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GLMA Position Statement on Scope of Practice for Primary Healthcare Clinicians

At its December 2021 meeting, the GLMA Board of Directors adopted a position statement recognizing that “a culturally competent, interdisciplinary, collaborative healthcare team is needed to combat LGBTQ health disparities.” The statement reaches the conclusion that “culturally competent healthcare professionals of all disciplines and all levels of practice play a vital role in meeting the needs of LGBTQ people” and supports the removal of restrictions on scope of practice for primary care clinicians to improve access to care for LGBTQ individuals. 

A PDF of the GLMA Position Statement on Scope of Practice can be accessed here and the full text of the statement is below.

136-21-105. Scope of Practice for Primary Healthcare Clinicians

Adopted December 2021

 

Introduction

 

GLMA: Health Professionals Advancing LGBTQ Equality (GLMA) is the world’s largest and oldest membership association of LGBTQ healthcare professionals and allies. Founded in 1981 as the American Association of Physicians for Human Rights (AAPHR), GLMA’s mission is to ensure health equity for LGBTQ and all sexual and gender minority (SGM) individuals, and equality for LGBTQ/SGM health professionals in their work and learning environments. To achieve this mission, GLMA utilizes the scientific expertise of its diverse multidisciplinary membership to inform and drive advocacy, education, and research.

Background

LGBTQ Health Disparities

LGBTQ people face many health disparities, suffering from significantly higher rates of certain diseases, conditions, and infections than the general population. LGBTQ people are at greater risk of suicide and suicidal thoughts, mood disorders and anxiety, eating disorders, and alcohol, tobacco, and substance use disorders1; are more likely to report their health as poor and report more chronic conditions2; have higher rates of breast cancer3, HPV infection4, and cervical cancer4; are more likely to be obese5; and gay and bisexual men are more likely to have HIV/AIDS6. These disparities have led the National Institute on Minority Health and Health Disparities to identify the LGBTQ community as a “health disparity population,” largely due to their difficulty in finding accessible, unbiased care7.

LGBTQ people face widespread stigma, discrimination, and institutional bias in the healthcare system. In a 2017 national survey conducted by the Center for American Progress, one in 10 LGBTQ people reported that a healthcare professional refused to care for them in the prior year due to their actual or perceived gender identity; nearly three in 10 transgender people reported that a clinician refused to see them8. Significant shares of LGBTQ people report other negative experiences when seeking care, ranging from disrespectful treatment to lack of awareness of specific health needs. A Lambda Legal survey found that more than half of all respondents reported healthcare professionals using harsh language or even blaming the patient’s gender identity as the cause of their illness9. Such experiences lead many to conceal their sexual orientation or gender identity when seeking healthcare or avoid seeking care altogether. An increased number of culturally competent healthcare clinicians could help alleviate this problem.

Need for Culturally Competent Healthcare

Medical education curricula for physicians, PAs (physician associates/physician assistants), and nurse practitioners (NPs) do not routinely encompass the health needs of LGBTQ people, with more than half of all medical schools lacking any LGBTQ content beyond HIV/AIDS10. Yet recent years have brought gains in this area: the American Medical Association (AMA), American Academy of PAs (AAPA), American Association of Nurse Practitioners (AANP), and American Nurses Association (ANA) have all issued statements of diversity, equity, and inclusion that recognize the importance of addressing and understanding LGBTQ health needs. Nonetheless, a 2018 survey found that 80% of clinicians said they think it is inappropriate to ask about a patient’s sexual orientation or gender identity—while only 10% of LGBTQ people would choose not to disclose this to their clinician11.

Discussion

Interdisciplinary Healthcare Team

A culturally competent, interdisciplinary, collaborative healthcare team is needed to combat LGBTQ health disparities. Every member of the team plays an essential role, including physicians, PAs, NPs, nurses, clinical pharmacists, behavioral health specialists, social workers, occupational, physical, and speech therapists, and other health professionals. Because each team member has unique skills and knowledge to contribute, each must be supported in practicing to the full extent of their training, experience, and education.

