Scope of Practice Unbound

The content discussed in this episode may be specific to the guests organization or location and may not be applicable to other organizations, states, territories or countries. The material presented in this podcast is for general information purposes only and should not be considered health, legal, or financial advice.

Medical administration is a rewarding profession, but it comes with challenges. So what is it like and what should you do if confronted with a monumental administrative difficulty? This is the podcast. Takes unfortunate scenarios. and explores the essentials of clinical governance to find solutions.

I'm Dr. David Rankin, a very experienced medical administrator and lead fellow with the Royal Australasian College of Medical Administrators. And this is Safeguarding Healthcare, the Essentials of Cleaning. Today, scoping a surgeon's clinical practice. Very, very important that we as medical administrators are at working to ensure that we with best evidence are actually considering how we enable the system to provide better care.

That's Dr. Leah Barrett Beck, the Deputy Chief Medical Officer at Metro North Health in Queensland, and I'm challenging her with a difficult scenario. This is a scenario which raises a number of professional concerns. In particular, from a clinical governance and patient safety perspective. In today's scenario, a respected senior surgeon quietly raises a concern during a corridor conversation.

One of his general surgeon colleagues has recently undertaken a very complex pancreatic procedure on a patient with cancer. The surgeon admitted the patient for gallbladder surgery. The patient consented to both procedures and appears to have made a good recovery. But you are concerned that the surgeon has not been trained in pancreatic surgery and that this procedure is outside their scope of practice at your hospital.

I started by asking doctor Leah Barrett Beck what concerns this scenario raises. So we've got concerns raised informally at this stage. And without verification, it may be that the surgery was done very reasonably. However, right now I've got an informal concern raised that in fact this might be outside the scope of practice of this particular surgeon. But aren't surgeons able to do everything? They're qualified as surgeons, they've got their fellowship.

Can't surgeons do anything? So from a registration perspective in Australia and of course in New Zealand, when you are registered as a general surgeon, you have a full scope In accordance with your training through the college. However, for any particular facility, any hospital, you need to have an approved

scope of clinical practice for that particular facility. So it's individual to you and it's individual to that facility. And we go through a process to approve that scope of clinical practice with consideration of both of those things. So you as a surgeon and that particular facility and what the capability of that facility is. So how do you define a scope of practice? How do you work out what each surgeon is able to do or can do in your hospital? Sorry.

Colleges and our professional organizations set those standards in terms of scope of clinical practice. the range of areas in which that specialty practices and helps to set that standard in terms of ongoing care professional standards that we try to maintain as a profession. So we try as hospitals and as governors of the system of Patient care to enable that scope of clinical practice where it's appropriate and to the extent that we can for the clinical service capability of our facilities.

And it follows a process of credentialing where we review and verify the various credentials of an individual. So credentials are things like qualifications, the kinds of training and experience the individual has, and the evidence of that.

evidence of their registration and other licenses and requirements that might be in place from a regulatory perspective. With those credentials, we then review those and assign an approved scope of clinical practice. And that is defined quite specifically, dependent on the facility, and can be actually split between the course scope of clinical practice and the specialized scope of clinical practice.

So you're suggesting that neurosurgeons would have a different Scope of practice to say colorectal surgeons. That's right. So for every particular specialty there will be a core scope of clinical practice. So that's defined really as the core training and qualifications that arise at the end of fellowship prior to any further experience. So that's core scope of clinical practice.

So, someone that undertakes training in neurosurgery will gain a fellowship of the Royal Australasian College of Surgeons in the area of neurosurgery, for instance. compared to a colorectal surgeon who will be, you know, again specialist registration of a surgeon and possibly also in general surgery, but then we'll be able to, depending on the way it's defined in your particular facility, potentially have a sub specialisation and specialized scope of clinical practice in colorectal surgery.

Yeah, particularly in things like using a robot. Um where you need to be proctored and supervised and shown to be competent. um be before you're able to use the robot in that a particular hospital. That's a very, very good example and a very specific example. I guess a robot

pretty easy because it's a big piece of equipment in the way that we use them right now. And so it's very easy to define what that specialized scope of clinical practice is relating to robotic surgery. And we've got lots and lots of experience now in Australia. in understanding the training and and experience required to undertake surgery in robotic surgery, because we really started a lot of that back in the early two thousand and tens in the area of urology in particular.

