Physician Voices for Patient Safety
On this page:
About the bill
Impact on patients in DC
Impact of physicians in DC
What can you do?
Resources
About the bill
In November 2023, DC Health introduced B25-545, the Health Occupations
Revisions General Amendment Act of 2023. This bill was a comprehensive
rewrite of the law overseeing medical licensing and regulation in
Washington, DC. Unfortunately, the bill as written overhauled
scope of practice, place allied health professionals in oversight
positions of medical licensing, and remove the physician from the center
of the care team. After much work and a number of legislative wins, the bill passed the Council on May 7.
MSDC has long advocated that a physician is the most qualified professional at the head of a care team. Physicians have the most health education and pre-practice experience of any health professional, and thus must be involved in all but the most mundane health care decisions. Allied health professionals are a valuable part of the care team, but their medical education and experience limits their role.
The Medical Society of the District of Columbia (MSDC) is the leading voice for physicians in Washington, DC, committed to uniting physicians to advocate for physician-led health care in Washington, DC that protects patients from harm and increases access to quality care. MSDC is leading a coalition of Washington, DC specialty medical societies to advocate against the Health Occupations Revisions General Amendment Act of 2023.
Impact on DC medicine
Below is a breakdown of some of the major changes the bill contains; click on the title to expand how the bill would change that item.
Currently the Board of Medicine is composed of 10 physicians and 4 members of the public. The bill as amended would reduce the number of physicians to 9 and adds 2 physician assistants but keep
the four members of the public health.
The concern: The bill would codify that APRNs could independently diagnose, prescribe, and administer medicine.
The details: See the analysis from G2L Law Firm on the APRN provisions | See our one-pager on this issue that you can share with colleagues and the Council
The solutions: Independent Advanced Certified Nurse Practitioners should have a defined scope of practice limited to the following functions:
- Practice only in the field of certification;
- Comprehensive physical assessment of patients;
- Certify to the clerk of the court that an adult has given birth;
- Certify to the Transportation authority that an individual has special needs for certain health reasons;
- Complete date of birth and medical information on a birth certificate;
- Complete a death certificate if medical examiner does not take charge and deceased was under the care of the PN;
- Establish medical diagnosis of common short-term and chronic stable health problems;
- File a replacement death certificate;
- Issue a “do not resuscitate order” in medical emergencies;
- Order, perform, and interpret laboratory and diagnostic tests;Prescribe drugs and devices under DC controlled substance Schedules II-V with a valid DEA license, and medical marijuana under DC laws;
- Provide emergency care within the scope of their skills;
- Refer patients to appropriate licensed physicians or other health care providers;
- Certify to utility company that a client has a serious illness or the need for life-support equipment;
- Witness an advanced directive;
- Sign off on home health/care orders.
The concern: As seen below, additional allied health professions are permitted to apply anesthesia. Most concerning is the scope expansion that could permit nurse anesthetists to practice without physician collaboration.
The details: See our one-pager on this issue that you can share with colleagues and the Council
The solution: This bill asks to repeal Section 603 of DC official code ₰3-1206.03, and this action will allow nurse anesthetists to administer anesthesia without an anesthesiologist or other physician's direct collaboration. Language seeking repeal of Section 603 of DC official code ₰3-1206.03 should not be included.
This bill adds Sec. 605a, which contains language that a CRNA may plan and deliver anesthesia, pain management, and related care to patients or clients of all health complexities across the lifespan. Language adding Sec. 605a should be removed from this bill.
The expands audiologists' scope to include "cerumen management" and "interoperative neurophysiologic monitoring" and permits audiologists to screen for cognitive, depression and vision.
The bill completely rewrites the definition of the practice of "chiropractic". Chiropractors could:
- Diagnose and treat biomechanical or physiological conditions that compromise neural integrity or organ system function
- Refer patients for further medical treatment or diagnostic testing
The details: See our one-pager on this issue that you can share with colleagues and the Council
The bill would expand pharmacists' scope to include:
- Ordering labs
- Scheduling and monitoring drug therapy
- Ordering, interpreting, and performing more tests
The details: See our one-pager on this issue that you can share with colleagues and the Council
The bill would permit physical therapists to independently evaluate and treat disability, injury, or disease. PTs may also order imaging as part of their treatment plan.
The concern: The bill expands podiatrists scope of practice to allow:
- apply anesthesia as part of treatment; and
- administer vaccines and injections.
The details: See our one-pager on this issue that you can share with colleagues and the Council
Throughout the bill, restrictions on nursing scope of practice are removed or loosened throughout. Specific language outlining what and how nurses can practice is removed and replaced with more vague language giving the Mayor (read DC Health)
the ability to dictate scope. This applies to many different nursing types, like APRNs and NPs.
