DOI: 10.1542/peds.111.2.426 2003


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DOI: 10.1542/peds.111.2.426 2003

  1. 1. Scope of Practice Issues in the Delivery of Pediatric Health Care Committee on Pediatric Workforce Pediatrics 2003;111;426-435 DOI: 10.1542/peds.111.2.426 The online version of this article, along with updated information and services, is located on the World Wide Web at: PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2003 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from by on August 13, 2010
  2. 2. AMERICAN ACADEMY OF PEDIATRICS POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children Committee on Pediatric Workforce Scope of Practice Issues in the Delivery of Pediatric Health Care ABSTRACT. In recent years, there has been an increase bers to use with legislators, policy makers, and other in the number of nonphysician pediatric clinicians and stakeholders in deliberations on nonphysician scope an expansion in their respective scopes of practice. This of practice issues. To the extent possible, the text of raises critical public policy and child health advocacy the policy statement, from which the recommenda- concerns. The American Academy of Pediatrics (AAP) tions have been derived, proposes examples and believes that optimal pediatric health care depends on a team-based approach with coordination by a physician strategies that address the practical aspects or imple- leader, preferably a pediatrician. The pediatrician is mentation of the recommendations. uniquely suited to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through OVERVIEW OF THE EXPANSION OF all stages of treatment, in all practice settings. The AAP NONPHYSICIAN SCOPE OF PRACTICE recognizes the valuable contributions of nonphysician In recent years, there has been a significant in- clinicians, including nurse practitioners and physician assistants, in delivering optimal pediatric care. The AAP crease in the numbers and roles of nonphysician also believes that nonphysician clinicians who provide clinicians in the health care market. The AAP has health care services in underserved areas should be sup- monitored these trends in the delivery of care to ported by consulting pediatricians and other physicians pediatric patients by nonphysician clinicians, includ- using technologies including telemedicine. Pediatricians ing but not limited to nurse practitioners, physician should serve as advocates for optimal pediatric care in assistants, psychologists, pharmacists, massage ther- state legislatures, public policy forums, and the media apists, physical therapists, occupational therapists, and should pursue opportunities to resolve scope of prac- optometrists, acupuncturists, naturopaths, homeo- tice conflicts outside state legislatures. The AAP affirms paths, and chiropractors. that as nonphysician clinicians seek to expand their Some nonphysician clinicians are seeking ex- scopes of practice as providers of pediatric care, stan- dards of education, training, examination, regulation, panded scopes of practice, including the right to and patient care are needed to ensure patient safety and provide types of care traditionally reserved for phy- quality health care for all infants, children, adolescents, sicians. Nonphysician clinicians have succeeded in and young adults. increasing their autonomy, scope of practice, pre- scriptive authority, and third-party reimbursement in most states. The AAP believes that as these non- ABBREVIATIONS. AAP, American Academy of Pediatrics; CAM, complementary and alternative medicine; HPSA, Health Profes- physician clinicians expand their roles, high stan- sion Shortage Area; FOPE II, Future of Pediatric Education II. dards of education, training, examination, regula- tion, and patient care must be adopted to protect INTRODUCTION patient safety and ensure effective quality health care for all infants, children, adolescents, and young T his policy statement is intended to serve as an overarching document that will consolidate adults. some of the concepts in existing American Academy of Pediatrics (AAP) policy on pediatric THE PEDIATRIC HEALTH CARE TEAM care provided by nonphysician clinicians and, The provision of optimal pediatric care depends thereby, replace previous AAP policy on the role of on a team-based approach to health care with coor- the nonphysician provider.1 AAP policy statements dination by a physician leader, preferably a pediatri- have generally addressed particular types of clini- cian. In the team-based model of pediatric care, the cians, practice settings, or types of care and have not pediatrician, or when no pediatrician is available, the articulated a global AAP position on pediatric care physician, assumes overall responsibility for the care delivered by nonphysician clinicians.1–13 The recom- of the patient. As leader of the pediatric health care mendations in this policy statement have been writ- team, the pediatrician oversees and coordinates the ten to serve as an advocacy tool for the AAP as a delivery of care, and when appropriate, delegates whole as well as for individual chapters and mem- patient care responsibilities to nurse practitioners, physician assistants, and other nonphysician clini- PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- cians within their legislated scopes of practice. This emy of Pediatrics. role includes supervising patient care delivered by 426 PEDIATRICS Vol. 111 No. 2 February 2003 Downloaded from by on August 13, 2010
  3. 3. nonphysicians. The pediatrician also determines priate pediatric care by providing support to non- when referral to a pediatric medical subspecialist, physician clinicians who practice in underserved, pediatric surgical specialist, or other physician is rural, or otherwise remote areas. warranted. When patient care responsibilities must The AAP likewise supports the concept that pedi- be shared by multiple providers, the pediatrician atricians, because of their broad base of knowledge oversees the full range of health care services to and skills, must supervise the pediatric health care ensure continuity of care within the child’s medical delivered by nonphysician clinicians using telemedi- home. The team-based model of pediatric care seeks cine and other technologies, when applicable, to as- to provide high-quality, cost-effective care by mini- sist in the delivery of pediatric health care. Accord- mizing duplication of clinical effort and promoting ing to Black’s Law Dictionary, to supervise means “to the appropriate and timely use of all health care have general oversight over, to superintend or to providers on the team. inspect.”14 The AAP also believes that the pediatri- The efficacy of this team-based approach in im- cian should participate in the training and educa- proving patient outcomes is widely accepted by phy- tional experiences of nonphysician clinicians to help sicians and nonphysician clinicians as well as the ensure the competency of all team members. As an public. A variety of indicators, including an increas- advocate for optimal pediatric care, the pediatrician ing pediatric population, the continuing specializa- should educate