BILL ANALYSIS Ó
AB 1992
Page 1
Date of Hearing: April 26, 2016
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Rudy Salas, Chair
AB 1992
(Jones) - As Introduced February 16, 2016
NOTE: This bill is double-referred. If passed by this Committee,
it will be referred to the Assembly Committee on Arts,
Entertainment, Sports, Tourism and Internet Media.
SUBJECT: Pupil health: physical examinations.
SUMMARY: Authorizes a licensed doctor of chiropractic (DC),
naturopathic doctor (ND), or nurse practitioner (NP) practicing
in compliance with the respective laws governing the licensee's
profession to perform a physical examination that is required
for participation in an interscholastic athletic program, as
specified.
EXISTING LAW:
1)Requires the governing board of a school district to make
rules for the physical examination of the pupils in the public
schools under its jurisdiction to ensure proper care of the
pupils, as specified. (Education Code (EDC) § 49450)
2)Specifies that, when a school district or a county
superintendent of schools requires a physical examination as a
condition of participation in an interscholastic athletic
AB 1992
Page 2
program, the physical examination may be performed by a
physician and surgeon or physician assistant (PA) practicing
in compliance state licensing laws relating to PAs. (EDC §
49458)
3)Authorizes a licensed medical doctor (MD), a licensed NP
qualified to perform a medical examination, a licensed PA, or
a licensed DC listed on the most current National Registry of
Certified Medical Examiners, as adopted by the United States
Department of Transportation, to perform a medical examination
for purposes of an application for an original or renewal
certificate to drive a school bus, school pupil activity bus,
youth bus, general public paratransit vehicle, or farm labor
vehicle, as specified. (Vehicle Code (VEH) § 12517.2)
4)Authorizes a licensed MD, a licensed NP qualified to perform a
medical examination, a licensed PA, or a licensed DC listed on
the most current National Registry of Certified Medical
Examiners, as adopted by the United States Department of
Transportation, to perform a medical examination for purposes
of an application for issuance or renewal of a class A or
class B driver's license, or class C driver's license with a
commercial endorsement, as specified. (VEH 12804.9(a)(2)(A))
5)Prohibits any person who practices or attempts to practice, or
who advertises or holds himself or herself out as practicing,
any system or mode of treating the sick or afflicted in this
state, or who diagnoses, treats, operates for, or prescribes
for any ailment, blemish, deformity, disease, disfigurement,
disorder, injury, or other physical or mental condition of any
person, without having at the time of so doing a valid,
unrevoked, or unsuspended certificate as provided in this
chapter or without being authorized to perform the act
pursuant to a certificate obtained in accordance with some
other provision of law. (Business and Professions Code (BPC)
§ 2052)
AB 1992
Page 3
6)Authorizes a licensed physician and surgeon to use drugs or
devices in or upon human beings and to sever or penetrate the
tissues of human beings and to use any and all other methods
in the treatment of diseases, injuries, deformities, and other
physical and mental conditions. (BPC §§ 2041-2051)
7)Authorizes a licensed PA to perform delegated medical services
under physician supervision, as specified, including the
physical examination and other specified medical services for
students, teachers, and employees of public schools and
community colleges under the Education Code. (BPC §§ 3501,
3502, 3502.2)
8)Authorizes a licensed ND to order and perform physical and
laboratory examinations for diagnostic purposes, including
physiological function tests. (BPC § 3640)
9)Authorizes a registered nurse (RN) and a certified NP to
perform nursing functions, including observation of signs and
symptoms of illness, reactions to treatment, general behavior,
or general physical condition; determination of whether the
signs, symptoms, reactions, behavior, or general appearance
exhibit abnormal characteristics; and implementation, based on
observed abnormalities, of appropriate reporting, or referral,
or standardized procedures. (BPC § 2725(b))
10)Defines "standardized procedures," for purposes of nursing,
as policies and protocols developed either by a licensed
health facility or an organized health care system, as
specified. (BPC § 2725(c))
11)Authorizes a licensed chiropractor to practice chiropractic
AB 1992
Page 4
in the State of California as taught in chiropractic schools