For many operations, surgeons have to do a minimum volume. We've recently had that come into play with colonoscopy. So you have to do a certain number of colonoscopes every year to maintain your competence. I know as a general practitioner, many years ago doing obstetrics, I was required to deliver a certain number of babies if I wanted to continue to be a GP obstetrician. Can you talk to us about volume and competence? Even for things like hip replacements.

There's a reasonable correlation between the number that you do and the outcomes for patients. Yeah, look you bring up some really, really important examples. And if we look at the history of this emerging in terms of evidence, I think the best example that you've mentioned already is that of. lower GI endoscopy or colonoscopy. So that came about through the collaboration of multiple colleges because a number of different specialties actually undertake

lower GI endoscopy in this country. And so a conjoint committee of those colleges came together and commenced the process of certification to say, you've done the training, you can therefore do colonoscopy. But over time, with evidence emerging, it was revealed that actually in terms of volume against outcomes and also certain aspects of undertaking a colonoscopy that actually

The pickup rate of the kinds of abnormalities we're looking for for colonoscopy gets better at a certain volume of completion. And so there was emerging very, very good evidence that on a number of indicators gets better outcomes for patients. The evidence isn't always that clear. And we've had a lot of debate about very complex pancreatic surgery.

And whether you have to do a certain number of those a year to retain competence. It's extraordinarily complex, probably the most complex surgery that's undertaken on humans, and yet we haven't been able to determine a minimum volume. What's involved in trying to determine Safety. It's a really important example, ribble surgery, and I think the reason it's

It's so useful to consider is because it is just about, as you say, the most complex surgery that we do. You know, this is a surgery that takes on average six hours to complete in is a major procedure known to um you know be very high risk. risk and have the potential for very serious complications. And so

Unfortunately it is though a procedure that occurs frequently both in Australia and internationally. So early on it was considered whether or not these surgeries should be done in single centres with higher volume. And of course when you've got something that complex. It needs to be done somewhere that has got the support services around it. In order to support the preoperative, intraoperative, and post-operative care required for these patients from the whole of the multidisciplinary team.

So there was already a tendency for these sorts of surgeries, of course, to be done in tertiary centres, larger hospitals with all of those ancillary services available. And so that trend over time already existed.

But of course the history is that the training in this sort of surgery meant that lots and lots of people were doing these. And so amassed over time is quite a significant amount of information about volumes, outcomes, etc. The Royal Australasian College of Surgeons actually undertook some work to look at the available research in this space and published that a few years ago, looked at multiple measures. against outcomes for Whipple surgery.

So not just in terms of volume relationship to outcomes. but other factors that might exist in terms of the hospital size and other factors. And interestingly, there was a statistically significant relationship between volume of surgery and outcome. And so we know that

There is a relationship there, but that was not to say that a minimum number could be set that was appropriate for an individual surgeon or an individual hospital. What it tells us is this is a very, very complex situation that we need to keep on monitoring.

I think time and trends tell us that big hospitals with all of these services tend to do the most complex surgery on the sickest patients and so for those at that high risk that's going to be really important. But You know, in a country such as Australia with such a vast geography and such an inequity in access to care across our country just because of geography, we need to do everything we can to not limit care in the right setting for that patient.

So we don't want to jump in conclusions if we don't have all of the evidence there. It's a really complex example, but very important, and it will be really interesting to keep on pulling together that evidence over time. It's something we need to continue to collect the evidence on. But you raise a really interesting point. that it's not just about the surgeon.

The surgeon can be really skilled and able to do a procedure at the major metro hospital, but if they move out to a rural hospital that has different nursing skills and different anesthetic skills and different postoperative, perioperative nursing capability, it may not be appropriate for them to do that procedure. So How do we work out whether a hospital is a suitable setting to undertake a procedure?

There's been a variety of ways over time that that's been thought through. And I think as we've become more and more organized, most jurisdictions, and I guess as we've got more and more evidence, most jurisdictions now have very uh extensive published requirements, both in the public and private setting, around what the clinical services capability is for different kinds of procedures and within different specialties.