patients, their families, and their tion of medicine, and improvements in access to care, caregivers as well as policy makers about scope of have predicted an increased need and demand for practice issues and the use of complementary and pediatric health care services in the near future. To alternative medicine (CAM). respond to these changes, it will be necessary for the physician leader to coordinate the care delivered by PEDIATRIC NURSE PRACTITIONERS AND physicians, nurse practitioners, physician assistants, PHYSICIAN ASSISTANTS and other nonphysician clinicians who provide care Pediatric nurse practitioners and physician assis- to children. The AAP acknowledges the complexities tants frequently practice under the supervision of and difficulties inherent in this role but believes that physicians. Table 1 illustrates the educational and the pediatrician’s coordination of care is essential to practice differences among general pediatricians, pe- ensuring the provision of optimal pediatric care. diatric subspecialists, pediatric nurse practitioners, and physician assistants. THE PEDIATRICIAN AS LEADER OF THE Although studies highlight the ability of nurse PEDIATRIC HEALTH CARE TEAM practitioners and physician assistants to provide care The AAP believes that pediatricians are optimally comparable with that delivered by a physician suited to serve as leaders of the pediatric health care (sometimes associated with a higher degree of pa- team because of their unique ability to manage, co- tient satisfaction), these studies are limited by their ordinate, and supervise the entire spectrum of pedi- focus on short-term outcomes for isolated medical atric care, from diagnosis through all stages of treat- problems managed by health care professionals ment, in all practice settings. As the clinician most working in a supervised environment in which they extensively educated in pediatric health care, the have ready access to consultation.15–17 The ability of pediatrician has a pivotal role in delivering optimal nonphysician clinicians to manage all levels and pediatric care and providing a “medical home” for complexity of care independently has not been ad- patients. According to the medical home concept, the dressed by such studies, and until well-controlled pediatrician possesses the clinical skills, medical studies demonstrate comparable outcomes for care knowledge, and other competencies necessary to rendered by all such clinicians, the AAP opposes provide accessible, continuous, comprehensive, fam- independent practice, independent prescriptive au- ily-centered, coordinated, compassionate, and cul- thority, and reimbursement parity for these nonphy- turally effective pediatric care, 24 hours a day, 7 days sician clinicians. a week.2 Pediatricians are equipped to assess basic To ensure the health and safety of all children, a and complex health issues, involving areas as diver- process must be in place through which the creden- gent as molecular genetics, toilet training, school tialing of all individuals claiming to be competent to problems, environmental health and safety, and the care for children is systematically examined. Cur- long-term care of children with chronic illness or rently, nurse practitioners and physician assistants disability. As part of this leadership role, the pedia- must pass qualifying examinations developed by trician should serve as a consultant for other mem- their certifying bodies; this is not the case, however, bers of the team who also play an important role in for all CAM practitioners. Consumers rely on gov- the care of infants, children, adolescents, and young ernment agencies to ensure certain standards of care. adults. The AAP believes it is ill advised, even in Legislators must base their decisions on knowledge, underserved areas, to create a system of care that not on testimonials by a limited number of satisfied allows for the independent practice of nonphysician individuals. clinicians. Such health care delivery could result in a The AAP concurs with the position of the Ameri- 2-tiered system that would compromise the quality can Academy of Physician Assistants that physician of health care that should be available to all pediatric assistants should continue to practice medicine un- patients.2 The role of the pediatrician consultant, der the supervision of a physician, in recognition of therefore, is particularly important as a strategy to the training and education of physician assistants ensure the delivery of safe, competent, and appro- and the importance of patient safety and strength of AMERICAN ACADEMY OF PEDIATRICS 427 Downloaded from by on August 13, 2010
  4. 4. 428 TABLE 1. Comparison of Pediatricians, Pediatric Nurse Practitioners, and Physician Assistants No. of Certified No. of Length of Training Educational Attainment Certifying Body Independent Practice Prescriptive Providers Accredited or Supervision Authority Training Programs General pediatricians 71 716* 208† Baccalaureate degree Doctor of Medicine (MD) or American Board of Pediatrics Independent practice In all states (approximately 4 y), Doctor of Osteopathy American Board of medical school (4 y), (DO) Osteopathic Pediatrics residency (3 y) Pediatric subspecialists 13 407* 970† Baccalaureate degree Doctor of Medicine (MD) or American Board of Pediatrics Independent practice In all states (approximately 4 y), Doctor of Osteopathy and other specialty boards medical school (4 y), (DO) for certain pediatric residency (3 y), subspecialties fellowship ( 2 y) Pediatric nurse 5850‡ 67‡ Baccalaureate degree Master’s degree minimum, National Certification from Variation by state Variation by state practitioners (approximately 4 y), doctoral degree in Board of Pediatric Nurse 2 y of advanced nursing (PhD, DScN) Associates and education and common Practitioners supervised clinical training Physician assistants 40 469§ (4% in general 129§ Physician assistant 2 y of college courses in Certification by the National Direct physician 47 states plus SCOPE OF PRACTICE ISSUES IN PEDIATRIC HEALTH CARE pediatrics and program comprises basic science and Commission on the supervision in all District of pediatric 2 y in classroom and behavioral science as Certification of Physician states Columbia and subspecialties) 25–27 mo clinical prerequisites to physician Assistants Regulated in all Guam§ training in primary assistant training. states plus District care¶ Baccalaureate degree not of Columbia and required§ Guam§ Downloaded from by on August 13, 2010 * Source: American Board of Pediatrics. ABP workforce data main menu 2000. Available at: Accessed March 19, 2002. † Source: Accreditation Council for Graduate Medical Education. Available at: Accessed March 19, 2002. ‡ Source: Dunn AM. 1997 NAPNAP Membership Survey. J Pediatr Health Care. 1998;12:203–210. § Source: American Academy of Physician Assistants. Facts at a glance. Available at: Accessed March 19, 2002. Source: American Academy of Physician Assistants. Physician assistants in pediatrics. Available at: Accessed March 19, 2002. ¶ Source: American Academy of Physician Assistants. The physician-PA team. Available at: Accessed March 19, 2002.