Limitations on Scope of Practice

Although PAs and NPs undergo training and education that is accredited by national organizations and become board-certified by passing national exams, scope of practice for both disciplines varies state-to-state. PAs may have supervisory, collaborative, or other relationships with the healthcare team, including physicians, depending on the state in which they are practicing12. NPs work independently or have reduced practice in the majority of jurisdictions, and restricted practice in only a few jurisdictions13. PA and NP practice can change significantly across state lines, which limits patient access to care—often where it is needed the most. 

Restrictions on scope of practice have not been supported by research. Since the NP and PA roles were established in 1965, research has consistently demonstrated excellent outcomes and high quality of care provided by these practitioners. The body of literature supports the position that NPs and PAs provide primary care that is safe, effective, efficient, equitable and evidence based. Furthermore, NP and PA primary care is comparable in quality to that of their physician colleagues, demonstrated by numerous studies that conclude no statistically significant difference across outcome measures14-27. Limitations on scope of practice restrict clinicians’ abilities to meet their patients’ needs and to effectively target LGBTQ health disparities. 

Conclusions and Recommendations

GLMA: Health Professionals Advancing LGBTQ Equality calls for interdisciplinary healthcare professionals to work together to provide culturally competent care for LGBTQ people, thereby increasing access to care and decreasing health disparities. GLMA recommends expanded education and training in LGBTQ cultural competence for all healthcare professions in recognition that culturally competent healthcare professionals of all disciplines and all levels of practice play a vital role in meeting the needs of LGBTQ people.

GLMA further recommends the removal of restrictions on scope of practice that prevent all culturally competent primary care clinicians from practicing to the full extent of their discipline’s education, experience, and training. We believe that this supportive practice maximizes the effectiveness of all members of the interdisciplinary team to reduce the barriers to access to care.

References

1. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2020). Injustice at every turn: A report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force. Retrieved from: https://www.icpsr.umich.edu/web/RCMD/studies/37888/datadocumentation

2. Lick, D., Durso, L. E., & Johnson, K. L. (2013). Minority stress and physical health among sexual minorities. Perspectives on Psychological Science, 8(5): 521-548.

3. National LGBT Cancer Network. (2019). Lesbians and breast cancer risk. Retrieved from: https://cancer-network.org/cancer-information/lesbians-and-cancer/lesbians-and-breast-cancer-risk/ 

4. National LGBT Cancer Network. (2013). HPV and cancer. Retrieved from: https://cancer-network.org/cancer-information/hpv-and-cancer/

5. Centers for Disease Control and Prevention. (2014). Sexual orientation and health among U.S. adults: National health interview survey, 2013. National Health Statistics Reports, July 2014.

6. Centers for Disease Control and Prevention. (2017). HIV among gay and bisexual men. Retrieved from: https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-msm-508.pdf

7. Kates, J., Ranji, U., Beamesderfer, A., Salganicoff, A., & Dawson, L. (2018). Health and access to care and coverage for lesbian, gay, bisexual, and transgender (LGBT) individuals in the U.S. Kaiser Family Foundation. Retrieved from: https://www.kff.org/report-section/health-and-access-to-care-and-coverage-lgbt-individuals-in-the-us-health-challenges/

8. Singh, S. & Durso, L. E. (2017). Widespread discrimination continues to shape LGBT people’s lives in both subtle and significant ways. Center for American Progress. Retrieved from: americanprogress.org/issues/lgbtqrights/news/2017/05/02/429529/widespread-discrimination-continues-shape-lgbt?peoples-lives-subtle-significant-ways/

9. Lambda Legal. (2014). When health care isn’t caring: Lambda Legal’s survey on discrimination against LGBT people and people living with HIV. Retrieved from: https://www.lambdalegal.org/publications/when-health-care-isnt-caring

10. National LGBTQIA+ Health Education Center. (2019). Recruiting, training, and retaining LGBTQ?proficient clinical providers: A workforce development toolkit. The Fenway Institute. Retrieved from: https://www.lgbtqiahealtheducation.org/wp?content/uploads/2019/05/Recruiting-and-Retaining-LGBTQ-proficient?providers.pdf

11. Lighthouse LGBT. (2018). Why Lighthouse? Retrieved from: https://www.lighthouse.lgbt/about 

12. American Medical Association. (2018). AMA advocacy resource center: Physician assistant scope of practice. Retrieved from: https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/state-law?physician-assistant-scope-practice.pdf

13. American Association of Nurse Practitioners. (2021). State practice environment. Retrieved from: https://www.aanp.org/advocacy/state/state-practice-environment

14. Buerhaus, P., Perloff, J., Clarke, S., O’Reilly-Jacob, M., Zolotusky, G., & DesRoches, C. M. (2018). Quality of primary care provided to Medicare beneficiaries by nurse practitioners and physicians. Medical Care, 56(6), 484-490.

