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AMA SOPP Escalates Campaign Against Nurses, Chiropractors, Naturopaths, Midwives and Others PDF Print E-mail
Written by John Weeks   
Saturday, 21 June 2008

AMA SOPP Escalates Campaign Against Nurses, Chiropractors, Naturopaths, Midwives and Others

Summary:  In June meetings, the House of Delegates of the American Medical Association (AMA) kicked off an escalating round of attacks on the advancement of other healthcare professions. Targeted this year were all disciplines with doctoral-level training, as well as licensed midwives. Chiropractors, naturopathic physicians and nurses - who cited Wilk v AMA - are among those that have been quick to challenge the AMA. The AMA actions are part of that guild's divisive AMA Scope of Practice Partnership (SOPP), announced in January 2006. Meantime, one action at the House of Delegates meeting suggests that the snake on the AMA's caduceus may be biting its own tail. Resolution 235 is an effort to keep the AMA's own specialty societies from legislative actions that seek to restrict each other's scope of practice.
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"Whereas, The economics of medicine have put financial pressure on all physicians ... "
- from the AMA House of Delegates "Friendly Fire" Resolution 235

Image
Rooted in an old world view?
The American Medical Association has sought to escalate its war against advances of all other disciplines with action by their House of Delegates at their June 14-18, 2008 meeting. Four separate resolutions continued the AMA's Scope of Practice Partnership (AMA SOPP), formally established in January 2006. The AMA SOPP is a systematic campaign to limit the scope of practice of other professions, except MDs, osteopaths and dentists. In an AMA slide show made available to the Integrator, the AMA describes the
SOPP as "A Partnership to Oppose Unwarranted Nonphysician Scope of Practice Expansions."

The AMA SOPP has been relatively quiet since its initial flurry of activity. [For information on the initial efforts, see "AMA Scope of Practice Partnership" at Integrator Archive by Subject: 2006 or go directly to
AMA Targets Nursing Doctorate and ND License: Old Boys vs the Emerging Medical Matriarchy? (August 8, 2006), Coalition Battles AMA Campaign to "Thwart" Other Disciplines' Scope Expansions (June 21, 2006), and the August 2, 2006 article CAM-IM Responses to AMA Scope Campaign; Coalition Plans Next Steps. ]

The first round of this activity made it clear that the AMA did not make its case against the nursing doctorate, and against naturopathic physicians and others, based on evidence that these disciplines have caused harm. This second round of AMA activity appears to also lack an evidence base.

   
  A point of clarity made in the
first round is that
the AMA did not make its case against
the nursing doctorate, and against
naturopathic physicians and others
based on evidence that these
other disciplines have caused
harm by their scopes.


This round of AMA activity appears
to also lack an evidence base.



Below is basic information on the various resolutions in the current campaign, followed by some of the responses of the professional associations which the AMA is targeting.

Resolution 232 (formerly 303) - Protection of the titles "doctor", "resident," and "residency"

Directly in AMA's sights at the June 2008 meeting were the "doctor-nurses" - Doctors of Nursing Practice. But all other health professional practices with doctoral level training were also targeted by Resolution 232 (formerly Resolution 303). This Resolution, in its original form, would have clarified that only MDs, dentists and DOs should have any right to be called "doctor" in a medical setting. Only their fields could use the terms "resident" and "residency." The original resolution which was under consideration is printed at the bottom of this article. Notably, Illinois, which introduced the Resolution, is one of the states where chiropractors have their broadest scope and where naturopathic physicians are currently pressing for licensing. 
Following debate, the AMA's House backed off. They acknowledged, as noted in the "Report of Reference Committee B" on House action, that "any individual who has received a terminal degree in their area of study has the right to be called 'doctor,'" according to a report on what was clearly a heated debate. The House chose to adopt a milder Substitute Resolution 232, which states that:

RESOLVED, That our AMA advocate that professionals in a clinical health care setting clearly and accurately identify to patients their qualifications and degree(s) attained and develop model state legislation for implementation. (Directive to Take Action)

 

RESOLVED, That our AMA support state legislation that would make it a felony to misrepresent ones’ self as a physician (MD/DO).


ImageResolutions #204 and #205 - Against homebirth and keeping an eye on Certified Professional Midwives 

Resolution 204, Midwifery Scope of Practice and Licensure, urges the AMA to ensure that the only midwives its members should support are those that are represented by the American College of Nurse-Midwives.  Even these, however, should be watched closely regarding their scope expansions. Not mentioned in this section in the report from the House of Delegates are the Certified Professional Midwives who
are trained to provide home births but are not nurses. The opposition to home birth is reaffirmed in Resolution 205 which is specifically against "home deliveries."

