Purpose
ACEP’s effort to mitigate the expansion of non-physician Scope of Practice (SOP) requires national education and advocacy alongside state-level efforts to influence proposed legislation and regulation.
Historically, once a group has succeeded in getting their SOP expanded, it’s nearly impossible to dial it back to the previous status quo.
We, as emergency physicians, need to keep the focus on patient safety. We have succeeded by highlighting the unique nature of emergency care and the training and education that make emergency physicians the most qualified professionals to lead the emergency care team.
Our efforts are working. A prime example of this is the 2023 Indiana legislation requiring a physician in the ED. The successful campaign was used as the basis for the same effort in Virginia. We can build upon the work of our colleagues in other states and craft them to address the particular legislative and practice climate in our own state.
But to stop the spread of these harmful policies, legislators and policymakers need to hear directly from you.
As stated in ACEP’s June 2023 revised Guidelines Regarding the Role of Physician Assistants and Nurse Practitioners in the Emergency Department: “Physician assistants (PAs) and nurse practitioners (NPs) serve as integral and valued members of the physician-led emergency department care team. They do not possess the training and expertise in emergency medicine that may only be acquired through successful completion of an ACGME accredited emergency medicine residency training program - there are no exceptions. The American College of Emergency Physicians (ACEP) believes that regardless of where a patient lives, all patients who present to emergency departments (EDs) deserve to have access to high quality, patient-centric care delivered by emergency physician-led care teams”.
How to Use This Toolkit
Utilizing this toolkit as a framework for a discussion about how to approach passing state legislation is the first step. The next step is to talk with legislative leaders in other states who have dealt with the same or similar issues. Your state chapter should also be working closely with your state medical association. They will have additional AMA resources as well as a lobbyist to help guide your thought process. Lastly, forming coalitions with other medical specialties will be essential to your success. Finding common ground with other similar specialties can lead to stronger coalitions when it is time to pass meaningful legislation.
ACEP has also created a Scope of Practice talking points memo. This is helpful when starting conversations with legislators about how to fix the current scope of practice issues in your state.
The State Legislative & Regulatory Affairs Committee also maintains a work group dedicated to helping states with scope of practice issues. Additional information is available by contacting Adam Krushinskie, ACEP’s Senior Director of State Legislative and Reimbursement at akrushinskie@acep.org
Why It Is Important
Our patients prefer emergency physician-led care teams. Nine in ten adults say it is an “essential” or “high” priority for people to have 24/7 access to the ER, the highest of any utility or service that communities provide. Emergency physicians are the most highly trained and qualified health care professionals able to make medical decisions in an emergency.
When it matters most, patients want the most qualified health care professionals in the room. There is no substitute for a licensed, trained, and board-certified emergency physician.
Shifts in the emergency department are exhilarating and unpredictable, but a licensed and board certified emergency physician completes thousands of hours of training, and more than a decade of expert-level education, so that they are prepared in a moment’s notice for any challenge that comes their way. An emergency physician is required to complete 11 or more years of training and is the only member of a care team that completes a medical residency. In comparison:
- Registered nurse: 4 years of training
- Nurse practitioner: 5-8 years of training
- Physician assistant: 7 years of training
Emergency physicians also have significantly more hands-on training with real patients than the other professionals on their team. An NP is required to clock at least 500 clinical hours. For a physician the requirement is at least 12,000 hours. As the leader of a care team, emergency physicians work closely together with nurses, NPs, PAs, and others. Each team member has unique skills and training that allows them to make important contributions to the team.
Patients have difficulty identifying who leads their care while they are in the emergency department. While they prefer to be treated by an emergency physician, they are often not clear about the roles of each team member or who is leading their care. There should be less ambiguity about the distinctions between different members of a care team, especially in an emergency.
Physician PA Supervision Ratios
PA scope of practice is usually determined by the supervising/collaborating physician in the emergency department where they work. ACEP advocates for limitations on the number of PAs a single EM physician must supervise at one time in the ED.
Limiting the number of PAs supervised by EM physicians will prevent:
- Poor quality of care
- Mistakes that could lead to malpractice claims
- Burnout/ and lack of physician well being
39 states have established limits on the number of PAs a physician can supervise or collaborate with. The national average for supervision ratios is four (4) PAs for every one (1) physician.
