Scope of practice expansion: Patient safety is sacrificed for greater access


When a patient seeks the care of a professional, they expect that person to be well trained, experienced, and constantly continuing their education. As an ophthalmologist, I completed a 4-year undergraduate program at Virginia Commonwealth University, 4 years of medical school training at The University of North Texas Health Science Center, a year of a rotating internship, and a 3-year residency program in ophthalmology at Tulsa Regional Medical Center. After becoming a physician, I studied for, and passed, a rigorous didactic exam, followed by an oral exam. Finally, once I submitted my first year of surgical cases for review and approval, I became board certified in ophthalmology.  Participating in the requisite continuing education process enables me to remain on the cutting edge, and best serve the needs of my patients.

The years of hard work necessary to become a physician are well worth it. With the exceptions of my marriage and my two wonderful children, serving and helping patients as a practicing physician is my life’s greatest privilege.

The job of a physician is to provide the highest quality care to patients, while fostering a relationship based on trust. There are serious consequences for the health of our patients if that standard is eroded and compromised by well-intentioned, but misguided, interest groups, and politicians.

Our health care system is a complex tapestry of players who have specific roles in patient care. Regrettably, the federal government, and many state governments, are attempting to “fix” the already complicated and overly burdensome system beyond reasonable and safe limits, and they are considering some outlandish possibilities.

An idea being discussed here in Virginia is giving pharmacists the ability to practice medicine.  One can see the thinking: Why can’t a pharmacist just give someone a flu test and Tamiflu if a patient suspects that they have contracted the influenza virus?  While this is a great sales pitch for pharmacists seeking a new revenue stream, any physician would find such a question absurd. When legislators ask, “What’s the big deal?” it is no exaggeration to say, “life itself!”

According to the Journal of the American Academy of Pediatrics, “rapid influenza tests had an overall sensitivity of 63 percent.”  That means that patients may get a false negative reading 37 percent of the time. According to the Center for Disease Control (CDC), “the positive and negative predictive values vary considerably depending upon the prevalence of influenza … in the patient population being tested.”  While it isn’t obvious to politicians, testing, and diagnosis of the flu is complicated. A physician is trained to look beyond a test result at the other presenting symptoms and a patient’s history. A physician is trained to draw on their broad base of knowledge of other mimicking diseases and co-morbidities of the patient. A pharmacist may just see the negative test result and feel justified in withholding treatment.  This is a potentially life-threatening oversight.

In addition, when a patient has the flu or other illness, it often is their point of entry to the primary care physician. Too many patients put off health care until they are sick, meaning that patients who come into a doctor’s office for a possibly minor ailment may also have been living with hypertension, asthma, or other untreated chronic illnesses.   A pharmacist is not trained to diagnose or treat these conditions. Limiting patients’ access and point of entry to a primary care physician by increasing scope of mid-level providers, reduces the opportunity to diagnose and treat those often unknown, and potentially life-threatening diseases.

Battles involving scope of practice are going to increase as more and more legislators look for health care answers.  All it takes is one interest group to convince a legislator that diagnosing a disease is easy, or performing a procedure is simple.

Here in Virginia, for example, optometrists brazenly pushed a bill that would permit them to perform any ocular surgery except those requiring lasers or those that would require general anesthesia.  The mood of our legislators that year was to do all things that would increase patient access to care. We never even had a debate on the committee floor; instead, the General Assembly asked for a bill that optometrists and ophthalmologists could “live” with. Fortunately, we minimized the damage by restricting that far-reaching bill to the injection of a chalazion with a steroid only.  While this was a ‘win’ for Virginia health care, there was never any consideration of what the patients’ could “live with.”

Like pharmacists are now doing, optometrists are seeking to elevate themselves to the status of an eye physician and surgeon. They, however, want to skip medical school and the years of training required to become a board-certified eye physician and surgeon. They are focused on attaining that status through the political process and turning a blind eye to the health and safety of patients.

I suggest that if the privilege of practicing medicine, appropriately earned after years of rigorous medical school and residency training is eroded, by the passage of myopic expansion of scope legislation, every patient will be at risk.   There are no shortcuts to educating highly skilled, competent, and qualified physicians.

Physicians must stand up for patient safety and advocate on behalf of patients – specialty and state medical societies can help.  Your legislators are listening to stakeholders at their doorstep.  To be a part of the solution, you must remember to step outside the polarizing and political arguments, and simply stay true to patient care and safety.  Many legislators simply do not know, what they do not know.  It is our job to inform them! It is up us to inform legislators of the unintended consequence of legislating medical and surgical privilege and enable them to keep the safety of their constituents, and our patients, first and foremost.

As we say here in Virginia, if you are not at the table, you and your patients will be on the menu.

Suzanne M. Everhart is an ophthalmologist and immediate past president, Virginia Society of Eye Physicians and Surgeons, and member, Medical Society of Virginia.

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