Resolution #214 - Against the Doctor of Nursing 

According to Resolution #214, the National Board of Medical Examiners (NBME) - the examining board for MDs - has begun "developing a voluntary (Doctor of Nursing Practice-DrNP) certification exam based on the same exams given to medical doctors to obtain their medical license."  Such a certification would clarify which nurses might help meet the estimated shortage of 85,000-200,000 primary care providers. NBME was urged not to assist the nurses. Resolution #214 opposes the NBME "participating in any credentialing procedures for Doctors of Nursing, and refrain from producing test questions to certify these DrNP candidates." The Resolution also asserts that DrNPs "must be part of a medical team under the supervision of a licensed MD who has final authority and responsibility for the patient."


Resolution 235: Against physicians warring against other physicians 

The rationale the AMA offers for these resolutions is typically protection of the public health, despite the fact, as noted, that evidence is not presented to show harm. It is interesting in this light to look at an additional resolution, also about scope of practice concern. Only here, the target is not nurses, chiropractors, naturopathic physicians, midwives, Doctors of Acupuncture and Oriental Medicine or any other field. It seems that in the midst of this flurry of activity to keep the natives from climbing the ramparts, the AMA was discovering that some of their fellows had circled the wagons and begun shooting at each other. Resolution 235 may be dubbed the "Friendly Fire" resolution.

According to Resolution 235, members of one specialty are sometimes deciding that a certain procedure or surgery typically associated with another specialty is within its possible practice scope. This then is apparently stimulating some specialties to seek to protect their privilege by running to their state legislatures to limit the scopes of encroaching specialties. Resolution 235, printed in full below, begins with an honest acknowledgment of the economic issues which are behind all of the activity, of the AMA and of the other, emergent doctoral-level organizations.

____________________________

The "Friendly Fire" Resolution
#235:
Physician Regulation of Other Physicians

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES

Whereas, The economics of medicine have put financial pressure on all physicians; and

Whereas, Some medical specialty societies have elected to seek the introduction of state level legislation that regulates or restricts other physicians’ practices; therefore be it

RESOLVED, That our American Medical Association, with the intent of improving patient care and promoting interspecialty collaboration, develop a process for national specialty groups to urge their state affiliates to work through the state medical association prior to the introduction of any state legislation that seeks to regulate or restrict the practice of other physician groups or specialties. (Directive to Take Action)

Fiscal Note:  Implement accordingly at estimated staff cost of $10,836.

Received:  06/10/08
____________________________

Image1.    Response of the American Association of Naturopathic Physicians


The American Association of Naturopathic Physicians (AANP) sent a news update to their members prior to the AMA's action entitled "AANP Response to AMA Resolution 303." (Note that 303 was later passed as 232 and significantly amended.) The AANP letter begins bluntly
: "The American Medical Association is poised to make a move that could have a huge impact on our ability to call ourselves Naturopathic Doctors." The AANP noted that Resolution 303 "ignores laws already on the books" and it "discounts federal standards." The AMA is "creating a national agenda to ensure the current hierarchy in health care is maintained - regardless of a shortage of primary care practitioners, the obvious need to transcend from disease management to a wellness-based system, and the rising numbers of consumers who are choosing non-conventional treatment."

The AANP's letter,
signed by president Lise Alschuler, ND, NABNO, states that the AMA's moves will "only serve to unfairly penalize legitimately trained providers of primary care services from practicing their trades." The letter then underscores that this agenda is "deeply rooted in an old story and worldview that simply does not reflect today's reality" in which "MDs, NDs and nurses already work side by side, collaborating on patient care in venues across the country."

Note: I have not seen AANP commentary since Resolution 303 was changed and amended. However, the profession clearly asserts the right to be considered "physicians" and also have this as a title right in many jurisdictions.

Image2.     American Chiropractic Association Response

The American Chiropractic Association sent out a press release against Resolution 232 on June 21, 2008, after the AMA House of Delegates concluded its meeting. The ACA states that "
under federal statute, all doctors of chiropractic are considered physicians in Medicare and doctors of chiropractic are legally deemed chiropractic physicians in an overwhelming majority of states." Glenn Manceaux, DC, ACA president is quoted: “It is not the role of organized medicine to regulate the titles and terminology used by other providers; it is the responsibility of federal and state legislators to bestow the title of ‘physician.’  As a trade association, the AMA is clearly overstepping its bounds.”

The ACA statement makes two points also made by the AANP, regarding the role of consumers and the potential damage to the growing number of professional relationships that currently exist between their members and medical doctors. The release states: "
Within the chiropractic profession, concern also exists that supporters of the resolution are acting in their own self-interest at the expense of consumers, and that the new policy statement could jeopardize the inter-referral relationships many allied health providers—including doctors of chiropractic—have developed with their MD-counterparts."

ACA, known for its legislative successes against the organized medical profession, urges its state associations to be vigilant. The organization notes that it will be working with two separate coalitions to see that any AMA-backed legislation related to Resolution 232 does not advance.

Image3.   Nurses Respond to #303 and #214

In separate letters on June 11, to Craig Anderson, MD, chair of the AMA committee which oversaw the resolutions, the American Nurses Association opposed Resolution #214 and #303. On #303, the ANA made the point, which eventually prevailed (and which the AANP also made), that no profession owns the title "doctor." Hence, they state, the term "medical doctor" was created, to designate what types of doctor. Ditto "medical resident" and "medical residency."