Note: State with no ratios include: AK, AR, ME, MA, MI, MN, MS, NM, NC, ND, RI, TN
47 states require PAs to be supervised by a practicing physician. In only 2 states, PAs are subject to collaborative agreements with physicians (AK, IL).
2 states allow for an alternate arrangement: New Mexico calls for supervision for PAs with less than 3 years of clinical experience, and for specialty care PAs, and in Michigan, PAs work under a participating physician.
ACEP strongly advocates for states to establish supervision ratios that do not exceed four (4) PAs for every one (1) EM physician.
Here is a listing of supervision laws by state.
Truth in Advertising Laws
Challenge
The TIA campaign is to help ensure patients know the education, training, and qualifications of their health care professionals. Many different healthcare professionals now offer a “doctor” degree, but just using the title “Dr.”does not decipher who is a physician with a MD or DO degree. There is a great difference between a doctor of psychology and a medical doctor who practices psychiatry.
Opportunity
- ACEP believes that TIA laws should address specifics in health care professionals’ education and licensure so that patients have relevant information about the person who is providing their care.
- Emergency physicians are working to ensure that when health care practitioners advertise their services, they are clear about the license they hold, and are not promising more than what their education, training, and licensure permits.
ACEP is a member of the AMA Scope of Practice Partnership, a coalition of more than 100 medical expert groups aligned in support of physician leadership. The AMA SOPP has created model legislation and an advocacy toolkit to help support its adoption. Here is a link to the AMA’s toolkit and model legislation.
There are three main requirements under this model bill (see page 11);
- The healthcare practitioner must wear a name tag during all patient encounters that clearly identifies the type of license held by the health care practitioner.
- The health care practitioner must display in his or her office writing that clearly identifies the type of license held by the health care practitioner
- Third, the health care practitioner must identify his or her license in all advertisements for health care services. These ads must be free from deceptive or misleading information.
Right to See Physician Laws
Only seven states currently have a law that clarifies whether a patient has a right to see a physician. The remainder of the states either do not expressly prohibit PAs and NPs from claiming to be a doctor and providing treatment without the second opinion of a licensed physician.
CT, DE, GA, HI, MD, NC, and VT are the only states to have a law defining the physician-patient relationship.
Here is the complete list of state laws.
Other Legislation Important to Scope of Practice
Beyond PAs and NPs attempting to expand their scope, naturopaths, optometrists and many other medical practitioners are increasingly pushing for additional scope beyond their training. Optometrists, for example, have introduced legislation in several states that would allow them to perform surgical operations of the eye. Pharmacists have asked for authority to administer strep throat and urinary tract infection testing and treatment. Unfortunately, in South Dakota, optometrists are allowed to perform limited surgeries. Pharmacists have been able to do limited testing in more than a dozen states.
As NPPs chip away at existing state laws that protect patients, physicians have pushed back successfully by showing examples of malpractice. The key to defeating legislation expanding scope for NPPs is to demonstrate that education matters.
Here is a resource the AMA developed comparing naturopath training to physician training.
Mitigating Opposition
Physicians should be responsible for managing and supervising NP/PAs in the medical care of patients for many reasons.
The number one reason is patient safety. With the exponential increase in NP/PAs in the past decade, physicians have noticed significant patient care and safety issues with unsupervised medical care. The education of nurse practitioners and physician assistants is not equal to the education of physicians. It is the knowledge and experience of physicians that guides appropriate testing, diagnosis, and treatment of patients. Emergency physicians regularly see patients with misdiagnosis or delayed diagnosis of serious medical conditions which cause harm. Other issues in unsupervised medical care include the operation of independent NP/PA aesthetic practices, hydration clinics, and hormone therapy (compounded drugs are not regulated by the FDA).
Secondly, in the past decade we have seen increased cost of medical care with an increased utilization of services and consults. The Hattiesburg Clinic study showed that unsupervised NP care had a higher overall cost and utilization of services. If this study was extrapolated nationwide, this could make a huge impact on the cost of medical care. After the report conclusion, the Hattiesburg Clinic changed their practice and does not allow independent NP medical care but must have physician oversight.
Third, we need oversight to be able to protect the integrity and transparency of the healthcare system. At this time in the United States, nearly 80% of physicians are employed by an entity (corporate, academic, or institutional). Physicians no longer have the complete ability to advocate for patients without fear of retaliation. Often, the entity directs the physician to have an NP/PA in their department and requires “supervision” without providing the time or education needed to properly supervise. Patients have a right to know what type of practitioner is providing their medical care and if a supervisor is present on site, and the supervisor’s information.