  5. 5. the physician assistant-physician relationship.18 The the digitization of health care information, and wire- AAP likewise opposes the independent practice of less technologies, have demonstrated the great po- nurse practitioners, but endorses a collaborative tential to increase access to health care services by and structured relationship, in keeping with their circumventing the distance between clinicians and training and experience. Nurse practitioner educa- consultants. Implementation of telemedicine technol- tion and training overlaps with and complements ogies, however, will require creative strategies to pediatric practice, and collaborative efforts serve to meet challenges in some areas of practice, such as benefit child health.19 The AAP realizes that nurse appropriate criteria for supervision of nonphysician practitioners, physician assistants, and other non- clinicians, reimbursement for telemedicine services, physician pediatric clinicians may care for children privacy of patient information, universal standards in underserved areas where patients have limited or for telemedicine technologies, professional and med- no access to a physician. However, the AAP, which ical liability, regulatory and jurisdictional issues re- dedicates its efforts and resources to attaining the lated to multistate licensure of clinicians, and high optimal physical, mental, and social health and well- costs of transmission of medical information. being for all infants, children, adolescents, and Solutions to address difficulties in implementing young adults, does not support independent practice telemedicine technologies have already assumed for nurse practitioners, physician assistants, and many forms and have involved a range of stakehold- other nonphysician pediatric clinicians. The issue of ers. Research is being conducted, for example, to patient access and underserved areas defies an easy measure the impact of telemedicine on government solution. This problem may be related to maldistri- expenditure and third-party payers, patient and cli- bution of pediatricians in some parts of the country. nician satisfaction with telemedicine,23 and increased As of June 2002, there are 3216 primary medical access to particular services through telemedicine. In Health Profession Shortage Areas (HPSAs), needing California, Blue Cross is exploring the potential of to provide care for 57 212 915 persons. The number telemedicine by establishing a statewide telemedi- of physicians currently based in these HPSAs can cine network for its enrollees. To address high trans- accommodate only 22 million of these patients (Rob- mission costs, the Federal Communications Commis- ert M. Politzer, ScD, Health Resources and Services sion established in 1997 the not-for-profit Universal Administration, written communication, August 14, Service Administration Company to provide a dis- 2002). Data suggest that the participation of midlevel count on telecommunication transmission charges to practitioners in the health care of persons in under- rural health care professionals. The Federal Commu- served areas is less than anticipated, and that such nications Commission has subsequently refined the practitioners relocate from underserved areas be- Universal Service program to enhance and promote cause of quality of life issues and a desire to be closer the provision of telemedicine services by eliminating to the amenities of urban centers.20 limits on bandwidth and the number of services that Because of these issues, the AAP recognizes the can be supported by the program.21 pressing need to provide support for nonphysician clinicians in rural, remote, or otherwise underserved COMPLEMENTARY AND ALTERNATIVE MEDICINE areas by ensuring access to a pediatrician-consultant In recent years, the role of CAM has also received who has the education, skills, and expertise to ad- increased attention. Controversy exists about the ef- dress the entire spectrum of pediatric health care ficacy of many of the modalities incorporated under issues. the heading of CAM. Although many definitions exist,24 the National Center for Complementary and USE OF TELEMEDICINE TO IMPROVE ACCESS TO Alternative Medicine defines CAM as “those treat- AND QUALITY OF PEDIATRIC CARE ments and health care practices not taught widely in The AAP believes that telemedicine technologies medical schools, not generally used in hospitals, and will facilitate the pediatrician’s vital role as the leader not usually reimbursed by medical insurance com- of the pediatric health care team. The US Department panies.” According to the National Center for Com- of Health and Human Services defines telemedicine plementary and Alternative Medicine, “some ap- as the use of electronic communication and informa- proaches are consistent with physiologic principles tion technologies to provide or support clinical care of Western medicine, while others constitute healing at a distance.21 The Task Force on the Future of systems with a different origin. Although some ther- Pediatric Education II (FOPE II) affirmed that these apies are far outside the realm of accepted Western technologies would allow the pediatrician to provide medical theory and practice, others are becoming and support health care at a distance while monitor- established in mainstream medicine.”25 ing and enhancing quality of care and improving Although this policy statement will not address communication with other members of the pediatric the treatments but rather the training of individuals health care team.22 Because telemedicine will most who provide such treatments to children, it is impor- likely reshape the relationships among physicians, tant to note that little scientific evidence exists re- patients, and other members of the multidisciplinary garding the safety and efficacy of CAM therapies in care team, the pediatrician is optimally suited to children. Indeed, there have been few randomized, oversee and ensure the proper use of telemedicine in controlled, double-blinded clinical trials on the use of the global management of patient care from diagno- CAM therapies in the pediatric population. Table 2 sis through all stages of treatment. summarizes information on 5 of the most common Recent technologic advances, such as the Internet, practitioners of CAM. AMERICAN ACADEMY OF PEDIATRICS 429 Downloaded from by on August 13, 2010
