“Bye Bye Bye” By-Laws

By  |  January 28, 2019 | 

There are so much evolution and progression with NP/PA practice. States are passing independent practice statutes for NPs; twenty-two states now allow more independent practice. Our own Institute of Medicine has acknowledged the benefit of NP/PA practice related to alleviating work shortages. And there have been rigorously controlled studies that definitively demonstrate the safety, efficacy, and benefit of integration of advanced practice providers.

But do you know what barrier hasn’t changed? By-laws.

I’m currently in a role where creation of more standardized NP/PA practice is needed. But it’s pretty hard to create standardization when one hospital only allows NP/PA providers to disimpact people and give immunizations, and another allows all advanced practice providers to be members of the medical executive committee and carry an independent panel of patients.

By-laws have not kept pace with modern medical care delivery. Perhaps the by-laws were drafted in the semi-distant past and with no updates or review since. The physician that runs the medical executive committee may have had a large and impactful practice in the past but is not familiar with current hospital medicine practice. Limitations on NP/PA practice are often put in place to protect the financial interests of consultants. For example, if you have two competing gastroenterologists in the same small community hospital, having one GI doc who is able to deploy an APP while he/she goes and does procedures could be an advantage over another who hasn’t the volume or inclination to move in that direction. At other times, by-laws reflect a more draconian interpretation of Medicare rules. Or worse, reflect some of the dismay and fear of physicians as they confront changes in the way care delivery is evolving.

All of those etiologies are human and understandable. I believe that compassion must come before change. Until all parties take the time to walk in another’s shoes, no true evolution can take place. My physician partners are under tremendous stress and pressure. Who they are, their role within society, within the framework of medical care, is shifting in some ways. That instability is hard on anyone. On everyone.

And so to confront the “bye bye bye” of by-laws, I recommend the following interventions:

  1. First, seek to understand. Why do the by-laws exist in their current permutation? Were they developed out of someone’s personality, due to some unfounded fear of litigation, to protect the financial interests of someone? Try to create a dialogue that contains the narrative of the past. It may help you find the right lever to pull, the right words to say to exert evolution.
  2. Develop a specific framework for NP/PA practice. In my mind, if there are specific guidelines for both NP/PA scope of practice and physician oversight, then medical executive teams may view the NP/PA integration with a calmer and more realistic perspective.
  3. Enroll hospital leadership in this process. C-suite executives see the value in utilizing an NP/PA workforce as a lower cost, safe and quality alternative. They need support to enroll their physician leaders. Give it to them. Integrate specific and sensible guidelines outlining when an APP will consult a physician partner, a care escalation process, etc., to provide some guidance to the C-suite.
  4. Don’t take “no” for the final answer. This is a dialogue that takes time. It’s multiple conversations, over multiple episodes and time periods. Just keep trying and keep the communication lines open.
  5. Use the word “pilot”. Take a definitive patient population with targeted metrics and see if you can demonstrate safety and efficacy within a certain and specific lane.
  6. Finally, get involved. Join medical executive committees. Share sensible by-laws. Talk about the tangible and intangible benefits of NP/PA providers.

By-laws are like a rock in a river. If you go canoeing in a river, and you see a rock, you don’t get out of the river. You learn to navigate around that rock. So don’t get out – go around it!


  1. Avatar
    Martin January 28, 2019 at 8:53 am - Reply

    It is true that hospital by laws dictate scope of practice, not state governments. Welcome to the game. Take a number. Please note even physicians have had difficulty obtaining privileges for artificial reasons.

  2. Avatar
    Anthony P Dasaro January 28, 2019 at 12:33 pm - Reply

    There need to be specific guidelines for the oversight of NP/PA practitioners especially in the hospital setting. The skill sets vary in terms of acute care capability. In the outpatient setting, NP/PA are supposed to be of assistance in under served areas and yet, even in states with many such areas, they mostly want to be in the local urban setting.

    I chair our MEC and have been Department Chief of Medicine. I have worked with NP and PAs for 15 years as director of Hospital Medicine and am a charter member of SHM.

    Those assigned to our team, after a suitable period of building experience and vetting, are perfectly capable of practicing with a great degree of independence. They know when to ask for help when needed just as we would ask for a consult. We are working towards a “credentialing process” that will allow such independence.

    Unfortunately, there are those in the group, nationally, that feel they are capable of this by virtue of completing their program. My personal observation and experience does not validate this idea.

    To be closed minded about the growth and use of these practitioners is a huge mistake but, as you have said, we must take a careful look at creating a process that provides safe and consistent practice patterns for the benefit of both patients and the NP/PA practitioners.

    Anthony P Dasaro MD MS

    • Avatar
      Crystal White February 21, 2019 at 2:45 pm - Reply

      Dr. Dasaro:

      I agree with much of what you’ve written, but wasn’t sure I would when you began with “supposed to be of assistance in under served areas.” I am very proud of many of my colleagues who choose to practice in rural areas, but if they are qualified to serve in those areas, they are just as qualified to serve in urban areas. Where they serve should be totally up to the practitioner and the one hiring. Since research shows NPs deliver high-quality care, wit similar outcomes, I think it would be a big mistake to in any way imply we should have a two-tiered health system where rural, under served populations see NPs and urban populations see MDs. Also, it has been my experience, that after residency, physicians usually require some experience and vetting as well.

      Thank you for sharing your insight. Having an open mind, protecting physicians, NPs, and most importantly patients, should be the goal of everyone.

      Crystal White, FNP

  3. Avatar
    T January 30, 2019 at 12:43 am - Reply

    You want standardized practice, start with the education first. NP education is not standardized at all. The modern medical care model stinks. It is run like a fast food joint. The fact that it is the status quo does not make it right or good. It is a disaster. Sure, the C-suite sees mid-level practitioners as a way to make a profit, doesn’t have a damn thing to do with care to the patients or the value you believe you add. If you believe they care one whit about MLP’s, I have a bridge I want to sell you in Timbuktu.

    Medicine should never be run as a business. Bylaws as written are the only factors keeping medicine somewhat safe. Remove those regulations, it will be like removing the regulations from the banking world. A resounding crash will occur. And it will be the patients who pay the price.

  4. Avatar
    sandy oestreich February 2, 2019 at 10:27 pm - Reply

    Some good, mature, thoughtful logic expressed here.

  5. Avatar
    Lorraine Britting March 23, 2019 at 8:04 am - Reply

    This is a thoughtful and considered piece with practical suggestions. I especially agree that we should not take no for an answer. Change is incremental. Thank you for your insight.

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About the Author: Tracy Cardin

Tracy Cardin
Tracy Cardin, ACNP-BC, SFHM is currently the Vice President, Advanced Practice Providers, at Sound Physicians and serves on SHM’s Board of Directors as its secretary. Prior to this, she was the Associate Director of Clinical Integration at Adfinitas Health, the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations. In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.


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