Other Useful Resources
American Medical Association Resources:
The American Medical Association (AMA) creates hundreds of advocacy tools and resources for medicine to utilize when fighting scope expansion that threaten patient health and safety. To access these resources, please see here.
Health Workforce Mapper: The AMA Health Workforce Mapper Customizable, interactive tool that illustrates the geographic distribution of the healthcare workforce. Whether looking at state, county, or metropolitan area data, users can filter physicians and non-physician health care professionals by specialty and occupation setting. Even in states where certain practitioners practice independently, the AMA research shows that non-physicians have not changed their practice location and have not alleviated the shortage problems in rural areas.
Issue Briefs: These AMA backgrounders provide valuable information on a range of issues. One-page infographics on Nurse Practitioners, Physician Assistants, and Pharmacists why it is essential to protect patients’ access to physician-led care and highlight that physicians are trained to lead. Additional briefs are available for members.
Model Legislation: Those looking to strengthen scope of practice laws in their state can use AMA legislative templates and model bills. A model bill on the physician-led team is among several that are available for members only. The AMA Truth in Advertising Campaign is designed to ensure health care providers clearly and honestly state their level of training, education, and licensing. The campaign involves talking points that explain why transparency is important for patient safety and promote the Health Care Professional Transparency Act, a model bill developed by the AMA. The campaign and model bill have been developed to help address patient confusion evidenced in a nationwide patient survey by AMA about who is a physician.
State Law Charts: Scope of practice laws vary from state to state. AMA charts provide specifics in a given state; these are with members-only access.
Geographic Mapping Initiative: The AMA created over 4,500 “geomaps” that compare where physicians practice versus where non-physicians practice in all 50 states and the District of Columbia. The geo maps demonstrate that expanding scope does not equal expanding access to care. The geo maps are available upon request.
Scope of Practice Data Series Modules: These AMA modules can help educate legislators, regulatory bodies, and other policymakers about the education and training of certain health care professionals, as well as about the qualifications that physicians must attain to accept the responsibility for full, unrestricted licensure to practice medicine. Advocates can use the modules to challenge the campaigns of non-physician health care professionals who seek unwarranted scope of practice expansions that may endanger the health and safety of patients. These modules are available upon request.
Studies
Education and Training
A study published in the Journal of Nursing Regulation found that over one-third of family nurse practitioners had not interpreted results from diagnostic tests in more than 10 cases. Of the nearly 4,000 family nurse practitioners surveyed for the study, almost 60% said their training was done fully or mostly online.
AM McNelis, et al. Types, Frequency, and Depth of Direct Patient Care Experiences of Family Nurse Practitioner Students in the United States. Journal of Nursing Regulation 12:1, 19-27, (April 2021) https://doi.org/10.1016/S2155-8256(21)00021-1 https://www.journalofnursingregulation.com/article/S2155-8256(21)00021-1/abstract
An overwhelming majority of physician assistant program directors and educators said that their current curriculum does not prepare graduates to practice without “a supervisory, collaborating or other specific relationship with a physician.” More than 90% of physician assistant students themselves have said the collaborating physician relationship is either essential or very important.
Report from the Physician Assistant Education Association OTP Task Force: Optimal Team Practice: The Right Prescription for All PAs? 2017
Productivity
A three-year study of emergency departments in the Veterans Health Administration found NPs delivering care without physician supervision or collaboration increased lengths of stay by 11% and raised 30-day preventable hospitalizations by 20% compared with emergency physicians.
DC Chan and Y Chen. The Productivity of Professions: Evidence from the Emergency Department. National Bureau of Economic Research (October 2022) DOI 10.3386/w30608 https://www.nber.org/papers/w30608
The Hattiesburg Clinic 2017–2019 CMS cost data on Medicare patients without end-stage renal disease and who were not in a nursing home showed that per-member, per-month spending was $43 higher for patients whose primary health professional was a nonphysician instead of a doctor. This could translate to $10.3 million more in spending annually if all patients were followed by APPs, says the analysis. When risk-adjusted for patient complexity, the difference was $119 per member, per month, or $28.5 million annually.
