Scope of Practice: Playing at the Top of My License?

flying cadeuciiThe Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.”Often, you’ll hear people advocate that every healthcare worker should “practice at the top of their license”.

What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.

So I would like to know, please, when I’ll get to practice at the top of my license?

As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time.

Yet I spend a lot of time performing tasks that could be done by someone with far less training.

Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.

I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.

First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart.

This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.

(Just for fun, I sent an email one day to the head of environmental services at my hospital, asking if the cleaning crew could attach a new suction canister to the anesthesia machine after they remove the dirty one from the previous case. The answer was no. His reasoning was that this would delay the workflow of the cleaning crew.)

Then I checked the circuit on the anesthesia machine, assembled syringes and needles, and drew up medications for the case. To each syringe, I attached a stick-on label with the name of the medication, and wrote by hand on each label the date, the time, and my initials. These tasks, as you might guess, don’t require an MD degree either. A pharmacy can issue pre-filled syringes, and clever machines can generate labels with automatic date and time stamps.

It was now 7 a.m., and I moved on to the preoperative area to meet my first patient. I introduced myself, and started to interview her. Then I noticed that no one had started her IV yet. I asked the patient’s nurse if he would set up the IV fluid, which had already been ordered via the electronic medical record. “If I have time,” he replied.

The nurse, in fairness, was busy with his own tasks–few of which required a nursing degree. He was doing clerical data entry in the computer, recording answers to a host of questions such as whether or not the patient had stairs in her home. In between, he was answering the phone, as there is no desk clerk to pick up the phone or check for incoming faxes.

So I got hold of a liter bag of IV fluid, attached sterile tubing to it, and flushed the air out of the tubing. Then I did my first clinical care of the day, inserting an IV catheter into a vein in the patient’s hand. For the record, IV starts are well within the scope of nursing practice and don’t require a physician.

Finally, at 7:07, I began my clinical assessment of the patient’s readiness for anesthesia, which was the first activity that approached working at the top of my license. Multiply the 22 minutes I had already spent doing lower-level tasks by hundreds of cases per year per physician, and you’ll start to see what a colossal waste of resources is occurring every day.

Not just at my hospital but also at hospitals nationwide, administrators have pared back support staff in an effort to cut costs. Their reasoning appears to be that lower-level support staff can’t do more advanced tasks, but their work can be “rolled into” what physicians and nurses do.

A nurse, so this thinking goes, can easily answer a telephone during idle moments, though most nurses I know would laugh bitterly at the idea that idle moments occur very often. A physician can type on a computer keyboard and enter data while doing a patient’s physical exam, regardless of how much extra time this takes compared to dictating the same information. Don’t think about how much the need to focus on the computer screen detracts from the doctor’s personal interaction and eye contact with the patient.

Bureaucrats and administrators advocate “practicing at the top of the license” as a not-too-subtle way of enabling healthcare workers with lower-cost skills to replace physicians. An alarming example of this is the Veterans Health Administration’s recent attempt to change VA rules so that advanced practice nurses could work without any physician supervision at all.

Vigorous opposition from veterans’ advocates has stymied this initiative so far, but it could rise again.

These same bureaucrats and administrators eliminate lower-paid personnel–desk clerks, transport orderlies, and dictation typists, for instance–to trim their budgets, with no regard for how much they prevent physicians and nurses from truly practicing at the top of their licenses. Someone still has to do the tasks that were previously done by those employees, and that someone, too often, is a physician or nurse.

The next time you wonder where your healthcare dollars are going, remember this: your physicians and nurses would like to spend more time taking care of you. But they may be too busy doing other things.

Karen Sullivan Sibert, MD (@KarenSibertMD) is a practicing anesthesiologist and associate professor of anesthesiology at a major medical center in Los Angeles. She writes at aPennedPoint, where this piece originally appeared.

25 replies »

  1. I am also an anesthesiologist, but I practice in a surgery center. Different setting, but no fewer problems. I will add to the above having to deal with daily shortages of almost every anesthetic, antiemetic, AND RECUSCITATIVE drug we use. Anesthetics almost always lower blood pressure. For decades the reflex response is to give Ephedrine IV. Not last week when we were completely out because of “national backorder”. Are there alternative drugs? Yes, a couple, but often not as good for a variety of reasons. Multiply this by all the drugs we use for everything. What’s the reason? Generic drugs like these have been cheap for a long time. But if you can’t get them, facilities are happy to pay ten, twenty, fifty times the normal price.
    Every day, for so many reasons I’m glad I’m in the autumn of my career. Things have drastically changed in the last few years. I remember when I used to enjoy practicing anesthesiology. I’m not looking for sympathy, but I am very concerned about who will be providing MY medical care, and how they will be able/told to do it.