The nurse association then evoked that AMA's most significant loss in its efforts to repress other professions: Wilk v. AMA - in which the chiropractic profession won a 10-year long restraint of trade battle. Said the nurses:
"If the real issue is competition, and this is an effort to make it more difficult for doctorates of nursing to train and practice in the same arena as medical doctors, that would constitute an improper - and possibly illegal - restrain of trade. In Wilk v. AMA, the US Court of Appeals for the 7th Circuit ruled that the AMA cannot "boycott" other healthcare professions, as this would violate the Sherman Antitrust Act. (Wilk v. AMA, 895 F. 2d 352 (7th Cir. 1990)
The opposition to #214 particularly focused on the requirement for supervision by an MD: "State law, state boards of nursing, and the nursing profession itself are the only appropriate entities to regular the practice of nursing." (The American Chiropractic Association made a parallel point.) The ANA clarified further its own Copernican revolution regarding the center of the medical universe: "The medical profession is not the 'starting place' from which all other professions must seek authorization to practice."

In the letter - both were co-signed by Rebecca M. Patton, MSN, RN, CNOR, the ANA's president and Linda Steele, MSN, RN, CNAA, BC, CEO -the ANA points to a 2007 document, developed collaboratively by representatives of six disciplines, including both nursing and medicine, entitled Changes in Healthcare Professions Scope of Practice: Legislative Considerations. The report noted that "it is no longer reasonable to have completely unique scope of practice, exclusive of all others. Overlap among professions is necessary. No one profession actually owns a skill or activity in and of itself."

________________________________________

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES

 Resolution 232 as Introducted

[NOTE THAT IT WAS NOT ADOPTED IN THIS FORM]


Introduced by:       Illinois Delegation

Subject:                 Protection of the Titles "Doctor," "Resident" and "Residency"

Referred to:           Reference Committee B (Craig W. Anderson, MD, Chair)


Whereas, Certain specialty societies recognize that many allied health care professions have improved their educational standards and incorporated doctorate designations in their training programs; and

Whereas, Many nursing schools have re-titled their training program as a Residency and their students as Residents, despite the traditional attribution of these titles to medical doctors and their training programs; and

Whereas, The growing trend of this title encroachment is of concern because patients will be confused when the titles of Doctor, Resident and Residency are applied to non-physicians who hold non-medical doctorates or to non-physicians in training; therefore be it

RESOLVED, That our American Medical Association adopt that the title “Doctor,” in a medical setting, apply only to physicians licensed to practice medicine in all its branches, dentists and podiatrists (New HOD Policy); and be it further [NOTE: iN DISCUSSION

RESOLVED, That our AMA adopt policy that the title “Resident” apply only to individuals enrolled in physician, dentist or podiatrist training programs (New HOD Policy); and be it further

RESOLVED, That our AMA adopt policy that the title “Residency” apply only to physician, dentist or podiatrist training programs (New HOD Policy); and be it further

RESOLVED, That our AMA serve to protect, through legislation, the titles “Doctor,” “Resident” and “Residency.” (Directive to Take Action)

Fiscal Note:  Staff cost estimated at less than $500 to implement.

Received: 04/30/08
_______________________________
Comment: One wonders if these leaders of the Illinois Delegation, and of the AMA House of Delegates, truly believe that they can set back the clock. The cows are already out of the barn. And there are millions of consumers who clearly like them there. Many politicians and policy makers believe these professions have significant roles to play, for instance, in easing the primary care shortage.

   
  I have long argued that all
of the distinctly licensed
complementary healthcare
disciplines owe the chiropractors
a deep debt of gratitude for Wilk.
 
But I never imagined that the
chiropractors' victory would
one day
be used by the nurses. 


It is fascinating, in this context, to note some rifts inside the fabric of organized medicine. First, Resolution 303 was not passed. The House woke up the the plain fact that, as was said in the final report of House action to the AMA, "any individual who has received a terminal degree in their area of study has the right to be called 'doctor.'" Yet the item still made it onto the agenda, attesting to the hold this repressive concept still has.

Second, the National Board of Medical Examiners - the MD examining agency - apparently thought it within its mission to enter into dialogue with the nursing profession on that profession's examination needs. How will NBME respond to this slap? How responsive will the NBME, a nominally independent entity, be to the AMA pressure?

Non-allied health

On the other hand, parallel positions of chiropractors, nurses and naturopathic physicians underscores the depth of shared interest in the Coalition for Patients Rights. Finally, the nurses' use of Wilk v. AMA drives home just how powerfully mis-allied the AMA is, on this issue, from what used to be known as the "allied health" disciplines. I have long argued that all of the distinctly licensed complementary healthcare disciplines owe the chiropractors a deep debt of gratitude for Wilk. But I never imagined that the chiropractor's long battle would be cover for the nurses.

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Last Updated ( Sunday, 29 June 2008 )
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