Now do I think all of that documentation is absolutely perfect and and tells us to the nitty gritty the absolute degree of what we can do where and when? No. But it provides us really good guidance with the evidence we've got at the moment. So the sorts of things that we consider in that situation is the staffing. So what sort of workforce we have within that particular facility, what the training is, how often they're there, is it 24 hour access for instance?

Then we consider the built environment, so for some specialty areas it matters. you know, what area we have available, what the filtration of air is, et cetera, those things can make all kinds of differences to the kinds of procedures or the kinds of services that we might provide. And then of course we also consider the other services that are there.

So is there supporting intensive care unit or HTU availability? Is there supported multidisciplinary cancer care services, pathology, radiology and the availability of those sorts of services within that organisation? And from that we can set various levels of services that can be provided to give us guidance around this consideration.

In surgery, it's particularly complicated because we don't just have the surgeon to consider and the multidisciplinary team and the hospital to consider, we also have to consider the risk for the patient. and that patient's anesthetic and surgical risk plays a really big part in whether or not they can have that surgery at a particular facility.

Because the higher risk patient, even with a very low risk surgery, might need that higher level of care that a larger and more tertiary level hospital can provide. All right. There are some things though that the doctor needs to get a certificate before they can do, and particularly laser, uh using a laser uh and using the image intensifier which involves radiation.

Can you tell us about this need for certification? Look, you've given two really good examples and in general radiation licenses Depending on the jurisdiction it works slightly differently, but those things are required really from a radiation safety and environmental safety, as well as of course patient and other occupational safety reasons.

So it's very important that we have processes in place to make sure that all of those requirements are set and confirmed and verified. And alongside those, the safety associated with those particular devices. Because those particular devices have, we know, significant risks associated with them in terms of their use of the in the environment and making sure that they're used properly. In terms of other uh certifications, often that relates also to ongoing recency of practice and training.

So we've touched on already in terms of volumes, but more and more we are seeing professional bodies and colleges requiring that certification of certain skills and logbooks of numbers of procedures. For instance, corposcopy from a gynecology perspective is one of those areas that there's ongoing certification.

in radiology for MRI, for mammography, and uh for certain other types of coronary CT and coronary MRI, increasing numbers of certification requirements from the professional organisations. So i it's a dynamic area. New techniques are evolving, new technology, new equipment. How does a surgeon go about saying, All right, I want to extend my scope of practice or the other way around saying, you know, um I've been around for a long time, I'd I'd I'd just like to reduce.

strict my scope of practice and just concentrate on day surgery for a while or something like that. How does a surgeon go about changing their scope of practice? This is such an important area and it's one of the situations that that transparency and those conversations really need to be encouraged. So particularly from a reduction or a restriction, as a surgeon may

decide to wind down practice or in fact change direction in terms of the areas of practice that they may wish to work in. That's a really important discussion. But if we just talk about the expansion of scope first, that really crosses across every specialty. And when you finish your fellowship, gain your specialist registration, you have undertaken the minimum standard as a specialist.

to gain that specialist registration. But our learning never stops there. And so we continue to gain further learning, professional development and expand our practice along with new innovations and new techniques. and things to learn along the way. So when that occurs, sometimes it's a gradual change that occurs over time and is in keeping with the entire specialty area, and that can happen naturally.

But sometimes there'll be areas of practice that expand that require really specific training. And those kinds of areas are things like we've mentioned already, like robotic surgery. which led to very specific training and proctorship programmes that were set up. to train individual surgeons in how to use that robotic technology for certain specialty areas. And of course that started with research and then moved into the space of ongoing practice in the community with good evidence.

that that actually was associated with good or better outcomes for some circumstances. So in those circumstances where there is delineated clear requirements for ongoing training or specific training, or rather where it's such a new procedure or a new kind of practice that you really do need to undertake additional training before you can do it. That's where credentialing comes in and the process of scope of clinical practice approvals.

Because what we would normally do in that situation is actually have an application process to add that specialized scope of clinical practice to an individual's approved scope. And usually whilst training in that to have that occur under supervision.