  6. 6. TABLE 2. Summary of 5 Major Providers of CAM No. of Providers No. of Programs or Length of Training Content of Training Pediatric-Specific Schools Training Chiropractic Approx 55 000– 16 accredited in the US 4 years chiropractic Years 1–2: biological 120 hours leading to 70 000a by the Council on college (at least and basic certification by Chiropractic 4200 hours)b sciences, clinical the International Education disciplines. Years Chiropractic Commission on 3–4: supervised Pediatric Accreditationb clinical training, Associationc often in college clinics Acupuncture 10 000 licensede 34 accredited by the Minimum 1725 hours, Acupuncture, herbal No Accreditation 1000 of which must therapies Commission for be didactic, and 500 Acupuncture and clinical, for Oriental Medicinef NCCAOM certificationg Massage Therapy Approx 160 000– 55 accredited in the US Usually minimum of Massage therapy No 220 000,h by the Commission 500 hoursk theory and approximately on Massage Therapy technique, 40 000 Accreditationj anatomy, Nationally physiology, Certified in business ethics, Therapeutic first aid, and CPR Massage and Bodywork (NCBTMB)i Homeopathy Unknown No current national Varies, but a Varies, but usually No standard for minimum of 500 includes didactic homeopathic hours (or a and clinical education. 19 combination of components of institutions are shorter training, classical currently accredited apprenticeship, and homeopathy and or undergoing clinical experience) basic sciences review for is required for CHC accreditation by the certification.n Council for Homeopathic Educationm Naturopathy Approx 1500o 4 (3 US, 1 Canada) 3 years of college 4 Clinical nutrition, No accredited by the years of acupuncture, Council on naturopathic studyq homeopathic Naturopathic medicine, Medical Education. botanical Another US program medicine, is a candidate for psychology, and accreditationp counseling NBCE indicates National Board of Chiropractic Examiners; NCCAOM, National Certification Commission for Acupuncture and Oriental Medicine; CPR, cardiopulmonary resuscitation. a Source: American Chiropractic Association. Available at: Accessed March 19, 2002 b Source: Council on Chiropractic Education. Available at: Accessed March 19, 2002 c Source: International Chiropractic Pediatric Association. Available at: Accessed March 19, 2002 d Source: National Board of Chiropractic Examiners. Available at: Accessed March 19, 2002 e Source: Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA. 1998;280:788 –794. f Source: American Academy of Medical Acupuncture. Accredited and candidate programs of the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). Available at: Accessed March 19, 2002. g Source: National Certification Commission for Acupuncture and Oriental Medicine. Available at: Accessed March 19, 2002. h Source: American Massage Therapy Association. Massage therapy: key questions and answers. Available at: http://www.amtamassage. org/about/faq.htm. Accessed March 19, 2002. i Source: National Certification Board in Therapeutic Massage and Body Work. Consumer’s guide to therapeutic massage and bodywork. Available at: Accessed March 19, 2002. 430 SCOPE OF PRACTICE ISSUES IN PEDIATRIC HEALTH CARE Downloaded from by on August 13, 2010
  7. 7. Educational Standardized Exams for Certifying Body Professional State Licensure Prescriptive Attainment Certification or Licensure Associations or Regulation Authority Doctor of Chiropractic NBCE Certificate of National Board of American Chiropractic 50 states, see No (DC) Attainment awarded Chiropractic Association, Federation of after passing exam Parts Examiners International Chiropractic I, II. Exams consist of Chiropractic Licensing NBCE Parts I, II, III, Association, Boardsa Physiotherapy, Special International Purposes Exam for Chiropractic Pediatric Chiropractic (SPEC), Association Part IV Practical Examinationd Varies, master’s NCCAOM Certification in National American Association 39 states and No degrees in Acupuncture is basis for Certification of Oriental Medicine, District of acupuncture and licensure. In some states, Commission for American Academy Columbiag doctoral degrees in the NCCAOM Acupuncture and of Medical oriental medicine certification in Chinese Oriental Medicine Acupuncture (OMD) Herbology, as well as other qualifications, is also required. Diplomates use the designation DiplAc (NCCAOM)g No terminal National certification exam National American Massage 30 states and No educational degree, qualifies diplomates to Certification Therapy Association District of such as a doctorate use the designation, Board for Columbial NCTMB. In most of the Therapeutic 29 states, this exam is a Massage and basis for licensure. In Bodywork the remaining states, a state exam is required.l No terminal A variety of exams and Council for North American Society 3 (homeopathic No educational degree, certifications by Homeopathic of Homeopaths, license such as a doctorate professional associations Certification, Homeopathic contingent exist, including the National Board of Academy of on holding designation, Certified Homeopathic Naturopathic current Classical Homeopath Examiners, Physicians medical (CHC), granted by the American Board license in Council for of that state)n Homeopathic Homeotherapeutics Certification. These are not, however, a basis for state licensuren Doctor of Naturopathic Physicians North American American Association 11 states and No Naturopathy (ND) Licensing Exam Board of of Naturopathic Puerto Ricoq Naturopathic Physicians Examiners j Source: Commission on Massage