BN Batson, et al. Targeting Value-based Care with Physician-led Care Teams. Mississippi State Medical Association Journal 63(1). 19-22 (2022) https://www.akleg.gov/basis/get_documents.asp?session=33&docid=27553
Resource utilization for patients assigned to a nurse practitioner was higher than that for patients assigned to a resident in 14 of 17 utilization measures (3 were statistically significant) and higher in 10 of 17 measures when compared with patients assigned to an attending physician (3 were statistically significant). None of the utilization measures for patients in the nurse practitioner group was significantly lower than those for either physician group.
A Hemani, et al. A Comparison of Resource Utilization of Nurse Practitioners and Physician Assistants. Effective Clinical Practice (1999) https://www.semanticscholar.org/paper/A-comparison-of-resource-utilization-in-nurse-and-Hemani-Rastegar/f62df8c79c15e2ceb74a8941acd0cc5d09639b48
Resident teams are economically more efficient than midlevel providers teams and have higher patient satisfaction.
MC Iannuzzi, et al. Comparing Hospitalist-Resident to Hospitalist-Mid Level Practitioner Team Performance on Length of Stay and Direct Patient Care Cost. J Grad Med Educ.7(1):65-9 (Mar 2015) doi: 10.4300/JGME-D-14-00234.1. https://www.ncbi.nlm.nih.gov/m/pubmed/26217425/
Advanced practice provider visits had lower RVUs/visit (2.8 vs. 3.7) and lower patients/hour (1.1 vs. 2.2) compared to physician visits. Higher APP coverage (by 10%) at the ED‐day level was associated with lower patients/clinician hour by 0.12 (95% confidence interval [CI] = −0.15 to −0.10) and lower RVUs/clinician hour by 0.4 (95% CI = −0.5 to −0.3). Increasing APP staffing may not lower staffing costs.
JM Pines, et al. The Impact of Advanced Practice Provider Staffing on Emergency Department Care: Productivity, Flow, Safety, and Experience. Acad Emerg Med 27(11):1089-1099 (2020 Nov) doi: 10.1111/acem.1407 https://pubmed.ncbi.nlm.nih.gov/32638486/
Referrals
The quality of referrals to an academic medical center was higher for physicians than for nurse practitioners and physician assistants regarding the clarity of the referral question, understanding of pathophysiology, and adequate pre referral evaluation and documentation.
RH Lohr, et al. Comparison of the Quality of Patient Referrals from Physicians, Physician Assistants, and Nurse Practitioners. Mayo Clin Proc 88(11):1266-71 (Nov 2013) doi: 10.1016/j.mayocp.2013.08.013. https://pubmed.ncbi.nlm.nih.gov/24119364
When caring for patients with DM, NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21–1.37), endocrinologists (OR = 1.64, 95% CI = 1.48–1.82), and nephrologists (OR = 1.90, 95% CI = 1.67–2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01–1.12)
Y-F Kuo, et al. Diabetes Mellitus Care Provided by Nurse Practitioners vs Primary Care Physicians. Journal of the American Geriatrics Society 63(10): 1980-1988 (October 2015) https://doi.org/10.1111/jgs.13662 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.13662
Patient sentiment
In a national survey of U.S. voters, 95% said it is important to them for a physician to be involved in their diagnosis and treatment and 62% said patients are most likely to be harmed from scope of practice changes
https://www.ama-assn.org/system/files/ama-scope-of-practice-stand-alone-polling-toplines.pdf
Not filling primary care workforce
Only 25% of all Nurse Practitioners in Oregon, an independent practice state, practiced in primary care settings according to an analysis.
Oregon Center for Nursing: Primary Care Workforce Crisis Looming in Oregon
Professional Liability
85.02% of malpractice cases against NPs were due to diagnosis (41.46%), treatment (30.79%) and medication errors (12.77%). The malpractice cases due to diagnosing errors were further stratified into failure to diagnose (64.13%), delay to diagnose (27.29%), and misdiagnosis (7.59%).
CF Sweeney, et al. Nurse Practitioner Malpractice Data: Informing Nursing Education. J Prof Nurs 33(4):271-275 (2017 Jul-Aug)
doi: 10.1016/j.profnurs.2017.01.002
https://pubmed.ncbi.nlm.nih.gov/28734486/
More claims naming PAs and APRNs were paid on behalf of the hospital/practice (38% and 32%, respectively) compared with physicians (8%, P < 0.001) and payment was more likely when APRNs were defendants (1.82, 1.09-3.03)
LC Myers, et al. A Description of Medical Malpractice Claims Involving Advanced Practice Providers. J Healthc Risk Manag 40(3):8-16 (2021 Jan)
doi: 10.1002/jhrm.21412
https://pubmed.ncbi.nlm.nih.gov/32362078/
Diagnostic Imaging Orders
Studies have shown that nurse practitioners order more diagnostic imaging than physicians, which increases health care costs and threatens patient safety by exposing patients to unnecessary radiation. A study in the Journal of the American College of Radiology, which analyzed skeletal x-ray utilization for Medicare beneficiaries from 2003 to 2015, found ordering increased substantially – 441% by non-physicians, primarily nurse practitioners and physician assistants during this time frame.
