The American Academy of Pediatrics (AAP) believes that optimal pediatric health care depends on a team-based approach with supervision by a physician leader, preferably a pediatrician. The pediatrician, here defined to include not only pediatric generalists but all pediatric medical subspecialists, all surgical specialists, and internal medicine/pediatric physicians, is uniquely qualified to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment, in all practice settings. The AAP recognizes the valuable contributions of nonphysician clinicians, including nurse practitioners and physician assistants, in delivering optimal pediatric care. However, the expansion of the scope of practice of nonphysician pediatric clinicians raises critical public policy and child health advocacy concerns. Pediatricians should serve as advocates for optimal pediatric care in state legislatures, public policy forums, and the media and should pursue opportunities to resolve scope of practice conflicts outside state legislatures. The AAP affirms the importance of appropriate documentation and standards in pediatric education, training, skills, clinical competencies, examination, regulation, and patient care to ensure safety and quality health care for all infants, children, adolescents, and young adults.
The American Academy of Pediatrics (AAP) advocates that every child receive high-quality, accessible, family-centered, continuous, coordinated, comprehensive care in a medical home. To this end, optimal pediatric care is best delivered in a team-based approach that is led by a primary physician, ideally a pediatrician, who assumes responsibility for managing the patient’s care. All professionals who provide pediatric care must hold to the highest standards of education and training and continually demonstrate their skills and competencies.
Comprehensive Team-Based Care With Physician Leadership
The provision of optimal pediatric care depends on a team-based approach to health care that is ideally led by a pediatrician. In this team-based model of pediatric care, the physician assumes overall responsibility for the care of the patient. As leader of the pediatric health care team, the physician oversees the delivery of care and, when appropriate, delegates patient care responsibilities to nurse practitioners (NPs), physician assistants (PAs), and other valued members of the heath care team. The pediatrician who leads the health care team also determines when referral to other physicians is warranted. When patient care responsibilities must be shared by multiple providers, the pediatrician should assume primary responsibility for managing the full range of health care services to ensure continuity of care within the child’s medical home.1 For some children, a general pediatrician and a pediatric medical subspecialist or surgical specialist may decide to comanage care. The medical home’s team-based model of pediatric care provides high-quality, cost-effective care by minimizing duplication of clinical effort, promoting the appropriate and timely use of all health care providers on the team, and ensuring that the care provided is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.2
Unique Qualifications of Pediatricians
As a direct result of their extensive training and experience, pediatricians possess the broad range of competencies required to best assess and manage health issues in children. Pediatric illness runs the gamut from basic to complex, from common behavioral disorders to rare metabolic and genetic diseases. In addition, diseases that present initially as a common condition such as a cold may sometimes progress to a severe and complex illness such as pneumonia or respiratory failure. The pediatrician is the clinician most extensively educated in pediatric health care and has the depth and breadth of knowledge, skills, and experience to deliver optimal care to children.
Professional Standards to Ensure Safety and Quality Care
The AAP supports safe, quality care for all children and their families and believes that any health care professional who wishes to actively participate in the care of children must demonstrate appropriate education, training, skills, and ongoing competencies in pediatric health within his or her scope of practice to ensure the highest standards of care. All members of the health care team should provide care consistent with their education, training, and licensure.
In recent years, the health care market has seen a significant increase in the number of nonphysician clinicians who seek to care for children. Professional associations for psychologists, pharmacists, massage therapists, physical therapists, occupational therapists, optometrists, acupuncturists, naturopaths, homeopaths, and chiropractors have actively sought expanded scopes of practice in the care of children. In an evergrowing and more complicated health care delivery system, patients and families need to know what services these clinicians are licensed and trained to provide and understand the differences in education and skills among them.
Support for such transparency is increasing and resulting in requirements that medical and health professionals be required to display or advertise their degrees, credential(s), or licenses according to a standard that is easier for consumers to understand. In addition, truth-in-advertising laws help patients distinguish between medical doctors and other health professions with doctoral degrees who are licensed to provide care.