Therapy Accreditation. Massage education institutions and programs. Available at: http://www. Accessed March 19, 2002. k Source: American Massage Therapy Association. Starting a career in massage therapy: what you need to know. Available at: Accessed March 19, 2002. l Source: American Massage Therapy Association. States with massage practice laws. Available at: lawstate.htm. Accessed March 19, 2002. m Source: National Center for Homeopathy. Education directory. Available at: Accessed March 19, 2002. n Source: Council for Homeopathic Education. Available at: Accessed March 19, 2002. o Source: The American Association of Naturopathic Physicians. About AANP. Available at: htm. Accessed March 19, 2002. p Source: The American Association of Naturopathic Physicians. Accredited schools. Available at: education/accredited_schools.htm. Accessed March 19, 2002. q Source: The American Association of Naturopathic Physicians. Frequently asked questions (FAQ). Available at: http://www. Accessed March 19, 2002. AMERICAN ACADEMY OF PEDIATRICS 431 Downloaded from by on August 13, 2010
  8. 8. Children may receive care from CAM practitioners method of delegation, and their oversight responsi- without it being revealed to their pediatrician. A bilities for the delegated duties. 1997 study reported that the percentage of American It may be necessary to remind legislators and adults using CAM increased from 34% in 1990 to health policy makers that a physician’s ability to 42% in 1997.26 The estimate for CAM use by the delegate authority is governed by statutory and con- general pediatric population is lower, ranging from tractual limitations. Moreover, health care entities, approximately 11% in 1994 to 20% in 1999.27,28 The such as hospitals or managed care organizations, rate for children with chronic or serious illness, how- may not authorize the delegation of more authority ever, is much higher, varying according to age, back- than is permitted by state laws, but they may impose ground, and access to services from 30% to more limitations on the delegation of authority that are than 70%, according to 1998 data.29 These figures more restrictive than are state laws. These policies raise serious concerns. The pediatrician cannot be also may be admissible in a medical malpractice responsible for overseeing the actions of CAM pro- lawsuit as evidence of the standard of care. Physi- viders, but can take a proactive role in asking pa- cians violating such policies may risk loss of employ- tients and families about their use of CAM therapies. ment or revocation of privileges. Physicians and As advocates for their patients, pediatricians need to health care entities must, therefore, be knowledge- advise patients and their parents that the interactions able about the terms of these statutes and should between some CAM therapies and conventional seek advice from a qualified attorney. medical treatments can cause complications and For nonphysician clinicians who choose to practice even death. Many people are unaware of this danger independently, there has to be exclusive professional and view CAM therapies as natural and, therefore, responsibility for the care they provide and adequate safe, and so often do not report their use of CAM to malpractice insurance to allow appropriate financial their physicians.30,31 The AAP has recognized the remedy for adverse settlements or decisions. States importance of this issue and has published a series of that license nonphysician clinicians should, there- recommendations on how to counsel families about fore, require that they abide by the same rules re- CAM use for children with chronic illness or disabil- garding malpractice insurance as do physicians. Be- ity.24 The pediatric community has questioned the cause physicians are held accountable for clinicians ability of CAM practitioners to identify serious or acting under their supervision, a pediatrician should complex medical conditions that require referral to a obtain legal counsel to identify any potential profes- physician for medical treatment.32 In addition, the sional or medical liability issues before establishing a opposition of some CAM practitioners to immuniza- pediatric health care team, especially a team that tions negatively affects the health and safety of chil- includes CAM practitioners. dren in their care. Because the integration of CAM with traditional No uniform standards exist across the country for medicine is relatively new, it follows that malpractice scope of pediatric practice of chiropractors, naturo- law involving CAM practitioners is relatively imma- paths, and other CAM practitioners. As summarized ture. At this time, very little is known about malprac- in Table 2, pediatric training and experience are not tice risks of CAM for independent practitioners or specifically outlined or regulated. Studies document- for allopathic and osteopathic physicians using CAM ing improved outcomes and efficacy of treatments in along with conventional treatment. The literature pediatric practice for CAM practitioners do not exist. contains some articles in which the theoretic liability In view of this lack of national standards for pediat- for referrals to CAM practitioners is extrapolated ric care by CAM practitioners, the absence of studies from what is known about liability for referrals to documenting that the quality of health care for chil- traditional nonphysician clinicians.33–35 However, dren provided by these practitioners is comparable the appropriateness of this assumption is un- with that provided by conventional clinicians, and founded. The complexity of these and many other the more extensive training and education of pedia- professional and medical liability issues demon- tricians, the AAP has concerns about the provision of strates the need for pediatricians, as advocates for health care services to pediatric patients by CAM their patients, to educate legislators and health pol- practitioners. icy makers about