DJ Mizrahi, et al. National Trends in the Utilization of Skeletal Radiography From 2003 to 2015. Journal of the American College of Radiology 15 (10):1408-1414 (Oct 2018)
doi: 10.1016/j.jacr.2017.10.007
https://pubmed.ncbi.nlm.nih.gov/29580717/
A study published in JAMA Internal Medicine found nurse practitioners ordered more diagnostic imaging than primary care physicians following an outpatient visit. The study controlled for imaging claims that occurred after a referral to a specialist. The authors opined this increased utilization may have important ramifications on costs, safety and quality of care. They noted that greater coordination in health care teams may produce better outcomes than merely expanding nurse practitioner scope of practice alone.
D.R. Hughes, et al., A Comparison of Diagnostic Imaging Ordering Patterns Between Advanced Practice Clinicians and Primary Care Physicians Following Office-Based Evaluation and Management Visits. JAMA Internal Med 175(1):101-07 (2014)
doi: 10.1016/j.jacr.2017.10.007
https://pubmed.ncbi.nlm.nih.gov/25419763/
Advanced practice clinicians and PCPs ordered imaging in 2.8% and 1.9% episodes of care, respectively. Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits .While increased use of imaging appears modest for individual patients, this increase may have ramifications on care and overall costs at the population level.
DM Hughes, et al. A Comparison of Diagnostic Imaging Ordering Patterns Between Advanced Practice Clinicians and Primary Care Physicians Following Office-Based Evaluation and Management Visits. JAMA Intern Med 175(1):101-107 (2015)
doi:10.1001/jamainternmed.2014.6349
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374
Prescribing
General
Further research is needed to understand the impact of differences in NP and PCP patient populations on provider prescribing, such as the higher number of prescriptions issued by NPs for beneficiaries in moderate and high comorbidity groups and the implications of the duration of prescriptions for clinical outcomes, patient-provider rapport, costs, and potential gaps in medication coverage.
U Muench, et al. Prescribing Practices by Nurse Practitioners and Primary Care Physicians: A Descriptive Analysis of Medicare Beneficiaries. Journal of Nursing Regulation 8(1): 21-30 (April 2017)
https://doi.org/10.1016/S2155-8256(17)30071-6
https://www.journalofnursingregulation.com/article/S2155-8256(17)30071-6/fulltext
96% of NPs had regular contact with pharmaceutical representatives. 48% stated that they were more likely to prescribe a drug that was highlighted during a lunch or dinner event.
EC Lad, et al. "Under The Radar": Nurse Practitioner Prescribers and Pharmaceutical Industry Promotions. Am J Manag Care 1;16(12):e358-62 (2010 Dec)
https://pubmed.ncbi.nlm.nih.gov/21291293/
Psychotropic Prescribing
NPs, relative to physicians, have taken an increasing role in prescribing psychotropic medications for Medicaid-insured youths. There was a 50.9% increase in the proportion of psychotropic medications prescribed by psychiatric NPs (from 5.9% to 8.8%) and a 28.6% proportional increase by non-psychiatric NPs (from 4.9% to 6.3%). By contrast, the proportion of psychotropic medications prescribed by psychiatrists and by non-psychiatric physicians declined (56.9%-53.0% and 32.3%-31.8%, respectively)
BK Yang, et al. Comparing Nurse Practitioner and Physician Prescribing of Psychotropic Medications for Medicaid-Insured Youths. J Child Adolesc Psychopharmacol 28(3):166-172 (2018 Apr)
doi: 10.1089/cap.2017.0112
https://www.ncbi.nlm.nih.gov/m/pubmed/29641238/
Opioid Prescribing
In states that allow independent prescribing, nurse practitioners were 20 times more likely to overprescribe opioids than those in prescription-restricted states. 6.3% of nurse practitioners and 8.8% of physician assistants prescribed opioids to more than half of their patients, compared with 1.3% of physicians.