Key Members of the Pediatric Health Care Team
For many years, pediatricians have worked closely with physicians in disciplines across the field of medicine to optimize the care of children. The AAP specifically acknowledges the key role that family physicians have played in providing care to children and the importance of their continuing collaboration with pediatricians. Pediatricians need to collaborate closely with family physicians in practice to provide pediatric support and consultation.
Nonphysician clinicians play an invaluable role in the provision of health care to infants, children, adolescents, and young adults as part of the physician-led team that provides pediatric health care. Learning to work in teams should begin in pediatric residency training, where collaborative learning with nonphysician clinicians can expose future pediatricians to the benefits of team-based care. In particular, the AAP also affirms that these nonphysician clinicians have been important participants in the care of children in the United States for many years.
PAs are educated in the medical model to provide medical care specifically under the direction and supervision of a physician. PAs must graduate from an accredited master’s-level educational program that includes didactic education and clinical rotations in pediatrics and must also pass the national certifying examination administered by the National Commission on Certification of Physician Assistants. The AAP is involved in the development of educational standards and national certification for PAs through appointed representatives on the boards of the Accreditation Review Commission on Education for the Physician Assistant and the National Commission on Certification of Physician Assistants. PAs support the concept of physician-directed, team-based care.
NPs are educated in graduate-level training programs, and the majority of NPs are certified by either the American Nurses Credentialing Center or the American Academy of Nurse Practitioners. In 7 states, national board certification is not required for licensing. The care provided by NPs can vary considerably on the basis of the laws in the state in which they practice. States may limit or deny NPs the authority to prescribe medications, to admit patients to the hospital, or to practice independently. As of 2012, more than half of the states required physician involvement (eg, collaborative practice agreement, physician delegation and supervision) for NPs to practice diagnosis and treatment and for prescriptive authority (for information on current state laws, please contact the AAP Division of State Government Affairs at firstname.lastname@example.org).3 Full admitting privileges for NPs would allow them to admit, provide care for, and discharge patients without physician supervision. Although NPs are rarely granted full admitting privileges, it is not uncommon for them to obtain associate privileges that permit them to admit a patient to a supervising physician. NPs can play an important role in the inpatient setting, but the AAP believes that a pediatrician should lead the health care team that is providing pediatric inpatient care.
In states that do not allow independent practice, a structured agreement with a physician is required. Recent studies have shown that even in states which allow independent practice for NPs, fewer than 15% of pediatric NPs actually choose to practice independently.4 Regardless of the state in which they practice, the vast majority of pediatric NPs choose to practice under the supervision of general pediatricians, pediatric medical subspecialists, or pediatric surgical specialists. The AAP endorses this collaborative and structured relationship and believes this choice reflects both a shared commitment to patient safety and the positive nature of current pediatrician–NP relationships in US health care.
Of note, some reports have called for changes in the education of NPs so that they might spend additional time in clinical training and increase their likelihood of independent practice. These reports have also called for changes in the scope of practice for NPs in efforts to meet a workforce demand in areas with physician shortages.5,–7
Considering the educational aspect, NPs generally receive a master’s degree or postmaster’s certificate. These NP training programs provide 500 to 720 hours of clinical training.8 However, in 2004, the American Association of Colleges of Nursing endorsed a position statement calling for NP training programs to move the current level of preparation necessary for advanced nursing practice from a master’s-level to a doctorate-level degree (eg, Doctor of Nursing Practice [DNP] or Doctor of Philosophy [PhD] in Nursing) by 2015.9 The American Association of Colleges of Nursing’s The Essentials of Doctoral Education for Advanced Nursing Practice (2006) recommends that programs—designed for individuals who have already acquired the competencies in The Essentials of Baccalaureate Education for Professional Nursing Practice (1998)—be “three calendar years, or 36 months of full-time study (including summers) or four years on a traditional academic calendar.”10 This requirement is equivalent to the currently required 3 years of graduate training for the master’s degree program. Subsequently, the number of doctorate-level nursing programs in the United States has grown from 20 in 2006 to 182 in 2011.9
Increases in the duration of education or the final degree (eg, a DNP or PhD in Nursing) will not achieve educational parity with physicians. In comparison, with 4 years of medical school and 3 years of pediatric residency at a minimum, the pediatrician has invested between 12 000 and 14 000 clinical hours at the completion of basic pediatric training alone. Therefore, the AAP believes that pediatricians and NPs are not interchangeable in the delivery of pediatric health care.