professional and medical liability issues and their implications for patient safety. PROFESSIONAL AND MEDICAL LIABILITY ISSUES COLLEGIAL RESOLUTION OF SCOPE OF The expansion of the scope of practice of nonphy- PRACTICE ISSUES sicians, including CAM practitioners, has created Scope of practice legislation falls under the juris- new challenges for physicians in addressing profes- diction of individual states. State legislatures are, sional and medical liability issues in all specialties. therefore, the loci of deliberations on these issues. Specific areas of risk for physicians supervising non- Legislatures must evaluate the evidence and testi- physician clinicians are improper delegation of au- mony of a variety of stakeholders, including physi- thority, vicarious liability for medical care provided cians and nonphysician clinicians, when considering by nonphysician clinicians, and liability for nonmed- changes to scope of practice legislation. These com- ical acts committed by nonphysician clinicians. peting political agendas and perspectives often gen- When delegating authority to nonphysician clini- erate highly charged, polemical, and even acrimoni- cians under their supervision, physicians should ous debates that damage professional relationships consider the legality of the delegation, the proper between physicians and nonphysician clinicians. 432 SCOPE OF PRACTICE ISSUES IN PEDIATRIC HEALTH CARE Downloaded from by on August 13, 2010
  9. 9. Some states, however, have attempted to shift Optimal pediatric care is best rendered using a these deliberations from the state legislature to an team-based approach with a physician, preferably a alternative arena. The goal of this shift is to promote pediatrician, as leader. The pediatrician can coordi- collegial relationships between physicians and non- nate and direct patient care and assist nonphysician physician clinicians that focus on serving the best clinicians, even when these clinicians are practicing interests of the public. For example, Texas has suc- in rural or remote areas. The use of advanced tele- ceeded in diffusing the political tensions of these medicine technologies promotes quality health care debates since 1995 through its Ad Hoc Committee on for children who would otherwise be underserved Collaborative Practice. The committee comprises by the current health care system. Communication physicians and nonphysician clinicians, including between physicians and nonphysician clinicians is nurse practitioners and physician assistants. In Tex- essential to ensure appropriate health care and min- as’s legislative sessions of 1997, 1999, and 2001, the imize the risk of harmful interactions between differ- committee’s work obviated the need for scope of ent medical treatments. Because legislation regard- practice battles in the state legislature (A. Gilchrist, ing scope of practice falls under the jurisdiction of MD, Texas Medical Association, oral communica- individual states, pediatricians must be knowledge- tion, September 10, 2001). The AAP supports and able about law-making and policy-making processes encourages such nonlegislative forums to resolve and serve as advocates for quality health care for all scope of practice issues and commends efforts to infants, children, adolescents, and young adults. promote collegial, productive relationships between The AAP affirms the following policy recommen- physicians and nonphysician clinicians in the interest dations: of optimal patient care. When the resolution of scope of practice issues 1. A physician, preferably a pediatrician, should outside of the legislative arena is not possible, stake- serve as the leader of the pediatric health care holders with common positions on the issues should team. This leadership role is based on the pedia- explore opportunities for collaboration. A number of trician’s ability to manage, coordinate, and super- strategies can be used to pursue legislative action. vise the entire spectrum of pediatric care, from First, national medical and specialty societies can diagnosis through all stages of treatment and in coordinate their efforts on nonphysician scope of all practice settings. This role involves coordinat- practice issues when a nationally organized cam- ing and supervising the care provided by other paign is appropriate. Because most scope of practice pediatric clinicians, including care delivered via conflicts occur at the state level, however, it is im- telemedicine technologies. portant for AAP chapters, state medical societies, 2. Pediatricians, as leaders of pediatric health care and other state-level entities to collaborate. In these teams, must embrace their responsibility to edu- efforts, state-level groups should make use of re- cate patients, their families, and their caregivers; sources, particularly policy statements developed by health care purchasers; policy makers; the media; national medical and specialty societies, for their and the public about scope of practice issues and advocacy activities at the state level. Such activities the appropriateness of different care options, in- require physicians who are knowledgeable of law- cluding the use of CAM. Pediatricians should also making and policy-making processes and who have participate, as appropriate, in the training and the skills necessary to be effective advocates in leg- educational experiences of nonphysician clini- islative deliberations. For this reason, AAP chapters cians. should encourage, recruit, and train their members 3. Comparable standards of scientific evidence to serve as advocates of optimal pediatric health care should be applied to assess the outcome in all in state-level policy initiatives on nonphysician scope areas of clinical practice delivered by all providers of practice issues. This advocacy role should be ful- of pediatric care. filled through active participation in policy debates 4. Telemedicine technologies should be imple- conducted in state legislatures, the