The PMA Identity Crisis: Where Do We Go From Here?
Mention creating a legal scope of practice for the podiatric medical assistant (PMA) to a group of doctors and you will likely stir some opinions and controversy. Unfortunately, at this point, only opinions can frame the discussion. Without a written scope of practice, there is no standardization of what an assistant can and cannot do. There is only individual interpretation and this is usually based on personal experiences within one’s own office. Here is the only reality that we know to be true. Some individuals are hired to file charts, answer the phone and bring patients back to a treatment room while others are directly involved with hands-on patient care. Sadly, in the minds of many, “front” and “back” office staff are as close as we have come to defining our roles. The vast majority of doctors admit they have no idea what a PMA legitimately can and cannot do. Without this knowledge, doctors are left to make that determination themselves. As to whether doctors are interested in clarifying the role of PMAs, it depends upon whom you talk to. Some doctors are indifferent because, whatever the case, they have no intentions of changing their own office protocol. To the contrary, there are those who feel it would be helpful to know exactly where the lines are drawn so they can maximize their staff duties without crossing any ethical or legal boundaries. This also allows for clearer responsibilities and expectations between the employer and employee during the hiring process. Finally, there are practitioners who would oppose attaching any legally defined scope to the role of the assistant through an accredited curriculum because they feel that credentialed assistants would command a higher wage for what they do. As you might suspect, I would argue that a credentialed PMA would have a higher value but that is another topic. I first decided to become a PMA back in 1971. My employer, Rosario La Barbera, DPM, encouraged me to make the most of it. However, he noted there were no established educational courses available for assistants. Then I turned to the American Society of Podiatric Medical Assistants (ASPMA) as a possible resource for other options but was surprised to discover there were no legal guidelines concerning an assistant’s scope of practice. Worse yet, there were no efforts to create any. Unfortunately, this has not changed. I proceeded to contact my state legislators to see if there was anything written at the state level regarding this issue and, if not, what we could do to change that. The New Jersey State Board of Medical Examiners (the licensing board for New Jersey podiatrists) informed me that before the legislature could adopt a formal scope of practice for the PMA, the role of the PMA had to first be identified and documented, ideally through the creation of a formal educational course. Only a matriculated program, outlining the scope and training of a PMA, could open new doors for the profession. Coincidentally, around that time, a New Jersey vocational/technical school approached me and my friend/co-worker, Marlene Kern, RN, PRT, to write and introduce a PMA syllabus into its already credentialed medical assistant program. We enthusiastically laid the groundwork by developing the necessary syllabus and also agreed to be their first instructors. Sadly, after only two short years, the podiatric portion of the course was terminated. Aside from the fact that there was no one willing to continue teaching the course, there were not enough podiatrists in the area willing to employ the graduates. I feel we conquered the fight on our own turf but lost the overall battle. It was termed a successful failure. Why A Defined PMA Scope Of Practice Would Be Beneficial Today, after having spent 35 years as a PMA, I remain in a career that still suffers from an all too familiar identity crisis. While the scope remains undefined, concerned podiatrists everywhere continually ask me the unanswered question: “What am I legally allowed to let my staff do?” My response has not changed: “Without a formal, written scope of practice, the role of the PMA differs not only from state to state but from office to office. Ultimately, it comes down to allowing (staff) to do whatever duties you feel they can competently perform.” After all we went through, it is unnerving that the scope of practice for a PMA remains so ambiguous. As a practice management consultant, I have become more concerned about how the uniformity of this position impacts the business of practice. If specific job descriptions were in place for PMAs, there would be more established hiring criteria, more balanced salaries and standardized benchmarks to measure performance expectations. Does The Scope Of Practice For MAs Provide Any Guidance For PMAs? In 2001, the American Medical Technologists and the American Association of Medical Assistants accepted a unified understanding of a model state law outlining the scope of practice for medical assistants (MAs). Some might say we should not reinvent the wheel and instead should consider aligning ourselves with a similar scope with duties that are already defined. While the MA scope of practice does not distinctively address podiatry tasks, it does offer definitive guidelines in a medical practice. Medical assistants can perform delegated clinical and administrative duties within the supervising physician’s scope of practice. These duties are consistent with the certified medical assistant’s (CMA) education (through an accredited MA education program), training and experience while clarifying that these duties “shall not constitute the practice of medicine.” Section 18.402 of the Pennsylvania Code states that a medical doctor may not delegate the performance of a medical service if performance of the medical service or recognition of the complications or risks associated with the delegated medical service requires knowledge and skill not ordinarily possessed by non-physicians. According to a related article published by Michael N. McCarty, the Legal Counsel for the American Medical Technologists, the