A recent study of the geographic distribution of pediatric NPs found that the majority of states have fewer than 25 pediatric NPs per 100 000 children and that a state’s independent practice laws are not related to its density of pediatric NPs.11 In 2010, almost 85% of all NPs reported practicing in urban areas.12 Furthermore, a recent study from the University of Washington Rural Health Research Center found no statistically significant link between states that allow NPs greater practice autonomy and higher rates of NP practice in rural areas.
Because a greater supply of NPs in a state does not necessarily lead to an equitable distribution to areas that are underserved, the AAP does not support changes in scope of practice for NPs in these areas and believes it is ill-advised to create a system of care based on independent practice without any supervision or oversight by a physician. Rather, the AAP recommends incentives for physician relocation, including loan forgiveness, payment reform, and expanded health insurance coverage for children.13
Some have called for an expansion of retail-based clinics as a means to increase the provision of care for children in underserved areas. However, retail-based clinics are not staffed by physicians, and the nonphysician clinicians that are staffing these clinics often work without supervision or oversight by a physician (ie, independent practice). Also, a recent study of more than 900 retail clinics throughout the United States found that “retail clinics are currently located in more advantaged neighborhoods, which may make them less accessible for those most in need.”14 In light of its commitment to comprehensive team-based care, the AAP does not support the use of retail-based clinics for the medical care of infants, children, and adolescents.15 Because retail-based clinics are not founded on a medical home model, use of these clinics as a source of care for children poses a significant risk for fragmentation of care, limited follow-up, missed diagnoses, and decreased quality of care overall.
Scope of Practice Legislation
Scope of practice legislation falls under the jurisdiction of individual states. State legislatures are therefore the loci of deliberations on these issues. The competing political agendas and perspectives expressed during these deliberations often generate highly charged debates. To bring a uniformity of approach and an essential level of civility to this discourse, the AAP endorses the 2005 recommendations of the Federation of State Medical Boards regarding the approach to scope of practice legislation.16 A portion of the Federation of State Medical Boards statement follows:
“Changing or creating a new scope of practice for a health profession necessitates establishment of a legitimate need for the change, along with a systematic review of the impact of the proposed change on public health, safety, and welfare. Patient safety and public protection must be the primary objectives in making decisions on scope of practice. It is important for boards and legislatures to recognize that there are often significant differences in the prerequisites, the scope, and the duration of education provided to other health care practitioners when compared with that provided to physicians. Policy makers must ensure that all practitioners are prepared, by virtue of education and training, to provide the services authorized in their scope of practice in a safe, effective, and economical manner.”
The expansion of the scope of practice of NPs, PAs, and other nonphysician clinicians has created new challenges for physicians in all specialties in addressing professional and medical liability issues. Specific areas of risk for physicians when supervising nonphysician clinicians include improper delegation of authority, vicarious liability for medical care provided by nonphysician clinicians, and liability for nonmedical acts committed by nonphysician clinicians in which the physician is responsible for the negligent hiring, training, supervising, or retaining of the nonphysician clinicians. When delegating authority to nonphysician clinicians, physicians should consider the proper method of delegation and their oversight responsibilities for the delegated duties.
It is important that lawmakers and regulators remain attentive to the fact that a physician’s ability to delegate authority is often governed by contractual limitations as well as by statutes that govern health care facilities. Moreover, health care entities, such as hospitals or managed care organizations, may not authorize the delegation of more authority than is permitted by state statutes or regulations, but they may impose limitations on the delegation of authority that are more restrictive than state laws. These policies may also be admissible in a medical liability lawsuit as evidence of the standard of care. Physicians violating such policies may risk loss of employment or revocation of privileges. Physicians and health care entities must therefore be knowledgeable about the terms of these state statutes and regulations, as well as health care entity policies, and should seek advice from a qualified attorney.