And that's the same as the apprenticeship model of training in medicine. You know, we do that under supervision and learn over time. It's exactly the same no matter the stage of your training. And so for senior doctors, we do exactly the same thing. It's often referred to as proctorship. And will often include, particularly in procedural specialties,

a certain number or minimum of attainment of supervised cases, as well as a certification by the proctor that that individual is now able to practice either with remote supervision or independently after that point in time. So that's a process of expansion of scope. type of practice and it's really led by the profession and what we expect as a profession.

Back to your role as a medical administrator. Can you briefly outline what you would do in this scenario where the surgeon appears to have done a very complex pancreatic procedure when they ostensibly book the person in for a gallbladder? Because pancreatic surgery wasn't within their scope of practice. Informal concern has been raised with me. But this is a concern about patient safety.

So the very, very first thing that I would do is make sure that this patient is okay. I've been told that they're doing okay and that it's gone well, but I need to check that for myself and with the care team providing care for that patient and to ensure that they are getting whatever care they require.

If this is not an operation that we usually do at our facility, then that raises questions for me in terms of that postoperative care. So for me, that's the first and most important thing to make sure that that patient is okay and that care is being provided. Alongside that, in terms of immediate risk, it's about is there an ongoing risk right now for other patients?

And so the kinds of questions I would have, is anything else booked like this? Do we have another surgery booked for tomorrow like this? That's actually what we need to know to make sure there's no current ongoing risk for the public and the community. So that assured, I can then Revert myself to thinking about the situation with this surgeon and to get some more information about the situation. Now, in my experience,

The most common scenario would be that this uh individual practitioner actually has been trained in this procedure, does have recency of practice and is doing it elsewhere, but simply has not been doing this in our organization. So they're the kinds of things I need to find out. What is the situation? What was the surgery that was undertaken? Confirm all of those consent and other matters.

and find out from the surgeon information about their training, their experience, what their recency of practice is and what's happened here. Depending on how my facility defines scope of clinical practice in this specialised area. I have to say there is not standardization in place across Australia or New Zealand in relation to these kinds of surgeries and how they are delineated between core and specialized scope of clinical practice.

But once I understand that, I can understand from a policy perspective whether or not there's a formal breach of scope of clinical practice. in terms of the naming of the approved scope of clinical practice, but then aside from that, whether or not the true situation is that this individual has done this outside of their training, experience, and recency of practice. And if in fact that is the case, then that's a very, very serious matter that we need to uh take further.

There's of course the other scenario that when the surgeon actually got into the patient's abdomen. things were not what they expected and they felt it was appropriate to proceed and do something different to what they had expected when they started. All sorts of complicating issues. Absolutely, yes. Never can never is necessarily how it seems when it's first presented to you.

Lee, would you like to just final thoughts or observations on the scenario and scope of practice? Yeah, look I think this highlights for me a couple of issues. One of the matters that I think is really important to remember is when we are responsible for the systems of credentialing and scope of clinical practice. uh within an organization, we as medical administrators need to ensure that we make sure we're doing that well.

and in fact that the organization is managing that how we believe it should be from a policy and procedural perspective. And so that means actually undertaking audit to see what is happening. So whilst we may have wonderful and robust systems to undertake the credentialing process and the approval of scope of clinical practice, what is the care actually being provided in our organization? And is that within the approved scope of clinical practice of the individuals providing clinical service?

So that audit system should be robust. It should be constantly questioning where the risks are in the organisation. where innovation is occurring, testing to make sure our processes around the implementation of new medical procedures or new models of care is robust and inclusive of a credentialing and scope of clinical practice consideration.

and that we're constantly looking for those issues in our organisation. Very, very important that we as medical administrators are at the forefront of that and working to ensure that we with best evidence are actually considering how we enable the system to provide better care. And to also remove barriers to innovation so that we can get that care occurring for our patients as quickly as possible and effectively as possible with utmost safety.

That was doctor Leah Barrett Beck, the Deputy Chief Medical Officer at Metro North Health in Queensland. And that brings us to the end of this episode of Safeguarding Healthcare. I'm Dr. David Rankin. Follow Safeguarding Healthcare free on Apple Podcasts, Google Podcasts. Spotify, or wherever you listen to podcasts. This podcast is produced by Sound Cartel for the Royal Australasian College of Medical Administrators.