medical practice laws of a number of states expressly allow a physician to delegate basic clinical tasks to an unlicensed assistant provided that: • the task is generally one that can be delegated; • the task is within the scope of the assistant’s training; • the delegation is not prohibited by other laws or regulations; and • the assistant is under the supervision of a licensed medical practitioner (physician, osteopath, podiatrist, etc.), who assumes responsibility for the assistant’s actions. However, without applying specific definition to the terms “generally,” “basic,” “skill” and “training” to duties within our specialty (via an outlined scope of practice), is it left to the individual discretion of a podiatrist to interpret them any way he or she wishes? If this is the case, a doctor could say one of the following statements: • “My assistants ‘generally’ give local anesthesia to patients in my office.” • “I allow my assistants to do a ‘basic’ P&A procedure as long as I am somewhere in the office.” • “I have personally ‘trained’ my assistants to suture capsule and skin after surgery. I am confident they can perform these duties ‘skillfully’ and ‘competently,’ and am willing to accept full responsibility for their actions.” According to McCarty’s article, it appears that “only seven states (AZ, CA, FL, NJ, MD, SD and WA) have adopted laws or regulations directly addressing the practice of medical assisting” and while some (like SD and WA) stipulate that assistants or “health care workers” register with their state licensing board or health department, “none require that medical assistants be licensed.” Is There Any Clarity About What Constitutes ‘Invasive’ Procedures? Clearly, the majority of doctors I have questioned have expressed extreme opposition to allowing an assistant to perform any “invasive” procedure. Most say that assistants simply are not licensed to do so no matter how much “hands-on” training they have received in the practice. In fact, some admit they are even apprehensive delegating suturing to qualified hospital personnel. John Guiliana, DPM, a practice management consultant based in Hackettstown, NJ, agrees that the line of delegation is gray. He admits that distinguishing right from wrong should be based upon one's own value system as well as decisions based upon reason. His own personal decision of where to draw the line is based upon “invasiveness.” He feels there are three components of surgery: opening/dissection, wound closure and postoperative bandaging and care. Dr. Guiliana states that he could not, in clear conscience, delegate any of the invasive components of this process to non-licensed individuals. I recently lectured at two different seminars in which the discussion among assistants went down a very similar path. The overwhelming majority of assistants in attendance did not feel it was their place to perform anything invasive. In fact, one assistant questioned the legality of allowing a PMA to perform services from a billing perspective. The assistant asked, “How can the doctor bill for something he or she did not actually do?” This elicited a response from another assistant who stated that “bills are being generated for strapping and casting procedures not performed by the physician. How is that any different?” Sandra Lohrentz, PMAC, Executive Director of the ASPMA, offered a pamphlet, “Detailed Responsibilities of Certified Podiatric Medical Assistants,” which states, “If the procedure has a surgical code, the (certified) PMA should not perform the task. The podiatric physician/surgeon is the one getting paid for the surgical procedures. Thus, the physician must perform that procedure.” While this would seem straightforward, some still argue that the application of an adhesive strapping (while not invasive) carries a surgical code (29540). Is it or is it not acceptable for an assistant to perform this procedure? Ira Kraus, DPM, of Chattanooga, Tenn. points out there are some Medicare local coverage policies (LCP) that could possibly restrict an assistant from administering physical therapy or performing vascular studies. He recommends that, prior to performing these tests, one should review carrier LCPs or check with the local CAC representative. Assessing The Radiology Exception In an effort to research what (if any) laws exist to this end, I have enlisted the help of some knowledgeable individuals within our profession. The executive directors of the Washington, Ohio, New York, Illinois and North Carolina Podiatric Medical Societies and the New Jersey Office of the Attorney General provided valuable information. Each one acknowledged this is a “huge gray area” in our profession. They offered to help by sharing what they knew of their individual state regulations but most conceded there is nothing written that specifically addresses what a PMA can and cannot do. All of these folks unanimously agreed that radiology was the exception. Each of them recognized that certain requirements do exist (however divergent) from state to state with regard to taking X-rays. Having undergone approximately 120 hours of didactic and 80 hours of clinical study to get my required podiatric radiology technologist (PRT) license, which New Jersey legally requires in order to take limited foot and ankle X-rays, I was very familiar with the unbalanced regulations nationwide. Given these extreme variations, I will never understand why some states require stringent controls (and even licensing) to take X-rays while others require nothing more than a minimal hour course. In Washington, you need only take an eight-hour AIDS course to authorize taking X-rays. Don’t ask. Shouldn’t radiology safety be the same everywhere? Why the disparity? A Closer Look At The Existing Documentation On Assistant Duties Susan Scanlan, DPM, the Executive Director of the Washington State Podiatric Medical Association (WSPMA), directed me to a Department of Health Web site to read WAC 246-922-100: Acts that may be delegated to an unlicensed person. This was a great start. They also utilize the common verbiage, “… duties may be performed only under the