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Scope of Practice

Scope of Practice

The boundaries of each PA's scope of practice are essentially determined by four parameters: education & experience, state law, policies of employers & facilities, and the needs of the patients at the practice.

Education & Experience

A broad, generalist medical education prepares PAs to take medical histories, perform physical examinations, order and interpret laboratory tests, diagnose illness, develop and manage treatment plans for their patients, prescribe medications and assist in surgery.

See: PA Education and Training

Like other health professionals, after graduation PAs continue learning in the clinical work environment and through CME. PA scope of practice grows and shifts over time with advanced or specialized knowledge, with changes or advances in the medical profession overall or with changes in the PA’s practice setting or specialty.

State Law

Although there is still some variation in state law, the majority of states have abandoned the concept that a medical board or other regulatory agency should make decisions about scope of practice details for individual PAs. Most states now allow the details of each PA’s scope of practice to be decided at the practice level.

Many of the first state laws for PAs, passed in the 1970s, were simple amendments to the medical practice act that allowed a physician to delegate to a PA patient care tasks that were within the physician’s scope of practice. These were followed by more stringent regulatory lists of tasks in some states, but these detailed methods of regulation proved impractical and unnecessary. 

For example, in early 1996, the North Dakota Board of Medical Examiners changed the rules governing PAs to eliminate a procedure checklist and adopt a less restrictive scope of practice. Writing in the board’s newsletter, Executive Director Rolf Sletten stated:

"Historically, a PA's scope of practice has been defined by a checklist which ostensibly itemizes every procedure the PA is permitted to perform. The benefit of the checklist is that it is very specific and so, in theory, everyone (i.e., the PA, the supervising physician and the Board) knows the precise boundaries of the PA’s scope of practice. In actual practice, it is simply not so. PAs function in a great variety of practice situations, in a wide range of specialties.1"

The scope of practice of PAs currently licensed in WI is defined under Chapter Med 8 of the Wisconsin Administrative Code governing the state’s Medical Examining Board. Scope and Limitations are outlined in Med 8.07. In providing patient services, the entire practice of any PA shall be under the supervision of a licensed physician.  A PA’s practice may not exceed his or her educational training or experience and may not exceed the scope of practice of the supervising physician.  A medical care task assigned by the supervising physician to the physician assistant may not be delegated by the physician assistant to another person. A MD or DO may supervise up to 4 PAs simultaneously, and a PA may be supervised by more than one physician while on duty (8.10(1)), as is common in many settings such as emergency rooms where multiple physicians may be available at any given time.  Also, the physician providing the supervision must be readily identifiable by the PA through procedures commonly employed in the PAs practice (8.07(3)). The physical presence of the supervising physician is not necessary as long at the PA is able to stay in communication with them. 

Facility Policy

Licensed healthcare facilities (hospitals, nursing homes, surgical centers and others) have a role in determining the scope of practice for PAs in their institutions. In order to provide patient care services within an institution, PAs request clinical privileges, which must be approved by the medical staff, and ultimately, the institution’s governing body. This process defines a scope of practice that each individual is qualified to provide within that organization.

Institutions assess PA requests for privileges just as they do for physicians, including verification of professional credentials (graduation, licensure and certification) and documentation of additional relevant training, previous privileges and/or procedure logs, CME, or skills assessment under direct observation. 

Needs of the Practice

To a large extent, PA scope of practice is determined by physicians and PAs at the practice level. This allows for flexible and customized team function. As teams decide on clinical roles in a practice, the needs of patients and the education, experience and preferences of the team members shape these roles. Within each type of medical setting, from family practice to surgical facilities, the practice is able to plan for PA use in a manner that is consistent with the PA’s abilities, the team’s practice style and the patients’ needs. Over the years, studies have repeatedly shown that it is appropriate for scope of practice to be determined at the practice level as the care PAs provide is of high quality.2-4

Conclusion

As team practice evolves and research repeatedly shows the quality and safety of PA-provided care, states that once closely managed each PA’s scope of practice are deciding that individual scope of practice can safely be determined at the practice level. As states recognize the dramatic potential of PAs to ease workforce burdens, they are broadening laws and regulations, enabling PAs to diagnose, treat, prescribe and manage a wide range of medical conditions without having to submit detailed practice descriptions to regulators. This model allows PA-physician teams to rapidly and efficiently adapt to changes in workforce needs, medical knowledge, technological advances, payment systems and standards of care.5

Related Resources:

WI Chapter Med 8 Link

1: Sletten R. PA supervision requirements [editorial]. The Examiner Newsletter. North Dakota State Board of Medical Examiners.
Winter 1996.

2:Virani SS, Maddox TM, Chan PS. Provider type and quality of outpatient cardiovascular disease care. J Am Coll Cardiol.
2015;66(16):1803-12.

3:Smith G, Waibel B, Evans P, Goettler C. A recipe for success: Advanced Practice Professionals decrease trauma readmissions.
Crit Care Med. 2013;41(12), A149.

4:Everett C, Thorpe C, Palta M, Carayon P, Bartels C, Smith MA. Physician assistants and nurse practitioners perform effective
roles on teams caring for Medicare patients with diabetes. Health Aff (Millwood). 2013;32(11):1942-8

5:Davis A, Radix S, Cawley JF, Hooker RS, Walker C. Access and Innovation in a time of rapid change: PA scope of practice. Ann
Health Law. 2015;23:286-336.

WAPA Resource Library (Member-Only):

WI Chapter Med 8 PDF file