Articles on scope of practice
MSDC Submits Comments on Pharmacist Prescribing Proposed Regs
Today, MSDC President Dr. Susanne Bathgate submitted comments to DC Health on proposed regulations allowing pharmacists to prescribe hormonal birth control.
The proposed regulations permit DC pharmacists to prescribe self-administered hormonal birth control after completing a health assessment form. Visits with a medical provider are not required for the prescription, but a person must visit a medical provider to receive a refill.
MSDC submitted questions asking for clarification on the assessment, medical visit requirements, and more. MSDC stressed support for wider, more easily available birth control but cautioned over pharmacists going beyond their scope of medical training. The full comments are below.
Comments on the proposed regulations were due June 26. DC Health will review comments and issue revised proposed regulations in the future.
June 23, 2023
District of Columbia Department of Health
Attn: Phillip Husband, General Counsel
899 North Capitol Street NE, 6th Floor
Washington, DC
The Medical Society of DC is the largest medical organization representing metropolitan Washington physicians in the District. We advocate on behalf of all 12,000 plus licensed physicians in the District and seek to make the District “the best place to practice medicine”.
MSDC is responding to the “Notice of Proposed Rulemaking” N130656 in the May 26, 2023, District Register. The proposed regulations would give authority to certain pharmacists to prescribe and dispense self-administered hormonal contraceptives under specific conditions. MSDC’s comments and questions on the regulations are below.
MSDC believes in the importance of readily available birth control and contraception and supports making it easier to obtain a mutual goal. In addition, we support efforts like those at the federal level to make progestin-only birth control pills available over the counter. What differentiates that effort from these proposed regulations is that in the case of combined hormonal birth control, medical expertise and availability may be needed for prescription, follow up and management of adverse events that is absent in these proposed regulations.
Please see below for the following comments and questions as sought by the department:
Section 6517.1.b – the definition of protocol includes the phrase, “provides rules for certified pharmacists to determine if a prescription… is medically appropriate using the information provided by the patient in the self-screening questionnaire.” Determination of medical appropriateness is based on a questionnaire without a medical history available. It will be essential for this questionnaire to be thorough, to ensure the person seeking birth control can accurately document medical conditions that medical professionals would flag as problematic for hormonal birth control.
Section 6517.1.d – The questionnaire to be used by the “certified pharmacist” will be developed by the Boards of Pharmacy and Medicine. According to the DC Health website, four physician positions are vacant. There is a realistic scenario where the questionnaire could be completed by two entities where physicians are a minority of those serving, or where there will be no reproductive health specialists like a gynecologist. How would DC Health address this concern in these regulations? Would the department be amenable to ensuring subsequent regulation drafts require the body creating the questionnaire have a majority of physicians?
Section 6517.8 – The regulations do not specify the “appropriate counseling” that a patient is to be given. What counts as appropriate in a non-medical setting? A pharmacist – even PharmD – has fewer educational and clinical training requirements as physicians or other medical providers who can prescribe hormonal birth control now. How will “appropriate counseling” be determined based on this?
Section 6517.9 – The regulations state a pharmacist must refer the person receiving the prescription to a primary care provider or “reproductive health provider.” Is the Department concerned that this language is so vague as to allow a pharmacist to send a person to any type of provider to receive care? If the person does not have an established relationship with a primary care provider, how would a pharmacist refer the person and on what basis? This is especially important if the person seeking the prescription has underlying medical health issues that may interact poorly with hormonal birth control.
Section 6517.10 – The requirement to see a provider prior to a prescription is for a refill, not for the initial prescription. Even with the low risk of health issues, a patient’s medical history is important for hormonal birth control. We want to reiterate our question in Section 6517.1.b
General questions:
● If a patient suffers an adverse reaction to the prescription due to an underlying health condition, does the District’s medical malpractice laws allow for the pharmacist to be held accountable?
● Why do the regulations not cite or rely on medical information from the American Medical Association or American College of Obstetricians and Gynecologists when developing materials for pharmacists?
MSDC wants to work with the Department to ensure birth control is easily access in a medically safe way. Our questions seek to help us determine how we can help with this goal. We look forward to seeing how the department answers our questions and concerns. If you have any questions, please contact Robert Hay Jr., Executive Vice President, at 202-355-9401 or hay@msdc.org to contact me. Thank you for your assistance with this matter.
Sincerely,
Susanne Bathgate, MD, FACOG
President, Medical Society of the District of Columbia