MJ Lozada, et al, Opioid Prescribing by Primary Care Providers: A Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns. Journal General Internal Medicine 35(9):2584-2592 (2020)
doi: 10.1007/s11606-020-05823-0
https://pubmed.ncbi.nlm.nih.gov/32333312/
Antibiotic Prescribing
After adjustment, adult patients seen by an advanced practice practitioner were 15% more likely to receive an antimicrobial than those seen by a physician provider (incident risk ratio [IRR], 1.15; 95% CI, 1.03-1.29). In the pediatric sample, older providers were 4 times more likely to prescribe an antimicrobial than providers aged ≤30 years (IRR, 4.21; 95% CI, 2.96-5.97).
ML Schmidt, et al. Patient, Provider, and Practice Characteristics Associated with Inappropriate Antimicrobial Prescribing in Ambulatory Practices. Infect Control Hosp Epidemiol 39(3):307-315 (2018 Mar) doi: 10.1017/ice.2017.263 https://pubmed.ncbi.nlm.nih.gov/29378672/
In a study of ambulatory visits between 2006 and 2011 involving NPs and Pas, antibiotics were more frequently prescribed during visits involving NP/PA visits compared with physician-only visits, including overall visits (17% vs 12%, P < .0001) and acute respiratory infection visits (61% vs 54%, P < .001).
GV Sanchez, et al. Outpatient Antibiotic Prescribing Among United States Nurse Practitioners and Physician Assistants. Open Forum Infect Dis 10;3(3):ofw168 (2016 Aug) doi: 10.1093/ofid/ofw168 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047413/
Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics.
CL Rournie, et al. Differences in Antibiotic Prescribing Among Physicians, Residents, and Nonphysician Clinicians. Am J Med 118(6):641-8. doi: 10.1016/j.amjmed.2005.02.013 https://www.ncbi.nlm.nih.gov/pubmed/15922696
Anesthesia Care
Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care.
JH Silber, et al. Anesthesiologist direction and patient outcomes. Anesthesiology 93(1):152-63 (2000 Jul) doi: 10.1097/00000542-200007000-00026. https://pubmed.ncbi.nlm.nih.gov/10861159/
A study of ambulatory knee and shoulder surgery cases from 1996 and 2006 that were identified through the National Survey of Ambulatory Surgery examined the incidence of unexpected disposition status and risk factors for such outcome. An increased risk of adverse disposition was found in cases where the anesthesia provider was a non-anesthesiology professional.
SG Memtsoudis. Factors Influencing Unexpected Disposition after Orthopedic Ambulatory Surgery. J Clin Anesth 24(2):89-95 (2012 Mar) doi: 10.1016/j.jclinane.2011.10.002 https://www.ncbi.nlm.nih.gov/pubmed/22305625
Skin Biopsies
APPs performed significantly more biopsy procedures than did physicians to diagnose a malignant neoplasm in patients younger than 65 years and in patients without a history of skin cancer. The authors say the findings suggest that increased use of biopsies may increase the morbidity and cost of care provided by APPs when compared with that provided by dermatologists.
A Nault, et al. Biopsy Use in Skin Cancer Diagnosis Comparing Dermatology Physicians and Advanced Practice Professionals. JAMA Dermatol 151(8):899-902 (2015 Aug) doi: 10.1001/jamadermatol.2015.0173. https://pubmed.ncbi.nlm.nih.gov/25806897/
The authors say, “The data from billed CPT codes suggests that mid-level providers have largely moved into subspecialty practices and are practicing outside the scope of their expertise.”
HR Jalian, et al. Mid-Level Practitioners in Dermatology: A Need for Further Study and Oversight. JAMA Dermatol 150(11):1149-1151 (November 2014) doi:10.1001/jamadermatol.2014.1922 https://jamanetwork.com/journals/jamadermatology/article-abstract/1895672
Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists.
AM Anderson, et al. Accuracy of Skin Cancer Diagnosis by Physician Assistants Compared With Dermatologists in a Large Health Care System. JAMA Dermatol 1;154(5):569-573 (2018 May) doi: 10.1001/jamadermatol.2018.0212. https://www.ncbi.nlm.nih.gov/pubmed/29710082
Books
N Al-Agba and R Bernard. Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare (2020)
R Bernard. Imposter Doctors: Patients at Risk (2023)
