care in a: “Your problems aren’t serious enough to see the doctor,” manner? How long will Americans tolerate a system that devalues their medical complaints or conditions by establishing non-physician provider protocols for more money than they spend for week’s worth of groceries? This looks like a formula for sicker, uninsured patients AVOIDING standing in line to see the physician “extender,” because our culture has branded, cherished, and revered, MDs. The current, as well as past generations have come to “accept no substitutes,” when they’re not well. Affordable Care Act? Good luck with devaluing physicians?

  • Dave Mittman, PA, DFAAPA

    More turf nonsense. Practicing at the top of anyone’s license is the removal of barriers so that one is allowed to do what you were educated to do. Plain and simple.
    Don’t read more into it.
    PAs and NPs actually are educated. PA programs are eight weeks shorter in hours than physician medical schools. Then we keep learning. Let’s say after eight years of working in a specialty you move to a state with regulations that are so overbearing that you can not deliver care as you were educated to do. Or as you previously have. That is NOT practicing to the level you were educated at.
    I am sure our many readers here think that is fair, but it becomes a problem when there are people who need your care and you can’t deliver it. That is a problem.
    The constant bashing of NPs and PAs is unprofessional and only seems like pure turf protection.
    Dave