supervision of a licensed podiatric physician and surgeon.” However, they also provide a laundry list of acceptable tasks that non-licensed personnel can do which includes (but is not limited to): • patient education in foot hygiene; • deliver a sedative drug in a oral dosage form to the patient; • give preoperative and postoperative instructions; • take health histories; • measure the patient’s blood pressure; • perform a plethysmographic or Doppler study; • assist in obtaining material for a C&S test; • take scrapings from the skin or nails of the feet; • debride keratotic tissues of the foot; • remove and apply dressings and/or padding; • produce impression casting of the foot; • “prepare” the foot for anesthesia as needed; • apply a flexible cast (e.g., unna boot); • apply cast material for immobilization of foot and leg; and • remove sutures, debride nails and other instructional protocols. The aforementioned ASPMA pamphlet also lists a number of duties that focus on what a “certified” PMA could perform. Interestingly enough, while certification may pump up a sense of professionalism and self-esteem, it provides no legal status or endorsement (except for taking X-rays in less than a handful of states). In effect, the duties listed can be performed by any PMA, provided of course that the PMA’s supervising doctor feels he or she is trained and capable. Andrew Feldman, the General Counsel to the New York State Podiatric Medical Association (NYSPMA), provided me with a document from the New York Education Department, dated 1/9/03, that specifically concerns certified assistants for a podiatrist. This document does not recognize a “certified assistant” for a podiatrist and PMAs are referred to only as “unlicensed personnel” or “unlicensed assistant.” The document refers to PMAs in these terms “because they have met no particular qualifications” and giving them a title such as “podiatric assistant” could create a “misconception.” Essentially, without an identified scope, they are not officially recognized. Mr. Feldman’s memo refers to the “Office of Professions” Web site which addresses what an (unlicensed) assistant may do. These duties involve helping the patient on and off the treatment chair, removing bandages, taking the patient’s history and vital signs, and performing duties “which are not considered the practice of podiatry.” It states that the podiatrist may not delegate surgical procedures or ultrasound treatment to unlicensed personnel. However, this memo does recommend the podiatrist consider several factors including supervision, responsibility and pathology before delegating a task. As per the memo, podiatrists should: • remain in the podiatric office where the services are being performed; • personally diagnose the condition to be treated; • personally authorize the procedure; and • evaluate the services performed by the unlicensed person prior to dismissing the patient. Since the licensed podiatrist “must assume responsibility and accountability” for the services performed by the unlicensed assistant, it is also recommended that DPMs exercise prudent judgment in assigning tasks. What is the bottom line? If an unlicensed assistant is given authority to perform tasks that (specifically) require a license, these actions could result in charges of professional misconduct. I also contacted the PICA Group, a malpractice insurance company in Tennessee, in order to find out from PICA how a PMA with no written scope of practice fits into the risk management picture of health care. PICA cannot offer a list detailing what a PMA can and cannot do, according to Barbara Bellione, PICA’s Director of Risk Management. However, she does say that podiatric assistants should have appropriate education and training in the tasks they are to perform and be able to demonstrate competency in those tasks prior to performing them. Additionally, she points out that podiatric assistants should have written job descriptions that reflect any state laws, required education and training, continuing education requirements, necessary supervision, etc. Does much of this sound familiar? In Conclusion It is no secret that I am an absolute advocate of training an assistant to the highest level possible and then utilizing those skills to the maximum potential. Without formal schooling, our lack of training makes certain a continued unstable career. My hope for our scope of practice is, that someday soon, our profession will realize the importance of defining the PMA role, help facilitate appropriate credentialing through a recognized educational process and help create a standard of identity that can be accepted throughout the country. Based on the comments doctors nationwide have shared with me, the benefits of having an educated, skilled and clinically trained podiatric medical assistant on their team elevates the professionalism of their practice, greatly contributes to practice efficiency and, most importantly, to patient care. Moreover, legal standardization of the assistant’s role would provide a sense of “compliance comfort” when delegating duties (in much the same way that radiology standards have in some states). In a profession where DPMs continuously struggle to maintain their unique identity as the foot and ankle specialists, it is not surprising that PMAs have followed in their footsteps. We are identified not by what we do but by who we are. Indeed, the podiatric medical profession should move to legitimize the displaced careers of the PMA and proudly position them alongside those of the medical and dental assistants. That leaves just one unanswered question: what are we waiting for? Lynn Homisak, PRT, is a team partner and practice management consultant with SOS Healthcare Management Solutions, LLC (www.soshms.com). She is a member of the Board of Trustees of the American Academy of Podiatric Practice Management (www.aappm.com). Homisak has lectured internationally to both doctors and assistants on staff management-related issues and has published numerous articles on associated topics. For related articles, please visit the archives at www.podiatrytoday.com.