Tuesday, October 28, 2008

CMA vs. "Licensed Health Professionals"

The California Medical Association (CMA) is concerned that the California Department of Public Health (CDPH) has proposed regulations that would expand the power of non-physicians to perform certain medical procedures. The changes include:

Allowing psychologists to perform medical, as opposed to psychological, examinations (Section 70577);

Allowing "licensed health practitioners" to order restraint of patients (Sections 70577, 71545, 72319,72461, 73409, 79315);

Implying that "licensed health practitioners" may assume overall responsibility of a psychiatric unit (Section 70577);

Substituting "licensed health practitioner" for "physician" as the health professional who has primary responsibility for coordinating care (Section70707);

Allowing admission, transfer, and discharge decisions to be made by "licensed health practitioners" (Sections 70717,70749, 70751, 70753, 71517, 71553, 72515,73517); and
Proposing changes that affect the self governance of medical staffs (Sections 70703, 70706, 71503).

I generally believe that, so long as the patients have obtained full disclosure and have properly consented to non-physicians overseeing their treatments, then doctors should not object. Granted, when it comes to certain medical matters, physicians are more extensively trained than nurses, PAs, and certainly psychologists, and are likely to make fewer mistakes or misdiagnoses (Similarly, most doctors would be fired on Day 1 for incompetence, if they tried to take over a nursing job). However, requiring a physician to coordinate care for every patient comes with other unique costs, which I'll expound upon in a future post.

The power to order "restraint" of a patient or to oversee psychiatric a psychiatric unit is more controversial. In such cases, the patients are either unable or unauthorized to make informed decisions about their care. Even physicians are potentially treating many patients without their consent, a phenomenon that should be tread with caution. Do we really want to expand the number of people with the power to control the movements of a dissenting patient?

Obviously, in an acutely dangerous situation, everyone from the lab tech and billing officer should be allowed to restrain a patient, until the situation is considered secure. But once we've insured every one's safety, we should do all we can to maximize patient autonomy. (I should note that, as much as I respect Thomas Szasz's views on medical paternalism toward psychiatric patients, I support restricting the movements of someone whom I suspect could soon harm someone. Many nurses have been attacked and severely injured in psych units, and preventing such incidents trumps personal liberty).

The CMA is a physicians' lobbying group, so their views on the issue matches the circumstances that would reduce physician competition. Their list of "talking points" include:

Ignores Physician Responsibility for Medical Care

As the most extensively trained health care professionals, physicians are the most qualified to coordinate medical care. The proposed amendments offer that a psychologist may perform medical examinations, not just psychological examinations. This extends activities to psychologists beyond the scope of their professional licensure.

Jeopardizes Patient Safety

By authorizing "licensed health practitioners" to make medical decisions such as ordering restraints and making transfer and discharge decisions, the Department of Public Health is failing to protect public safety and ignoring a number of federal and state laws. Physicians are trained to consider the array of physiological factors that may affect a patient's condition and the regulations should reinforce that authority rather than undermine it. Although CDPH does not regulate health practitioners, it does have a stake in assuring quality standards of care in licensed health facilities as a matter of public health.

Leads to Confusion in Medical Decision Making

The regulations remove specific references to physicians in various situations. The regulations allow a "licensed health care practitioner acting within the scope of his or her professional licensure" to oversee admission decisions and the coordination of patient care. This amendment is overly broad and offers no clarity as to which practitioners are actually responsible for these functions in health facilities. Leaving individual facilities to interpret these regulations and the scope of practice of the various health care providers operating in hospitals may lead to varying standards of care across the state that are also inconsistent with statutory restrictions.

Undercuts the Independence of Medical Staff Committees

The organized medical staff is responsible for the quality of medical care in inpatient facilities. California law has upheld this authority as a part of the prohibition on the corporate practice of medicine. Self-governance and independence in medical quality decision making are foundational to patient safety. The amendments to the regulations propose that the organized medical staff is "subject to the bylaws, rules and regulations of the hospital.

If anybody ends up reading this, what do you think? Do any of the CMA's arguments have merit?

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