media, commu- mented as one means of improving the quality of nity-based programs, and other public forums. pediatric care available to children who otherwise have limited access to health care. The safety, CONCLUSION quality, and appropriateness of this care should In recent years, there has been an increase in the be ensured by addressing professional and medi- number of nonphysician clinicians in the health care cal liability issues and establishing technical stan- market, as well as an increased interest in an expan- dards and guidelines and clinical practice proto- sion of their roles, including autonomy, prescriptive cols for pediatric care provided through authority, and third-party reimbursement. Profes- telemedicine technologies. sional and medical liability issues are also coming to 5. Pediatricians should take a proactive role in ask- the fore of the scope of practice debate. The educa- ing patients and families about their use of CAM tion and evaluation of health care professionals is therapies. Pediatricians cannot be responsible for quite variable. Pediatricians are the most extensively overseeing the actions of CAM providers. Pedia- educated providers of pediatric care. Nurse practi- tricians can, however, advise patients and their tioners and physician assistants complete shorter but families about the use of CAM and that interac- well-defined educational programs and examina- tions between some CAM therapies and conven- tions. Other clinicians may participate in only abbre- tional medical treatments can cause complications viated educational experiences in pediatric care. and even death. AMERICAN ACADEMY OF PEDIATRICS 433 Downloaded from by on August 13, 2010
  10. 10. 6. Nonphysician clinicians acting independently of Jerold C. Woodhead, MD physicians should be held to the equivalent de- Past Committee Member gree of professional and medical liability as is a Staff physician. States that license nonphysician clini- Ethan Alexander Jewett, MA cians should, therefore, require that they abide by the same rules regarding malpractice insurance as *Lead author do physicians. Because physicians are held ac- countable for clinicians acting under their super- vision, a pediatrician should obtain legal counsel REFERENCES to identify any potential professional and medical 1. American Academy of Pediatrics, Board of Directors. The role of the non-physician provider in the delivery of pediatric health care. AAP liability issues before establishing a pediatric News. 1994;10:4. Available at: health care team, especially a team that includes Accessed March 19, 2002 CAM practitioners. 2. American Academy of Pediatrics, Medical Home Initiatives for Chil- 7. To promote the highest standards of care in each dren with Special Needs Project Advisory Committee. The medical state, scope of practice issues should be resolved home. Pediatrics. 2002;110:184 –186. Available at: policy/s060016.html. Accessed September 26, 2002 through nonlegislative forums (like those on the 3. American Academy of Pediatrics, Committee on Fetus and Newborn. model of the Texas Ad Hoc Committee on Collab- Advanced practice in neonatal nursing. AAP News. 1992;8:7. Available orative Practice), which include physicians and at: Accessed March 19, 2002 nonphysician clinicians, such as nurse practitio- 4. American Academy of Pediatrics, Committee on Hospital Care. Medical staff appointment and delineation of pediatric privileges in hospitals. ners and physician assistants. AAP chapters are Pediatrics. 1996;98:983. Available at: encouraged to take a leadership role in establish- re9640b.html. Accessed March 19, 2002 ing such forums in their respective states. 5. American Academy of Pediatrics, Committee on Hospital Care. The role 8. AAP chapters and state medical and specialty of the nurse practitioner and physician assistant in the care of hospital- societies, as well as national medical and specialty ized children. Pediatrics. 1999;103:1050 –1052. Available at: http:// Accessed March 19, 2002 societies, should be proactive in legislative advo- 6. American Academy of Pediatrics, Committee on Pediatric Emergency cacy and should partner in informing legislators, Medicine. The role of the pediatrician in rural EMSC. Pediatrics. 1998; health care purchasers, the media, and the public 101:941–943. Available at: about the differences in the education, skills, and Accessed March 19, 2002 knowledge of various health care professionals. 7. American Academy of Pediatrics, Committee on Pediatric Workforce. Pediatric primary health care. AAP News. 1993;11:7. Available at: Legislative advocacy includes opposing legisla- Accessed March 19, 2002 tion to expand the scope of practice of nonphysi- 8. American Academy of Pediatrics, Committee on Pediatric Workforce. cian clinicians, particularly independent practice, Pediatric workforce statement. Pediatrics. 1998;102:418 – 427. Available independent prescriptive authority, and reim- at: Accessed March 19, 2002 9. American Academy of Pediatrics, Committee on Practice and Ambula- bursement parity. tory Medicine and Committee on Fetus and Newborn. The role of the primary care pediatrician in the management of high-risk newborn ACKNOWLEDGMENTS infants. Pediatrics. 1996;98:789 –788. Available at: The Committee on Pediatric Workforce gratefully recognizes policy/pe000786.html. Accessed March 19, 2002 the many stakeholders that contributed valuable perspectives and 10. American Academy of Pediatrics, Committee on School Health. Health information during the development of this policy statement. In appraisal guidelines for day camps and resident camps. Pediatrics. 2000; particular, the committee acknowledges the AAP chapters, com- 105:643– 644. Available at: mittees, sections, task forces, and other bodies that provided input Accessed March 19, 2002 during the Scope of Practice Open Forum at the 2001 National 11. American Academy of Pediatrics, Committee on School Health. Role of Conference and Exhibition. The Committee on Pediatric Work- the school nurse in providing school health services. Pediatrics. 