Healthcare is a Team Sport

There is a well-known painting that endures as an icon for compassionate medical care. Entitled The Doctor, it was the creation of Sir Luke Fildes, a renowned artist of the Victorian Age. The painting depicts a gravely ill child in a poor family’s cottage. Watching over the child is the eponymous doctor, illuminated by a solitary lamp. In the background, the desperate parents are revealed by the predawn glow on the windowsill, perhaps foretelling a new day and hope for recovery. 

The Doctor Luke Fildes crop.jpg
The Doctor, Luke Fildes, Public Domain via Wikimedia Commons
Fildes was able to capture the drama of a life-threatening illness because he had firsthand experience. In 1877, his one-year-old son died of typhoid fever. This was before the age of antibiotics, immunizations, and public health. Doctors at that time had little scientific training and the nursing profession was still in its infancy. The prospect of surviving a serious infection was a matter of fate, and the doctor could offer little more than comforting words.

Happily, we live in a different age. Over the past 150 years, the mortality rate for children under 5 years of age has declined by ninety-eight percent. This remarkable achievement—and other gains in health and life expectancy for people of all ages—was due in part to advancements in medical science and improvements in our healthcare delivery system.

The Doctor may be an icon, but no parent today would choose the 19th Century version of healthcare over the scientific and technological advancements of the 21st Century. Fildes’ doctor may have been the embodiment of compassion, but his remedies could not compare to the skills of a modern team of physicians, nurses, and other highly trained professionals.

Healthcare is no longer a cottage industry where solo practitioners work in isolation. Modern medicine is delivered by systems of care. Integral to this model is Team-Based Care, in which physicians, nurse practitioners, PAs, and other medical professionals collaborate to serve the needs of patients, families, and communities.

Modern healthcare has become a “team sport.” The idea of a clinician working alone and without oversight is now considered archaic and dangerous. In the words of the Institute of Medicine,
“The clinician operating in isolation is now seen as undesirable in health care—a lone ranger, a cowboy, an individual who works long and hard to provide the care needed, but whose dependence on solitary resources and perspective may put the patient at risk.”
Today, most primary care physicians practice team-based care within group practices, hospital systems, and healthcare organizations where they are subject to oversight by their peers, and operate according to evidence-based protocols.

Beginning in the 1960s, the Advanced Practice Registered Nurse (APRN) and Physician Assistant (PA) roles were a direct outgrowth of the Team-Based Care movement. The visionary founders of this model recognized that teams work best when they can harness the complementary skills of all members. Over the ensuing decades, the scope of practice for APRNs and PAs gradually expanded to include many services once considered the exclusive domain of physicians, but always within the context of a collaborative relationship with physician-led care teams. Unfortunately, this relationship may soon change.

Proposed bills in the South Carolina Legislature would upend the decades-old relationship between physicians, APRNs, and PAs. Senate Bill 553 would grant APRNs “Full Practice Authority,” a scope of practice that eliminates the need for collaboration with physicians. According to the American Association of Nurse Practitioners:
“Full Practice Authority (FPA) is the authorization of nurse practitioners (NPs) to evaluate patients, diagnose, order and interpret diagnostic tests and initiate and manage treatments — including prescribing medications — under the exclusive licensure authority of the state board of nursing.”
This same bill takes a ham-fisted approach to granting PAs independent practice. It bluntly shoe-horns the PA title into the list of people authorized to practice medicine. It would still require a written scope of practice guideline for PAs who have not achieved minimum hours of postgraduate experience. However, once these minimums have been satisfied, a PA would be able to proclaim their right to independently practice medicine by virtue of a self-executed “Attestation Statement.”

Senate Bill 553 would place APRN and PA scope of practice on par with physicians. Physicians would still have to follow the arduous path of undergraduate degree, medical school, internship, residency, national boards, and career-long maintenance of certification. In contrast, APRNs would get their authority to practice medicine directly from the state Board of Nursing. PAs would get theirs by signing a form.

The American Medical Association and others have opposed independent practice for PAs and APRNs based on the substantial differences in education and training compared to physicians. These comparisons are stark, and it is tempting to rely on this argument—and concerns about quality and patient safety—to oppose legislation like Senate Bill 553. However, this tactic may be misguided. Furthermore, it is uncomfortably reminiscent of past criticism of family physician training.

Not too long ago, family physicians were on the other side of the scope of practice wars. There was a time when family physicians had to fight for recognition and respect. The history of our specialty is punctuated by challenges to our prerogatives—the right to establish hospital departments; to hold obstetrical, endoscopy, and ICU privileges; to practice as hospitalists; to manage complex conditions without mandatory consultation.

Family physicians, APRNs, and PAs ought to be natural allies. We have a common origin story and have faced similar struggles in gaining acceptance. All three disciplines arose from the progressive reforms of the 1960s. We share a mission to make healthcare more patient-centered; a drive to improve community wellness; and—hopefully—the disposition to subordinate our egos for the common goal of better health. The difference is, family physicians demonstrate their competence by adhering to rigorous educational and training standards. We do not seek to bypass these hurdles by lobbying the legislature to make us doctors by fiat.

Despite this difference, we should remain allies and support sensible changes in scope-of-practice laws that enhance the roles of PAs and APRNs in the healthcare team. Unfortunately, we continue to face the biennial distraction of independent practice legislation. One starts to suspect that these bills are motivated less by a pressing public need, and more by a desire to distract us with red herrings. South Carolina faces many challenges: Healthcare disparities; shameful levels of maternal mortality; regressive abortion laws, and the cruel denial of Medicaid expansion for the working poor. Declaring APRNs and PAs independent practitioners will do nothing to address these problems.

South Carolina does not need more “lone ranger” clinicians practicing independently without oversight or collaboration. We need more Team-Based Care. The days of the solitary clinician depicted by Sir Fildes are long past. However, we should not lose sight of why this image remains iconic. Fildes’ doctor was trusted and admired because he truly cared about his patient. Our concerns about PA and APRN independent practice stem from the same source.

We care about our patients, and we care about the future of our state’s healthcare system. We must continue to search for better ways to improve quality and access to care for all South Carolinians. Let us work toward these goals—together—by keeping doctors, nurses, and PAs on the same team.

Moore J. What Sir Luke Fildes' 1887 painting The Doctor can teach us about the practice of medicine today. British Journal of General Practice 2008; 58 (548): 210-213.

Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, and I. Von Kohorn. 2012. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC.

Issues at a Glance: Full Practice Authority, Revised March 2023. American Association of Nurse Practitioners. Accessed 3/31/2023.

2023-2024 Bill 553: Scope of Practice - South Carolina Legislature Online. Accessed 3/31/2023.