15. DesRoches, C. M., Clarke, S., Perloff, J., O'Reilly-Jacob, M., & Buerhaus, P. (2017). The quality of primary care provided by nurse practitioners to vulnerable Medicare beneficiaries. Nursing Outlook, 65(6), 679-688. 

16. Everett, C., Thorpe, C., Palta, M., Carayon, P., Bartels, C., & Smith, M.A. (2013). Physician assistants and nurse practitioners perform effective roles on teams caring for Medicare patients with diabetes. Health Affairs (Project Hope), 32(11).

17. Kippenbrock, T., Emory, J., Lee, P., Odell, E., Buron, B., & Morrison, B. (2019). A national survey of nurse practitioners’ patient satisfaction outcomes. Nursing Outlook, 67(6), 707-712.

18. Kuo, Y. F., Goodwin, J. S., Chen, N. W., Lwin, K. K., Baillargeon, J., & Raji, M. A. (2015). Diabetes mellitus care provided by nurse practitioners vs primary care physicians. Journal of the American Geriatrics Society, 63(10), 1980-1988.

19. Kuo, Y., Chen, N., Baillargeon, J., Raji, M. A., & Goodwin, J. S. (2015). Potentially preventable hospitalizations in Medicare patients with diabetes: A comparison of primary care provided by nurse practitioners versus physicians. Medical Care, 53(9), 776-783.

20. Liu, C. F., Hebert, P. L., Douglas, J. H., Neely, E. L., Sulc, C. A., Reddy, A., & Wong, E. S. (2020). Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care. Health Services Research, 55(2), 178-189.

21. Lutfiyya, M.L., Tomai, L., Frogner, B., Cerra, F., Zismer, D., & Parente, S. (2017). Does primary care diabetes management provided to Medicare patients differ between primary care physicians and nurse practitioners? Journal of Advanced Nursing, 73(1), 240–252.

22. Virani, S. S., Maddox, T. M., Chan, P. S., Tang, F., Akeroyd, J. M., Risch, S. A., & Petersen, L. A. (2015). Provider Type and Quality of Outpatient Cardiovascular Disease Care: Insights from the NCDR PINNACLE Registry. Journal of the American College of Cardiology, 66(16), 1803-1812.

23. Yang, Y., Long, Q., Jackson, S. L., Rhee, M. K., Tomolo, A., Olson, D., & Phillips, L. S. (2018). Nurse practitioners, physician assistants, and physicians are comparable in managing the first five years of diabetes. The American Journal of Medicine, 131(3), 276-283.

24. Kleinpell, R. M., Grabenkort, W. R., Kapu, A. N., Constantine, R., & Sicoutris, C. (2019). Nurse practitioners and physician assistants in acute and critical care: a concise review of the literature and data 2008–2018. Critical care medicine, 47(10), 1442.

25. Everett, C.M., Morgan, P., Smith, V.A., Woolson, S., Edelman, D., Hendrix C.C., Berkowitz, T., White, B., & Jackson, G.L. (2019). Primary Care provider type: Are there differences in patients’ intermediate diabetes outcomes? Journal of the American Academy of Physician Assistants, 32(6), 36-42.

26. Kurtzman, E.T. & Barnow, V.S. (2017). A comparison of nurse practitioners, physician assistants, and primary care physicians' patterns of practice and quality of care in health centers. Medical Care, 55(6), 615-622.

27. Jackson, G.L., Smith, V.A., Edelman, D., Woolson, S.L., Hendrix, C.C., Everett, C.M., Berkowitz, T.S., White, B.S., & Morgan, P.A. (2018). Intermediate diabetes outcomes in patients managed by physicians, nurse practitioners, or physician assistants: A cohort study. Annals of Internal Medicine, 169(12), 825–835.

 

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