Practice at the top of your license: What does that really mean?

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Much has been discussed in recent years around the concept of “practicing at the top of your license.”  But what does this really mean?

The most common definition is that each medical professional’s routine activities should utilize the full extent of their education, training, and experience, and that their time should not be spent doing things that could be effectively done by someone else with a different set of skills.  This typically relates to patient care where in some clinical settings it has been estimated that upwards of 80 percent of medical professional time may be spent performing activities such as clerical tasks that do not require a physician’s level of training.

I’m sure the experience of performing routine and often administrative activities that do not require advanced training is universal to all physicians.  This is not to suggest that practicing at the top of your license means that we should be detached from the day-to-day activities of caring for patients since directly engaging with them, often through performing basic clinical tasks that could reasonably be done by others (such as checking or confirming vital signs), is critical to developing and growing the doctor-patient relationship and helpful in creating the context in which the highest value clinical work is able to take place.  However, when the need to perform these essential activities is due primarily to lack of adequate support or staffing, and those with more advanced training are required to do them to ensure quality care, this keeps them from practicing at the top of their license and at its worst can markedly diminish the joy of practicing medicine.

However, there is another, perhaps even more important aspect of working at the top of your license that needs to be considered.  It is the fact that each medical profession involved in patient care brings a unique blend of philosophical approach, educational background, clinical experience, and specific set of skills to the process, and that working at the top of your license means that we are able to optimally take advantage of this cross-discipline richness in caring for patients.  But what seems to happen too often in our current health care system is that what each of us is uniquely qualified to do is either over-emphasized or under-appreciated.  This not only limits our ability to provide the best care possible, but also risks eroding the personal and professional satisfaction in doing what we were trained to do.

Over-emphasizing our professional differences can lead to fragmentation of care and the failure to recognize the overall context in which care is provided.  For example, I’ve worked with many specialist and subspecialist colleagues who maintain a very narrow focus in their area of expertise when seeing my patients.  They, therefore, tend to address only one isolated problem in an otherwise medically complex individual, thus failing to understand how their diagnostic and treatment recommendations fit into a comprehensive management approach that is centered on the unique needs and wants of a particular patient.

Conversely, under-appreciating the unique skills and abilities that each medical discipline brings to the table may fail to take full advantage of what each has to offer.  A prominent example of this occurs frequently in primary care settings where different medical disciplines – physicians of different training backgrounds, nurse practitioners, physician assistants, and others – are lumped together as “providers” without a clear delineation of what level of expertise each has and how they may best work together in caring for patients.  This “homogenization” of professions can have significant detrimental effects, with the lack of clarity of roles leading to the suboptimal matching of clinician skills with the needs of individual patients, and may also be confusing to patients as they are likely unable to appreciate the particular expertise of those involved in their care.  For individual clinicians, it may also engender a sense of demoralization and contribute to burnout as they may not feel as though their education, training, experience, and expertise is recognized or appreciated in addition to not being fully utilized in the patient care process.  And perhaps most damaging may be that the lack of delineation of different skill sets and their appropriate application in clinical settings may create an unhealthy “competition” between disciplines in terms of who is best qualified to perform specific clinical activities.

Truly working at the top of ones’ license, therefore, seems to mean that each of us involved in patient care needs to bring the best that our training and expertise enables us to provide to the clinical process.  Doing this collaboratively with other medical professionals requires that we have honest discussions with each other around our particular strengths so that we can best utilize our different skills in caring for patients in a comprehensive and complementary way, and ensuring that our clinical systems and teams are structured and adequately supported to make that happen.

We owe our patients the best care we can give, and the only way to do this is for us as medical professionals and the health care systems in which we work to understand what it means to truly practice at the top of each individual’s license.

Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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