ne definition of the practice of medicine is “the science and ‘art’ of maintaining and/or restoring human health through the study, diagnosis and treatment of patients.”¹ Since the 19th century, in most countries, a medical degree was required to practice medicine, which included scientific scholarship as well as the evaluation and treatment of individual patients. The general term “provider” of health care may include many in the allied health and paraprofessional areas providing treatments, but not necessarily including the equally important other two facets of the triad: study and diagnosis. In pain medicine, simple treatments without diagnosis and study are inadequate to address the complex and often chronic disease state we call pain.

In the United States, the three-legged stool in health care is inherently unstable. Of the three legs needed (consisting of three supports: quantity, quality and economy) — to provide excellence and comprehensive and affordable health care — only two of these parameters can be fully achieved at the same time. For example: A large quantity of services with high quality will result in very little economy, while conversely high quality and simultaneous economy necessitate a limited quantity of care. In an attempt to increase quantity and preserve economy, the use of health care “providers” has been thought by some to be a possible solution. The attempt to preserve quality in this scenario has resulted in state legislators and regulators defining the degree of physician supervision, if any. However, in assuming responsibility without control, the physician often over-multiplies his/her risk while limiting the quality of his/her care.

In pain medicine, there are ever more frequent attempts by state legislatures, regulators and insurers to establish educational requirements and certifications for the providers of medical care. The debate begins in differentiating “care providers” from physicians engaged in the practice of medicine, and the boundaries can become blurred between the two groups. Cost differentials between physician and “care providers” often are more location-dependent than correlated to education and experience.

Individual states have been entrusted with passing laws to set standards for health care. An example is Pennsylvania’s H.B. 700, Governor Edward Rendell’s proposal to create universal health care. Several provisions, such as increasing smoking restrictions, eliminating hospital-acquired infections and increased accessibility to affordable health insurance, are relatively uncontroversial, while others bear discussion. H.B. 700 included provisions that would expand the scope of practice of many allied health professionals. This would occur without studying the effect of the proposed changes on quality, safety or even economy. Due to constitutional requirements, many of those provisions became separate bills, some of which passed the legislature.

One of these bills is of particular interest to anesthesiologists: H.B. 1256. This bill would have allowed nurse anesthetists to administer anesthesia in collaboration with a physician or dentist, which would have been a first step toward an opt-out of the federal physician supervision requirement. While it’s possible that the bill could be voted upon later this year, it appears that H.B. 1256 has died this session after legislators withdrew their support.

In order to assess the projected scope of practice of nonphysicians, it may be helpful to review the standards set by the groups themselves. The American Nurses Association defines nursing as follows: “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” One can see that the nursing associations, though they neglect the inclusion of “study,” have defined their scopes of practice to include the diagnosis and treatment of patients. When one reviews state legislative and regulatory activities over the last year, one can see continued movement into scope of practice and provider issues. Legislation and proposed regulations in California, Connecticut, Illinois, Iowa, Louisiana, Massachusetts, Missouri, Nebraska, New Jersey, Utah and Wisconsin are most likely to threaten the definition of pain as the practice of medicine.

This activity can affect pain as the practice of medicine in three general ways. First, legislation was introduced that would have removed physician involvement and granted prescriptive authority to nurses for Schedule II-V controlled substances. If physician supervision is no longer required, then care of patients with pain falls under the definition of “pain management” rather than the practice of medicine. Legislation granting prescriptive authority died in committee in Connecticut, Illinois and Missouri. Most recently, the New Jersey Board of Nursing proposed regulations that could be interpreted to allow nurse anesthetists to administer anesthesia in collaboration with a physician and to prescribe controlled substances, even though the New Jersey Supreme Court in 2005 held that the administration of anesthesia is the practice of medicine. A similar bill enacted in Utah had sections deleted prior to enactment that would have granted prescriptive authority to nurse anesthetists who met certain qualifications. In Massachusetts, S.B. 1236 would enable the nursing board to delete unilaterally the requirements of physician supervision or medical direction. Existing law requires scope-of-practice regulations promulgated by the nursing board to be made in conjunction with the medical board. In addition to S.B. 1236, the nursing board recently proposed regulations that would delete the current requirement that a nurse anesthetist function under the overall medical direction of a physician.

Both Nebraska and Iowa introduced legislation and proposed regulations that would expand nurse anesthetist scope of practice to include the use of fluoroscopy (Nebraska) and to supervise the use of fluoroscopic systems (Iowa). These issues continue in both states. In Louisiana, S.B. 322 would have allowed nurse anesthetists to perform interventional pain procedures under the direction and supervision of a physician. The procedures would have included, but not been limited to, those involving the injection of local anesthetics, steroids and analgesics.  The procedures for pain management purposes would also have included, but not been limited to, peripheral nerve blocks, epidural injections and spinal facet joint injections when the nurse anesthetist could document education, training and experience in performing such procedures.  We physicians as a whole must decide if we are interested in maintaining the integrity of the practice of medicine for the greater good of society and our patients or if certain specialties and groups will choose to utilize alternative health care providers for personal advancement and economic gain. S.B. 322 passed the Louisiana Senate but never reached the House floor for a vote, and it died when the legislature adjourned.

In California, the nursing board released a statement that allowed nurse anesthetists to practice independently and to perform acute and chronic pain management procedures. The California Society of Anesthesiologists challenged the legality of this statement, and ultimately the nursing board removed the statement from its Web site. It is believed, however, that the board will propose regulations that mirror the statement. In Wisconsin, the board of medical examiners, following the recommendation of an administrative law judge, concluded that nurse anesthetists who hold a certificate to prescribe may work in a collaborative relationship with a physician. Collaboration applies to both prescriptive authority and the administration of anesthesia Finally, as is well-known by now, Governor Jim Doyle in 2005 opted out of the federal requirement that a nurse anesthetist administer anesthesia under the supervision of the operating practitioner or anesthesiologist who is immediately available if needed. So where does this lead us in the provision of care to our patients with pain problems?

In considering what has been called “pain management,” will this be used interchangeably with “pain medicine,” e.g., the practice of medicine as it pertains to the science, evaluation and treatment of pain patients? Is nursing care “pain management” or “pain medicine?” In any proposed health care delivery structure, the following questions must be addressed:

• Will quality be served to the patient and to society and the advancement of medical science?

• Will quantity justify shortcuts in training to increase the number of “providers”?

• Will even economy be served if physician care of pain patients is bypassed, as often the simplest answers are not the correct ones?

A quick solution may be more costly in the long term than a well-considered plan including science, diagnostic flexibility and the most appropriate treatment.

Reference:
1. Wikipedia online encyclopedia entry: en.wikipedia.org/wiki/Medicine. Accessed on October 31, 2007.

Many thanks to ASA State Legislative and Regulatory Affairs Manager Lisa Percy, J.D., for her editorial acumen in helping to prepare this article.

Doris K. Cope, M.D., is Professor and Vice-Chairman of Pain Medicine, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Beth H. Minzter, M.D., M.S., is Staff, Division of Anesthesiology, Critical Care Medicine and Comprehensive Pain Management, Department of Pain Management and the Cancer Center, Cleveland Clinic Foundation, Cleveland, Ohio.