  2. As a fellow anesthesiologist at a major medical center, I can sympathize with Dr. Sibert’s plight and it is a nationwide problem. It’s obvious that some people responding to this post are not directly involved in healthcare and seem to miss the point. My experience at work seems more like a real-life Undercover Boss episode than a professional workplace. I think part of the problem rests with physicians. In the interest of caring for our patients, we have abdicated administrative responsibility to those who are willing to take it. Often times, that means hospital administrators with little or no clinical experience or nurses. We then post on the internet about how the system is broken and inefficient. While this is true, we must shoulder some of the blame ourselves.

  3. I think hospitals are used to working in a very inefficient system. They don’t know their own costs or their profit centers. When they do recognize a profit center as pulling in far more money than other areas of the hospital they will simply focus on that area to bring in more and more revenues. Optimization of revenues seems to be a secondary thought.

  4. Continued:


    I never cease to be amazed at how dumb some administrators are.

  5. Not having any official business training or an MBA, I am consistently surprised by how dumb some business people/hospital administrators are.

    Classic example from Radiology. I can’t tell you how many times I have seen XRay techs get consent for contrast administration and start IVs on the gantry of a CT scanner. This dramatically slows the through put through a multi million dollar machine! In effect, the tech is using a CT scanner as a chair or table.

    The techs don’t care since they are paid by the hour. Surprisingly, the hospital admins don’t seem to understand/care either. I have gotten myself in trouble making a stink about it. Had the admin listened to me it would have allowed the hospital to substantially increase its revenue and/or decrease its expenses.

    When I was Chief of Radiology the hospital admin wanted to buy a second scanner because she believed we didn’t have enough capacity. I told her we did if we used the scanner more efficiently.

  6. Peter 1–I hope I made it clear in my article that I am very much in sympathy with nurses who work much of the time far below their skill level. This is a waste of resources no matter whether it is physician or nurse skills we are talking about, and I believe it is also a major source of frustration and burnout for nurses and physicians alike. As far as arrival time goes-it sounds as though your wife and I are on much the same schedule! We can both testify, I’m sure, as to how little traffic there is on the roads when we’re driving to work, even considering that I live in Los Angeles. This speaks to my point that many non-medical people would consider that an uncivilized hour, not that we’re feeling particularly sorry for ourselves.

  7. legacyflyer is exactly right about the employment issue–I’m not employed or paid by the hospital, so the hospital doesn’t care how much of my time is wasted, or how early I need to arrive to get everything done to start the first case on time. HOWEVER–and this is what I really don’t understand–when I need to repeat those same tasks between every case, it makes the turnaround time between cases much longer, and that will affect the hospital’s overall efficiency. Further, many physicians these days ARE hospital employees, yet hospitals seem to suffer from the same lack of realization about the amount of time they spend doing tasks far below their skill level. Data entry is perhaps the prime example, and as you say, it’s why they/we hate EMRs. And of course the nurses are all hospital-paid, so it is baffling why the hospital doesn’t care more about how their time is spent.

  8. “I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.”

    My nurse wife is up at 5:30 am and at work and working at 7am. Your too good for that?

    “What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.”

    My wife also does tasks that are below her training and skill level, but it just what keeps the organization functioning. Ask any business owner and they will tell you lots of stuff needs to get done, and they do whatever to make their business work.

    Seems the attitude here is a little Marie Antoinette, spoiled and self delusional.

  9. The airline equivalent would be, since we love airline analogies, pilots being paid by multiple travel insurers (who also incidentally pay for the passengers’ flight) and the airline paying the cabin crew; cabin crew refusing to serve water to passengers because they are too busy selling airline credit cards on which their bonus rests; pilots serving water and mid level cabin crew flying the plane, because the institute of flying thinks it is a good idea for cabin crew to expand their skill.

    Yes, I think it’s a bit like that.

