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:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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!