2001; force also thanks the American Academy of Physician Assistants, 108:1231–1232. Available at: the National Association of Pediatric Nurse Associates and Prac- Accessed March 19, 2002 titioners, and the Texas Medical Association for their thoughtful 12. American Academy of Pediatrics, Committee on School Health. School and constructive comments on scope of practice issues. health assessments. Available at: re9862.html. Pediatrics. 2000;105:875– 877. Accessed March 19, 2002 Committee on Pediatric Workforce, 2002–2003 13. American Academy of Pediatrics, Committee on School Health. School Carmelita V. Britton, MD, Chairperson health centers and other integrated school health services. Pediatrics. Michael R. Anderson, MD 2001;107:198 –201. Available at: *Carol D. Berkowitz, MD re0030.html. Accessed March 19, 2002 Aaron L. Friedman, MD 14. Black HC, Nolan JR, Connolly MJ. Black’s Law Dictionary. 6th ed. St Paul, MN: West Group; 1990 David C. Goodman, MD, MS 15. Mundinger MO, Kane RL, Lenz ER, et al. Primary care outcomes in Kristan M. Outwater, MD patients treated by nurse practitioners or physicians: a randomized trial. Richard J. D. Pan, MD, MPH JAMA. 2000;283:59 – 68 Debra Ralston Sowell, MD 16. Karlowicz MG, McMurray JL. Comparison of neonatal nurse practitio- ners’ and pediatric residents’ care of extremely low-birth-weight in- Liaison fants. Arch Pediatr Adolesc Med. 2000;154:1123–1126 Gail A. McGuinness, MD 17. Hooker RS, McCaig LF. Use of physician assistants and nurse practi- American Board of Pediatrics tioners in primary care, 1995–1999. Health Aff (Millwood). 2001;20: Past Committee Members and Liaisons 231–238 18. American Academy of Physician Assistants. Guidelines for ethical con- Frances J. Dunston, MD, MPH duct for the physician assistant profession. JAAPA. 2001;14:10 –12, National Medical Association 15–16, 19 –20. Available at: Jeffrey J. Stoddard, MD Accessed March 19, 2002 Immediate Past Chairperson 19. Murphy CE. Practice identity, collaboration, and optimal access to Walter W. Tunnessen, MD effective health care. J Pediatr Health Care. 2001;15:98 –100 American Board of Pediatrics 20. Medicare Payment Advisory Commission. Report to the Congress: Medi- 434 SCOPE OF PRACTICE ISSUES IN PEDIATRIC HEALTH CARE Downloaded from by on August 13, 2010
  11. 11. care Coverage of Nonphysician Practitioners. Washington, DC: Medicare 28. Gardiner P, Wornham W. Recent review of complementary and alter- Payment Advisory Commission; June 2002 native medicine used by adolescents. Curr Probl Pediatr. 2000;12:298 –302 21. Office for the Advancement of Telehealth. 2001 Report to Congress on 29. Breuner CC, Barry PJ, Kemper KJ. Alternative medicine use by home- Telemedicine. Rockville, MD: Office for the Advancement of Telehealth, less youth. Arch Pediatr Adolesc Med. 1998;152:1071–1075 Health Resources and Services Administration, US Department of 30. Gulla J, Singer AJ. Use of alternative therapies among emergency de- Health and Human Services; 2001. Available at: http:// partment patients. Ann Emerg Med. 2000;35:226 –228 Accessed March 19, 31. Berman BM, Swyers JP, Hartnoll SM, Singh BB, Bausell B. “The public 2002 debate over alternative medicine: the importance of finding a middle 22. American Academy of Pediatrics, Task Force on the Future of Pediatric ground.” Altern Ther Health Med. 2000;6:98 –101 Education II (FOPE II). The Future of Pediatric Education II. Organizing 32. Lee AC, Kemper KJ. Homeopathy and naturopathy: practice character- pediatric education to meet the needs of infants, children, adolescents, istics and pediatric care. Arch Pediatr Adolesc Med. 2000;154:75– 80 and young adults in the 21st century. A collaborative project of the 33. Dumoff A. Medical Malpractice Liability of Alternative/ pediatric community. Pediatrics. 2000;105(1 Pt 2):157–212 Complementary Health Care Providers: A View from the Trenches. 23. Pammer W, Haney M, Wood BM, et al. Use of telehealth technology to HealthWorld Online Web site. Available at: extend child protection team services. Pediatrics. 2001;108:584 –590 public/legal-lg/medmalpr/dumoff.htm. Accessed March 19, 2002 24. American Academy of Pediatrics, Committee on Children With Disabil- 34. Studdert DM, Eisenberg DM, Miller FH, Curto DA, Kaptchuk TJ, Bren- ities. Counseling families who choose complementary and alternative nan TA. Medical malpractice implications of alternative medicine. medicine for their child with chronic illness or disability. Pediatrics. JAMA. 1998;280:1610 –1615 2001;107:598 – 601 35. Studdert DM. Legal issues in the delivery of alternative medicine. J Am 25. National Center for Complementary and Alternative Medicine. What is Med Womens Assoc. 1999;54:173–176 CAM? NCCAM Web site. Available at: http://nccam. an/general/#whatcam. Accessed March 19, 2002 26. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990 –1997: results of a follow-up national survey. JAMA. 1998;280:1569 –1575 All policy statements from the American Academy of 27. Spigelblatt LS. Alternative medicine: should it be used by children? Pediatrics automatically expire 5 years after publication unless Curr Probl Pediatr. 1995;25:180 –188 reaffirmed, revised, or retired at or before that time. AMERICAN ACADEMY OF PEDIATRICS 435 Downloaded from by on August 13, 2010
  12. 12. Scope of Practice Issues in the Delivery of Pediatric Health Care Committee on Pediatric Workforce Pediatrics 2003;111;426-435 DOI: 10.1542/peds.111.2.426 Updated Information including high-resolution figures, can be found at: & Services References This article cites 25 articles, 21 of which you can access for free at: Citations This article has been cited by 12 HighWire-hosted articles: s Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Office Practice Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Reprints Information about ordering reprints can be found online: Downloaded from by on August 13, 2010