Scope of practice: First, do no harm

The access issues that our pa­tients encounter are an ongoing concern for everyone involved in delivering care. Over the last number of years, the provincial government has implemented programs designed to alleviate the problem—increasing medical school spots, opening more residency spots to foreign-trained physicians, and expanding scope of practice to other health care workers such as nurse practitioners and midwives. In January, the mandated scope of practice of pharmacists has increased, and currently regulation has been proposed to expand scope of practice to naturopaths and optometrists.

In the throne speech of February 2008, the lieutenant governor of BC portended what was to come. He expressed government’s commitment to ensuring patient accessibility, to maintaining a fiscally sustainable health care system, and to providing high-quality patient care that is medically appropriate. This in turn “obliges us to adopt new effective strategies that at once improve the health of our citizens, improve health delivery, and protect our public health system for the long term.” By amending the Health Professions Act, some health care providers will have the opportunity to “utilize their full scope of training and expertise,” said the lieutenant governor.

Doctors are now well aware of pharmacists’ ability to renew and alter prescriptions in certain circumstances. Government will establish a 3-year bachelor of nursing science degree, permitting nurses to attain their degree 1 year sooner and providing significant on-the-job training. Nurses will be trained to deliver a broader range of health services that traditionally have been provided by physicians: suturing, testing for allergies, administering local anesthesia, giving pain medication at triage, and ordering lab work, blood tests, and X-rays for treatment within the hospital. It is proposed that ambulance paramedics will be trained to treat and release, and midwives will be authorized to deliver a wider range of services without a physician present.

While it may be the profession’s role, subject to government approval, to set and administer standards of practice, it cannot determine its own scope of practice. Ultimately, that is determined by the government. But government must determine scope of practice with a dispassionate appraisal of numerous factors, including evidence, standards of care, knowledge base and qualifications, education and training, benefit to patients, and, above all, the risk of harm.

When a review of scope of health professions occurred in BC in the late nineties, the former Health Professions Council concluded that in most instances the training of medical practitioners is considerably greater than that of other health professionals, particularly in respect to scope of knowledge and the amount and nature of clinical training. The council concluded that the wish to have an expanded scope of practice must be substantiated in order to be accepted.

This can be an unsettling time, and I understand and share your frustration knowing that as doctors we have worked hard to qualify through our profession’s strict regulatory process, yet other health care providers are being given the opportunity to provide some of those services with education and training that is inadequate in view of established standards. There are times when we are called on to exceed our outlined scope of practice, but even as licensed medical practitioners we do so with trepidation. At all times, however, action is taken by the most knowledgeable team member, who also assumes the risk and responsibility to the patient. Where we perceive threat to this premise and our patients’ health is at risk, we are obliged to speak out. It’s okay to address patient access concerns and how our allied health provider colleagues might be involved, as long as they are held to a high standard of care, as we are.

Scope of practice and developing a collaborative model of health care is a complicated and important issue. After much hard work, we have come to a good compromise in addressing pharmacists’ increased scope of practice and how that will work within the borders of our health care system. If government has learned anything from our lengthy discussions on this topic, it is that legislation preceding consultation with the medical bodies ultimately responsible for patient care and safety will not work. Doctors need to be in the room while plans are being discussed that affect how physicians care for their patients.

Scope of practice is more about relationships than just the “things we do.” At present there is a great deal of collaboration among professions, but with changing scope of practice the picture becomes more complicated over the issues of supervision, delegation, and collaboration. It’s no longer a matter of who is doing what, but under whose supervision is it being done. This is where physicians can and should take the lead.

There is room in the health care system for appropriately trained and qualified health care providers to assist physicians and relieve the pressure, but they cannot function at cross-purposes to established medical practice. Ultimately, expanding scope of practice must come down to finding the best way to use every health care provider’s expertise, improve the health care system, and improve patient outcomes.