Unprepared For The Expected

It is quite possible to split all of medical care into another four box theory of life (see below).

I have so many angles I could take on this analysis that it may bore you to death. But hear me out. The above is one possible four box representation of your illness and your providers of care. It is an important one. Perhaps one of the most important. With talk of reform in the air, you should ask yourself which boxes are most important to you. For this blog post I'm going to talk about the left column. the expected course of disease. I will save the rest for later.

I can assume most people would not want to have an unprepared provider taking care of an expected course of illness. Perhaps that would constitute malpractice. Perhaps even negligence. As to the credentials of physicians, nurse practitioners, physician assistants, pharmacists and nurses, I would expect the vast majority of any of these health care workers to provide appropriate care based on the expected course of disease. That is what board certification in a field of study affords you. And it should give the lay public a sense of confidence in those providing the care.

In general, one need not worry that you will get unprepared providers of care for expected disease management, unless of course the scope of practice by the provider is beyond their level of training. So how does that happen? It happens when the scope of practice is not clearly defined. Most doctors will live most of their life in the prepared and expected quadrant. Their scope is defined. Their training defines their scope. They are trained well for expected courses of disease. I would say most NPs, PAs, PharmD, and RNs also practice most of their life in the prepared and expected quadrant. Is my preparation for the expected the same as a NP's or PA's preparation for the expected? Is the breadth of their prepared knowledge base of expected disease course the same as mine? No it's not.

	Expected	Unexpected
Prepared	Prepared/Expected	Prepared/Unexpected
Unprepared	Unprepared/Expected	Unprepared/Unexpected

The question becomes, should all front line independent providers of primary comprehensive care be equally certified by the same standards. Should they all be capable of managing the same scope of practice? If we do not define limitations of scope between MDs, NPs and PAs then we should expect all of them to pass the same certification standards.

If we don't have the same standards of certification, we risk having a large population of patients being cared for in the unprepared but expected quadrant. The quadrant where people die. Where bad things happen because you not only don't know what you are doing, but you also don't know what you aren't doing. I know exactly when I don't know what I'm doing. My scope of practice defines my care. If you don't define your scope, you don't know your limitations.

The unprepared but expected is a dangerous quadrant to practice in. Dangerous for patients. Risky for providers. Expensive for a system of care with frequent referral to other specialty societies.

I maintain that all providers of primary comprehensive care should be required to pass the same certification standards. If the scope of practice is the same, the standard certification process should be as well. If the scope is not the same, than than those limitations of practice scope should be defined. Right now they are not. To the best of my knowledge, states are allowing nurse practitioners equal scope of practice as many internists and other family medicine specialists. They should be required to meet the same certification standards as their MD counterparts.
Perhaps I am wrong. Is the scope the same? This is sometimes hard to define. What is the scope of practice for a NP? What is the scope of practice for a PA? For many, the boundaries are blurred. I would say most RNs and most PharmDs have defined scopes of practice. But where are the boundaries for NPs and PAs? For many who practice independently, how does the state know when they have moved from the prepared and expected quadrant to the unprepared for the expected quadrant? I think the vast majority of physicians will inherently limit their scope to the extent of their training in their defined scope. I don't do heart caths because I am not trained to do them.

How do NPs limit something that isn't defined? I think one of the inherent flaws of NP and PA training and their certification process is that the their scope is not well defined. They fill the role of internist provider, family medicine provider, cardiology provider, oncology provider. What is their defined scope? Should they be allowed the independent practice of cardiology? And if so, should they be required to pass cardiology boards? Should they be allowed the independent practice of internal medicine? And if so, should they be required to pass internal medicine boards? That's my biggest beef with the independent practice nature of providers who are certified to practice independently in my field, without having to certify in my field.

If you want to define the scope as something more focused than internal medicine, that's fine, define the scope and certify that scope. If you want to define the scope as internal medicine, then all practitioners of internal medicine should be required to pass internal medicine boards. If you want to defined the scope as family medicine, then all practitioners practicing family medicine should be required to pass family medicine boards. Only then do certification standards hold weight. Why should I be required to certify in internal medicine when nurse practitioners are given the right to do the same, without the benefit of internal medicine board certification. It's a fair and honest question. And one that should be answered.
If my scope is the same as theirs, then my unprepared for the expected box should be the same size as an independently practicing NP or PA. And I know, there ain't know way in Hell that that will ever be the case.
Just speaking the truth.