Practicing at the top of my license?

The 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 many non-medical people wouldn’t 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, spiked it with sterile tubing, 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.  Apparently they have no concern 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, this is excellent. I can’t wait for my next hospital Medical Executive Committee meeting.

I can cite you a few examples of my own: we anesthesiologists are constantly harangued and hounded about “first-case starts” and “turnover times”; this information is tracked minutely and pie charts are pored over like augurs examining sheeps’ offal. We must shave off minutes to ensure surgeon and patient “satisfaction”, lest the sky fall in (one presumes a safe anesthetic and a successful operation administered by people who are kind to you is not sufficiently “satisfying” to the modern, entitled, delicate flower of a patient.) I imagine it’s the same at your institution.

We’ve asked for a decade for an anesthesia tech — hell, anyone with an opposable thumb and brains enough to climb off a rock when the sun gets too hot would do — to change circuits and suction tubing and canisters. Nope. Too expensive. What is the cost, in recovered OR time, of eight hours at minimum wage?

(Never mind about the obstetricians at our hospital who routinely schedule C-sections upstairs during their OR elective lists, and depart the OR to do them while patients and teams await their return. Evidently, colleague satisfaction hasn’t a pie chart of its own.)

Another: we’ve suggested time and again that we move either to a “case cassette” system like we used at Duke for checking out and charging for drugs; or to a Pyxis in each OR that would both dispense drugs and track charges. No can do; pharmacy doesn’t have the staffing, machines are too expensive, etc, etc. No answer when I asked how much they’re losing in unrecovered drug charges.

In short, there’s a whole lot of stupid and hidebound to go around in the US healthcare “system”, and it doesn’t look to be getting better anytime soon.


Steve Lauhoff

Dr. Sibert and Dr. Sebastian,
As an administrator of 20+ years in physician practice management, I have devoted a large chunk of this time to helping doctors try to practice at the top of their license. Not always the easiest thing to do but one to which I believe all healthcare organizations must be committed. It makes me angry to read those anecdotes of the unwillingness to address your concerns. Stories like those motivated me to start my own consulting group to go about looking for places where I can fix exactly those kinds of problems. The physician (more specifically, your decision making ability) is the most precious resource in the healthcare system – without it, there is no healthcare system. What you have described are situations where there appears to be total ignorance of this fact by managers. All of these problems are at their core management problems and competent managers should be able to solve them with your help and input. I hope that you are able to make some progress at your facilities and if you need any help in dealing with those problems, please let me know. I want you to know that there are administrators in the world who get it and are committed to helping you achieve what you seek. Sorry that you are having to deal with this. Thanks for all you do for your patients.


Doug C.

Our orthodontist is his own administrator. He knows his time is valuable so he hires many assistants to allow him to practice at the top of his license. Some airlines are proud how pilots chip in and sling baggage, allowing them to practice at the bottom of their license. Engineers have been asked to carry out the trash to save on janitorial services, also at the bottom of their training. When performance review time rolls around, can the engineer state that they exceeded expectations while taking out the trash?


Don’t forget about the ridiculous amount of time we spend doing data-entry into incredibly poorly designed EMR’s centered around reimbursement rather than clinical care



As an anaesthesiologist who has seen pretty much identical work scenario…….y only solution is that actual , high grade medical grade hospital managers should be at work at 6:00 am ( on the dot); work until 21:00 and must must do on-call duties. Infact the management, HR and such departments should work on a shift pattern to mirror the hospital. No studies have proven that they should not be done this way.
This will give them a hands on experience, make them directly involved and impact positively patient well being. Imagine the joy, when patient will learn that a hospital manager ( without his entourage and minions) is at his beck and call to ensure the hospital journey a safer one.


Bradley E Smith

Re: “practicing at the top…”. Read: “Doctors lost control of their professional activities 30 years ago, to administrators and bureaucrats.” I was there. I fought it.But I “was just an old curmudgeon” to my colleagues, who couldn’t see that their bus was headed downhill without brakes.
It’s too late, Karen.




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