For nonphysician clinicians who practice independently of a physician, public policy should require both exclusive professional responsibility for the care they provide and adequate liability insurance to allow for appropriate financial remedy for adverse settlements or decisions. States that license nonphysician clinicians should therefore require that these nonphysician clinicians abide by the same rules regarding liability insurance as do physicians. Because physicians can be held accountable for clinicians acting under their supervision, a pediatrician should consider potential professional or medical liability issues before establishing a supervisory relationship.
The AAP believes that optimal pediatric care is best rendered by using a team-based approach led by a pediatrician. As the clinician most extensively educated in pediatric health care, the pediatrician has the depth and breadth of knowledge, skills, and experience to assume this role and should be held to the highest standards. Collaboration with family physicians is an important component of pediatric health care delivery, as are partnerships with nonphysician clinicians in an effort to provide safe and effective quality health care for all infants, children, adolescents, and young adults in the United States. The AAP recognizes the importance of team-based education and training. Furthermore, the AAP maintains that to ensure safe and effective care, all members of the health care team must be required to demonstrate adequate education, training, skills, and competencies in pediatric health within their scope of practice, and all members of the health care team must provide care that is consistent with their education, training, and licensure. Patient safety and public protection must be the primary benchmarks in making any decision on changes involving the scope of practice of those who care for children.
The AAP affirms the following policy recommendations:
A pediatrician should serve as the leader of the pediatric health care team. This leadership role is based on the pediatrician’s ability to manage, coordinate, and supervise the entire spectrum of pediatric care, from diagnosis through all stages of treatment and in all practice settings.
Pediatricians must assume responsibility for educating patients, families, health care purchasers, policy makers, the media, and the public about scope of practice issues.
Pediatricians should participate in the training and educational experiences of nonphysician pediatric clinicians, using evidenced-based and best-practice sources whenever possible. Similarly, training of pediatricians should include collaborative learning experiences in team care.
The AAP supports limitations on the scope of practice of nonphysician clinicians and opposes legislation that expands their scope of practice, including independent practice, hospital admitting privileges, and independent prescriptive authority.
Although the AAP opposes independent practice for nonphysician clinicians, in states that do allow independent practice, nonphysician clinicians acting independently of physicians should be held to the equivalent degree of professional and medical liability and abide by the same rules regarding liability insurance as would physicians.
To promote the highest standards of care in each state, scope of practice issues should be resolved according to the current guidelines developed by the Federation of State Medical Boards. These guidelines were designed to assist policy makers in ensuring that all practitioners are prepared, by virtue of education, training, and ongoing evaluation of competency, to provide services authorized in their scopes of practice in a safe, effective, and cost-efficient manner.
AAP chapters should encourage, recruit, and train their members to serve as advocates of optimal pediatric health care in state-level policy initiatives concerning nonphysician scope of practice. Such activities depend on physicians who are knowledgeable about law-making and policy-making processes and who have the skills necessary to be effective advocates in legislative deliberations.
AAP chapters and state medical and specialty societies, as well as national medical and specialty societies, should be proactive in scope of practice advocacy and should partner in informing policy makers, health care purchasers, the media, and the public about the differences in the education, skills, and knowledge of various health care professionals.
Richard P. Shugerman, MD
Mary E. Rimsza, MD, Chairperson
Committee on Pediatric Workforce, 2011–2012
William T. Basco, MD, MS
Andrew J. Hotaling, MD
Ted D. Sigrest, MD
Frank A. Simon, MD
Former Committee Members
Beth A. Pletcher, MD
Luisa I. Alvarado-Domenech, MD
Christopher E. Harris, MD – Section Forum Management Committee
Gail A. McGuinness, MD – American Board of Pediatrics
Holly J. Mulvey, MA
Carrie L. Radabaugh, MPP
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
The Committee acknowledges the contributions of Ethan Alexander Jewett, MA, a former member of the AAP Division of Workforce & Medical Education Policy, to the development of this policy statement.