Who’s signing my patient’s history and physical?

29th March, 2021

If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

A cardiologist who opined that my patient needed a permanent pacemaker, but it could wait until after his carotid endarterectomy because “this patient has a low risk of perioperative bradycardia. If he were to develop AV block intraoperatively, a temporary transvenous pacemaker could be placed.” (Wait. What? Carotid procedures are notorious for bradycardia. We’re going to insert a transvenous pacing wire through his open neck incision?)

An H & P from a community internist that “cleared” my patient with lung cancer for lobectomy so long as it could be done under local with sedation.

Then we have to deal with the widespread misconception that “minimally invasive” is synonymous with “trivial” when it comes to surgical procedures. My husband, Steven Haddy, MD, a cardiac anesthesiologist, loves to give a lecture to an internal medicine audience on pulmonary hypertension and anesthesia, and wait for the gasps when he shows the photo of a “minimally invasive” robotic prostatectomy with the robot docked, the abdomen insufflated, and the patient in steep Trendelenburg.

If non-anesthesiologist physicians can do such an inept job with preoperative assessments, what are we to expect from nurse practitioners?

What could go wrong?

I rely with complete confidence on the H & Ps of one experienced nurse practitioner who works in the office of a thoracic surgeon. She understands thoracic surgery procedures and their risks, knows the patients and their history, and orders exactly the right preoperative tests, every time.

What causes me anxiety, as an anesthesiologist, is thinking about the accuracy and thoroughness of a preoperative assessment I might receive from a primary care NP, working in an outpatient clinic with no physician consultation. In a brief H & P, we have no way to know what information may have been omitted. If there is little understanding of the surgery or the anesthetic impact of the patient’s underlying medical problems, how would that person know what’s important to include?

Currently, there are more than 290,000 licensed NPs in the US, and Becker’s Hospital Review reports that the number of FTEs surged 109% in the past decade. More than 30,000 NPs complete their academic programs each year.

Until I read the book, Patients at Risk, by Niran Al-Agba, MD, and Rebekah Bernard, MD, I had no idea how little breadth or depth there might be to a nurse practitioner’s education. “Registered nurses who already have a bachelor’s degree in nursing can become a Family Nurse Practitioner in under two years, with coursework completed entirely online,” the authors report. “Schools are now fiercely competing for students to fill their classrooms. One of the downsides of the increased capacity for students is that the criteria for entry have declined. In fact, at least nine programs boast 100% acceptance rates – every student who applies is guaranteed acceptance.”

Since nurse practitioners can earn higher pay than registered nurses, there is an ongoing exodus of RNs into NP programs. They have the option to select a patient population focus on acute care, either for adults or children. But most students – nearly 90%, according to the American Association of Nurse Practitioners (AANP) – certify in an area of primary care. Their certification exams are specific to primary care, and require no additional education or clinical precepting in perioperative care.

Protecting patients

If you already live in a state with full practice authority for NPs, then the camel – not just the camel’s nose – is already in the tent. There will be little you can do other than to have a low threshold for questioning the information, or lack of it, in a preop H & P generated by a non-physician you don’t know personally.

In California, though AB 890 has already passed, there is work to be done in terms of scrutinizing its language and guiding its implementation.

I find it discouraging that the law’s requirements (Section 4, Article 8.5) “are intended to ensure the new category of licensed nurse practitioners has the least [emphasis mine] restrictive amount of education, training, and testing necessary to ensure competent practice.”

I find it outright alarming that one of the conditions listed that would mandate referral to a physician is “any patient with acute decomposition [sic].” My hope would be that the patient would be referred to a higher level of care before decomposition started, but you never know.

To its credit, the California Medical Association (CMA) has established an AB 890 Task Force to provide “expertise and strategic advice” regarding the implementation of AB 890, and “to make recommendations relating to the education of NPs, patient access to care, and patient safety, among other topics.” I have the honor of representing anesthesiology on this task force, and will do my best to ensure that NP independent practice is never defined to include the practice of anesthesiology, perioperative medicine, or pain medicine.

This underscores the importance of having all physicians become members also of our state and county medical associations. If you don’t join, you won’t have a voice. There is always a need for guardrails and vigilance to ensure that everyone in healthcare – physicians and nurses alike – practices within the safe limits of their knowledge and training.

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An earlier version of this article appears in the April 2021 issue of the ASA Monitor.