  10. SamC,

    Not sure exactly what Dr. Sibert’s employment relationship is but …

    In many cases, the physician is NOT employed by the hospital. So when the hospital forces the physician to spend time doing some task that could easily be done by someone with less training/credentials, it is not spending its OWN money, it is (in effect) spending someone else’s and saving its own.

    The overall calculus from the perspective of the hospital is:
    – We saved 15 minutes of one of our employees, who makes $20/hr, time. Therefore we saved $5 of OUR money.
    – We forced a doc who makes $200/hr to spend 15 minutes of his/her time. Therefore we caused the expenditure of $50 or their money.

    And once you understand this principle, you have gone a long way to understanding why many/most docs hate EMRs.

  11. @Jennifer: ” since the evidence clearly shows that nurse anesthetist are just as effective and safe as a very expensive anesthesiologist ”

    Is that totally true without any disclaimers or questions regarding the data?

    If it is true then anesthesiologists need not go to medical school.

  12. I would like someone to explain what “working at the top of your license” means with regards to NPs and PAs.

    Does it mean “independently assessing patients and deciding on a treatment plan, and seeking consultation when deemed appropriate?”

    If that’s your definition, then how does that definition differ from the traditional license given to a physician? If it doesn’t substantially differ, then let’s be honest we’re redefining what a license to practice medicine is.

  13. As an internist for the last 20 years I understand completely what she is saying. (And before I go any further, the nurse anesthetist and the anesthesiologist are apples and oranges apart and this has nothing to do with turf wars The nurse does not know what she does not know). I spend at least 10 minutes of the 20 minute appt, (yes i had to go to 20 minute appts to get the work done and not shaft the patient too much), doing clerical work, i do my own transcription, (on epic) i have to specify 30 or 90 day scripts, mail order or local pharm, capsules or tablets, place my own orders, place my own referrals, enter lab orders and associate them with a diagnosis. then you can start adding all the meaningless use requirements and medicare pilot requirements if applicable. I could go on and on or others could add to the list of “below my license activities” One thing you have to remember, the medical record used to be used to keep track of the patient and now it is used to keep track of the Doctor.

  14. I never understand the nastiness and general uselessness of some people’s comments. The author is absolutely right in her assessment. And its got nothing to do with her specific hospital, but is actually an issue everywhere. It illustrates the point with very simple and straightforward examples while arguing appropriately for everyone in the process.

    If you think a nurse can do the same work as a highly trained anesthesiologist, please feel free to get one the next time you are put to sleep.

  15. Dr. Sibert is pointing out some great questions. To me the read is that a facility would rather spend about $15 in labor rather than .75 on replacing a suction canister. I understand that there might be some risk associated with changing the canisters that is 20 times the needed charge. Just a guess but, if I do the math of a Anesthesiologist wasting 22 minutes per day over a 360 day period the cost would only be about $37.8k vs $1890 as she has pointed out this process occurs perhaps more than once a day. For that kind of money a facility could consider hiring a canister changer!

  16. If this isn’t the way your hospital is being run, just wait . . . it will be soon.

  17. Hospitals, Insurers and Government Agencies would all like to make the most of YOUR FREE TIME! At least it is free to them!

  18. Beautifully crafted piece making a much deserved mockery of the managerial explosion.

    This is common place.

    Please continue to write about reality not just the stuff that makes me feel warm and fuzzy.

  19. I don’t think Jennifer knows what ad hominem means. It was not a personal attack, merely a complaint that many providers spend a significant portion of their day performing tasks that waste their time and abilities.

  20. Not sure what this article is intended to convey other than this hospital can’t figure out how to get basic workflow correct.

    We need more positive articles showcasing how things CAN be done rather than deconstructive, poorly argued, articles on why change is impossible.

  21. Wow Karen that has to be one of the worst ad hominem arguments I have seen in years. you mixed apples and organs (not a typo). Clearly your hospital lacks some of the most basic workflow necessary for safe patient care and I wouldn’t want to send any of my family members there for care. .

    It also sounds like you are trying to simply protect your turf since the evidence clearly shows that nurse anesthetist are just as effective and safe as a very expensive anesthesiologist who is putting equipment together.

    Perhaps if you have more Nurses you could instead have focused on clinical care and he could be putting equipment together and starting IV’s for you?