In any doctor’s office – any health care facility – the division of labor is always a little fluid: Doctors do the diagnostics, sure, and they prescribe the treatments, but nurses, certified nursing assistants, and even less-specialized staffers do plenty as well.
To some extent, says Dr. Robert S. Crausman, that’s perfectly fine. There’s nothing wrong with an unlicensed assistant taking down parts of someone’s medical history, setting things up for a test, putting hot or cold packs on a rehab patient.
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But at some practices, especially in “aesthetics” medicine, Crausman said in an interview, assistants are going too far: giving Botox injections, for example.
To try to curb such perceived excesses, the state Board of Medical Licensure and Discipline, for which Crausman is chief administrative officer, issued a “position statement” two years ago outlining what it viewed as appropriate responsibilities for medical assistants.
Shortly afterward, Crausman said, “we got lots of information directed our way” about practices that were allegedly not following those guidelines.
Now, to tighten things up more, the board has drafted the state’s first regulations defining what an unlicensed medical assistant can and cannot do – and how tightly a doctor must supervise him or her during each task.
The board has scheduled an “informal community review” of the draft regulations this Friday at 10 a.m. at the R.I. Department of Health. The full text is posted at www.health.ri.gov.
Crausman said the goal of the regulations is to “codify what is appropriate,” not to crack down on perfectly routine work done by medical assistants. But Kimberly I. McCarthy, a lawyer at Partridge, Snow & Hahn in Providence, said some of her health care clients – especially in rehabilitation services – are concerned that the rules are too strict.
“When I looked at [the regulations], I thought about unintended consequences,” McCarthy said. By her reading, she said, “very routine” procedures such as applying hot and cold packs would, in fact, not be allowed by the new rules.
Between the restrictions on what assistants can do, and the requirements for supervision, she said, “They’re going to have to have licensed practical nurses or doctors there all the time.”
As for her clients, she said, some worry “that the cost of doing business may increase so significantly that it may no longer be profitable,” especially in storefront urban facilities.
But Lisa Smolski, executive director of the Rhode Island Free Clinic, said the regulations would actually expand the duties of the clinic’s medical assistant – because lacking clear guidance on what’s allowable, the medical staff’s inclination has been to limit her duties.
“Now we will be able to draft a scope of delegation for her, and she will be able to provide more direct services to patients,” Smolski said. The clinic relies heavily on its physician and nurse volunteers, she said, and this “takes pressure off of them” and “spreads the work around among more people who can do it.”
So how strict are the rules?
For starters, they limit medical assistants’ practice to “routine technical acts,” defined as tasks not requiring medical judgment that are delegated by the physician treating the specific patient, and that – with few exceptions – can only be performed under supervision.
For example, assistants can do surgical technical acts ordered by a doctor who is present and in scrubs, and they can do non-surgical technical acts in accordance with written procedures. In addition, with on-site supervision, they can prepare and administer non-intravenous injections, establish peripheral intravenous lines, and inject some dyes, and with direct supervision, they can administer intravenous injection and dyes.
Without supervision, assistants can prepare patients for examination, compile elements of patients’ medical history, collect and process specimens, give out certain drug packets chosen by the doctor and perform clinical tests such as tuberculin skin tests, electrocardiography, basic pulmonary function tests, hearing tests and visual field tests, among other things.
The regulations would specifically forbid medical assistants, however, from conducting complete physical examinations, administering most forms of anesthetics, initiating any treatment other than cardiopulmonary resuscitation, giving medical advice without consulting a doctor, or providing physical therapy.
A medical assistant acting beyond the scope of the regulations could be found to be practicing medicine without a license, and subject to penalties, as could the doctor who allowed it.
Even so, Crausman said, “there’s nothing about this that says the health assistant can’t do a lot of work” – just not “doctor work.” If anyone feels an acceptable practice is being banned, he added, now is the time to speak up, so the language can be revised.
“We sent it around informally to a number of opinion leaders in medicine, and got very favorable feedback, but certainly it’s still at that state where it’s plastic,” he said.
