Scope of Practice

From the Chair of the Board on Chancellors

---

In providing my thoughts about the topic of scope of practice (SOP) in medicine, healthcare and, more specifically, radiology, I would like to frame the discussion by using the three pillars of Simon Sinek’s Golden Circle.

The Why

Why are we even having this important conversation?

Physicians invest at least seven to 12 years of education and training after college to develop a foundation of knowledge and the necessary medical skills to provide patients with the level of care they deserve. Given that medical knowledge and technology are advancing so rapidly, the years that physicians spend on education and training are more important than ever to ensure the safety and well-being of patients.

Non-physician providers (NPPs), such as nurse practitioners (NPs) and physician assistants (PAs), evolved in the mid-1960s as physician extenders. These two groups of NPPs were originally mandated to work under the supervision of a physician. With that understanding, their education and training were designed to be much more abbreviated and limited than that of a physician. For context, NPs and PAs have about two years of classroom education after college. The clinical training is 800 hours (less than six months) for an NP and 1,600 hours (less than 12 months) for a PA, assuming a 40-hour week.

With the creation of NPs and PAs, understanding their targeted education and limited clinical experience, the expectation was that they would be part of a physician-led team in a hub-and-spoke model. The hope was that these NPPs would help address access problems in primary care, especially in rural areas and underserved communities. However, for more than a decade, there has been a growing effort and desire among NPPs to not only practice independent of a physician’s supervision but also to increase their SOP into clinical arenas in which they have no or minimal formal education or clinical training. This movement by NPPs and their political supporters to expand their independence raises major concerns about patient safety. NPP competencies and patient well-being should be top of mind for all physicians, and especially for radiologists, as some NPPs have begun to report out and bill for diagnostic imaging studies.

The How

How did the healthcare profession, and specifically radiology, get into this situation?

A growing U.S. population and their healthcare needs have outpaced the increase in the number of physicians, creating a situation in which timely access to care is worsening. The increasing survival and longevity of patients with certain medical problems (such as cancer and heart disease) have made the management of these patients more complex and time-consuming for all providers. This further exacerbates patient-access issues and physician shortages.

Access to healthcare in rural areas and certain ZIP codes in metropolitan areas is even more problematic. The initial hope had always been that NPs and PAs would provide services in these underserved areas. However, what has been observed is that the geographic distribution of these NPPs essentially reflects that of primary-care physicians, leaving this need relatively unmet despite the growth in the number of PAs and NPs. Data also do not support an argument for changing laws to allow NPs to practice without physician supervision because such autonomy has not resulted in increased patient access to services in rural and underserved communities.

There are now more than 430,000 NPs and 175,000 PAs licensed to practice in the U.S., with that number expected to grow by 66% and 37%, respectively, in the next 10 years. There are data showing that the number of imaging studies being interpreted and billed for by NPPs is increasing, even though they have little to no formal education and training in the interpretation of diagnostic imaging studies. NPs who practice without physician supervision, even in the primary-care setting (a domain in which they have been educated and trained the most), contribute to poorer patient outcomes, more consultations, unnecessary lab and imaging tests and an increase in healthcare costs when compared to primary-care clinics run by physicians. When NPs staff an ER without physician supervision, lengths of stay increased by 11% and preventable hospital admissions increased by 20%.

Being in a fee-for-service reimbursement business environment, this void will be filled whether we like it or not. We cannot prevent that void from being filled. Therefore, how we address this conundrum is critical for our specialty, especially since SOP creep is just a symptom of the underlying problem: timely access to care and, in radiology, timely interpretations of studies.

The What

What can we do to address the SOP conundrum?

Physicians must recognize why the SOP issue has arisen: worsening access to healthcare services. In the process of addressing this issue, we should embrace certain fundamental principles, the most important one being patient safety. Patient well-being and cost efficiencies are best served by having the most appropriately trained and educated individuals providing these services. Literature and data support that patient outcomes and overall healthcare costs are better when a physician-led team provides healthcare services. In addition, board certification and credentialing processes are time-tested and largely preferred over legislative policies that declare clinical competency by fiat or eliminate the needed guardrails for an NPP to practice unsupervised. With that said, these physician-led teams must be available when needed.

In approaching SOP creep, physicians must also be solution oriented. We may need to make some compromises such as working with NPPs on a physician-led team, even when it comes to diagnostic imaging services. Although fear about having a “camel’s nose under the tent” or moving onto a “slippery slope,” we should not create barriers to service without providing alternative options or solutions for patients, legislators or healthcare administrators. Therefore, it will be to our benefit to come together as a specialty, understand that there is no singular answer for the current patient-access problems and develop solutions to address the issues at hand specific to each situation.

Many radiology practices are already employing NPPs to help them with their minor image-guided or fluoroscopy procedures, and many interventional radiology practices have embraced and very much appreciate having NPPs as part of their physician-led teams. Given that in some states NPPs can already practice independently, embracing our registered radiologist assistants (RRAs) is paramount as we think about solutions. The discussion around RRAs was very controversial a few years ago at the ACR Annual Meeting but more tempered in 2024. It should definitely be an option we reassess and strongly reconsider at ACR 2025.

As legislators come forward with proposed policies for NPPs to practice without the supervision of a physician and/or expand their SOP, we need to be able provide data and evidence for why such solutions are associated with patient harm and increased costs in the long run. Putting up roadblocks without data and/or solutions will not be acceptable. We should continue to leverage the resources and talent available at the Harvey L. Neiman Health Policy Institute^® and generate data that support physician-led teams. ACR has also provided grants in support of ACR state chapters’ advocacy efforts against SOP creep by NPPs. However, this advocacy tactic is likely only going to be helpful in the short term.

Access to timely healthcare is problematic and only getting worse. The population of NPPs is growing more rapidly than the number of physicians, but physicians remain the most educated and highly trained medical professionals to provide patients with the care they need and deserve. All physicians, including radiologists, must understand that the SOP conundrum is a symptom of the problem of timely access to care for patients. We need to develop solutions to address access to care and embrace novel partnerships and team-based care models. If we do not, SOP legislation will become even more prevalent.

To learn more about scope of practice efforts and how ACR is leading the field in protections for radiologists and their patients, read this month’s feature story.