Practice at the top of your license.
It’s an expression you hear a lot these days as healthcare organizations seek to improve the work experience of their employees and raise the quality of patient care, all while lowering costs.
What does it mean to “practice at the top of your license?”
It usually means someone with less training is enlisted to do work that was previously done by someone with more training.
On the face of it, this notion is irrefutable.
It brings to mind a memorable vignette in my undergraduate economics textbook, N. Gregory Mankiw’s Principles of Microeconomics. To introduce the concept of “comparative advantage,” Mankiw asked the introductory economics student a provocative question—if NBA star Michael Jordan in his Chicago Bulls prime were the best in the world at mowing lawns—is there ever a circumstance in which he should ever mow his own lawn?
Of course not.
Jordan should always hire a landscaper—because his time was more valuable spent on the basketball court.
In the same way, highly experienced healthcare professionals trained to diagnose and manage complex illness should not be burdened with routine tasks and documentation requirements whose fulfillment don’t require their skills and intellects.
This work can be done by others. Using this logic, many healthcare organizations have added positions to care teams, enabling people with advanced clinical training to focus on work that makes use of that training.
Initially, medical practices supplemented physicians with nurse practitioners (NPs) and physician assistants (PAs).
Before long, this practice led the business people who often drive the structure and organization of care began to ask a series of provocative questions:
If some of a physician’s work can be safely handed off to NPs and PAs, can some of the NPs and PAs work be handed off to registered nurses (RNs)?
If some of a NP or PA’s work can be safely handed off to RNs, can some of the RN’s work be handed off to licensed vocational nurses or medical assistants?
And if some of the RNs job can safely be handed off to licensed vocational nurses (LVN) or medical assistants (MA)—can some of their work be handed off to community health workers or, even, lay people with no medical training?
The business of American healthcare is consumed with asking these fundamental and (occasionally self-serving) questions about who should perform what tasks.
With a greater proportion of healthcare being delivered by large consolidated systems, publicly traded companies, retail chains, and startups (all focused on improving their bottom lines), there is real energy being applied to decreasing labor costs and addressing labor shortages by introducing new roles as an alternative to raising wages—and healthcare costs.
Hence all the gleeful chatter about enabling clinicians to “practice at the top of their license.”
This is a trend within clinical medicine—but also within other allied health professions, including dentistry (with the introduction of dental therapists), physical therapy (with the introduction of physical therapy techs), and others.
Questionable Underlying Assumptions
All of this focus on labor arbitrage is built on the assumption that tasks can be easily sorted by licensure or training without sacrificing quality.
This leads to an insidious equivalence being developed in which healthcare professionals are seen as potential substitutes for one another.
Significant differences in training length and intensity are casually being washed away.
But is there a natural limit to how much task-shifting can occur?
At a high-level, those in charge of health systems and allocating resources will say that complex patients should see clinicians with more training.
Seems simple enough—but it is precisely the undefinable nature of a patient’s condition that often makes it hard to know which patient is best suited to what kind of patient care.
Put another way, what defines what is complex or simple? How much do we know upfront whether a patient will require deep expertise?
A patient with a history of a brain tumor who presents with a headache might be triaged and cared for differently than a patient who presents with a headache in the setting of a traumatic injury.
Ultimately, it is often left to an unsupervised clinician to decide themselves whether something is complex or simple.
Dedicated and motivated clinicians of all types get it wrong, not out of willful incompetence, but often out of ignorance, inexperience or just error.
Complexity often lies in subtleties invisible to the untrained eye—and not all health professionals across and within professional groups are trained equally well to see those subtleties (in itself a controversial statement in some organizations).
Which is what is so vexing about healthcare’s great labor arbitrage.
Patient care is being moved around to individuals with different levels of professional training without any clearly defined architecture delineating where and how patients are best served (other than cost).
Systems that rely heavily on task shifting (including ones that I have led) often invest insufficiently in defining the boundaries of roles and fail to invest in other training and resources that enable clinicians to ask for help when they need it.
In the absence of such definition and training, many organizations are pushing on the upper bounds of what falls at the “top of one’s license” without any clear or definable limit.
As a result, it is patients—whose care is sometimes imprecisely or clumsily delivered or, worse, unsafe—who are suffering alongside clinicians who sometimes feel underpowered or unsupported in delivering the care that a patient needs.
Does this mean that we should quit trying to make healthcare more efficient and rely exclusively on sub-specialist physicians to deliver care?
Of course not.
But it does mean that organizations and advocates who push for new roles in patient care should be hyper-vigilant to ensure that—in the rush to lower the cost of care and allow people to practice at the “top of their license”—we are not irreparably degrading the quality of care through a cascade of false equivalences across professional lines.
To the extent possible, there should be clear boundaries delineating what level and type of care is appropriate for an individual to provide depending on their level of training.
Because these boundaries are so difficult to define, there should be clear systematic supervision protocols through which patients are seen by and presented to more experienced, more highly-trained clinicians at every step of the clinical process (not just by chart review) to ensure that clinical situations are appropriately sized up at the outset.
Some organizations excel at this kind of sorting—but others have yet to take on the hard work for economic reasons and, also, because it is increasingly a topic of sensitivity.
Many professional groups have increasingly focused on their ability to practice and deliver care “independently”—which is to say, without supervision or oversight from another clinician.
While I am supportive of such movements that are grounded in achieving economic freedom for oneself, I generally believe none of us should be practicing truly independently; independence for its own sake is not a virtue.
Great patient care is the highest goal, not any professional’s independence.
It is irrefutable that we deliver better care when we work in teams that harness a broader base of expertise and capability.
And the expertise that resides in every category of the health profession is distinct and often non-overlapping.
Our focus should be on designing systems that allow different professionals with different levels of training to collaborate with others and leverage their distinct expertise to contribute meaningfully to patient care—not exclusively on driving costs down by pushing work around that may or may not belong in the hands of another.