or colleges and to use all necessary mechanical, and hygienic
and sanitary measures incident to the care of the body, but
not the practice of medicine, surgery, osteopathy, dentistry,
or optometry, nor to use of any drugs or medicine with a
medical use. (16 CCR 302(b); Chiropractic Initiative Act of
California § 7)
12)Defines the scope of the practice of chiropractic as the
manipulation and adjustment of the spinal column and other
joints of the human body and, as required by the process, the
manipulation of the related muscle and connective tissue,
including the diagnosis and treatment of any condition,
disease, or injury in any patient, provided the diagnosis or
treatment is done in a manner consistent with chiropractic
methods and techniques and does not constitute the practice of
medicine by exceeding the legal scope of chiropractic
practice, as specified. (16 CCR § 302(a))
13)Specifies that it is unprofessional conduct for a licensed
chiropractor who, if in the course of a diagnostic evaluation
the chiropractor detects an abnormality that indicates that
the patient has a physical or mental condition, disease, or
injury that is not subject to appropriate management by
chiropractic methods and techniques, does not refer the
patient to a physician and surgeon or other licensed health
care provider who can provide the appropriate management of a
patient's physical or mental condition, disease or injury
within the provider's scope of practice. (16 CCR § 317(w))
THIS BILL:
1)Specifies that, when a school district or a county
superintendent of schools requires a physical examination as a
condition of participation in an interscholastic athletic
AB 1992
Page 5
program, the physical examination may also be performed by a
licensed DC, a licensed ND, or licensed NP practicing in
compliance with the relevant state licensing laws.
FISCAL EFFECT: None. This bill is keyed non-fiscal by the
Legislative Counsel.
COMMENTS:
Purpose. This bill is sponsored by the California Chiropractic
Association . According to the author, this bill will "allow
school districts to have better access to a larger population of
providers to perform pre-athletic physical examinations.
Students should not have to wait unnecessarily [for] these exams
and run the risk of not getting to play in the sport of their
choice. Every NFL team has a chiropractor on their team of
providers, shouldn't our kids have the same? This bill simply
allows for providers to perform these exams as long as it is in
their training and education and it[is] a part of their scope of
practice."
Background. State licensing laws aim to minimize harm to
consumers by establishing the minimum allowable competency to
practice a profession. As a result of the gravity of potential
harms to patients and the trust placed in providers, many
healing arts require a license to practice. In California, the
practice of medicine is limited to licensed MDs.
California law defines the practice of medicine as all methods
of diagnosis and treatment of physical and mental conditions in
humans. As a result, other health care practitioners are only
able to practice through carve-outs, delegation of services
agreements, standardized procedures or protocols, and MD
supervision.
AB 1992
Page 6
Further, all healing arts practitioners, including MDs, are
limited by their training and individual areas of competence.
It is unprofessional conduct for a healing arts licensee to
provide services outside of the licensee's competence and scope.
Unprofessional conduct is subject to disciplinary action by the
respective licensing board, including fines, revocation, and
referral for criminal action.
Because DCs, NPs, and NDs are each authorized under state law to
do some types of physical exams, this bill seeks to specify that
they may also perform the physical exams for interscholastic
athletic programs if competent to do so and allowed under their
licensing laws.
Interscholastic Athletic Pre-Participation Physical. Currently,
school districts are required to ensure the safety of students
and personnel, including establishing requirements for physical
exams. To meet the mandate, school districts are authorized to
require a pre-participation physical exam (PPE) for
interscholastic sports. However, because school districts have
the discretion to determine the breadth of the examination,
there is no standard PPE. Some schools may require no physical,
while others may require more extensive physicals.
Therefore, some schools might only require a provider to ask a
few health history questions and fill out a form. Others may
require a physical exam similar to what a patient would receive
during an annual check-up.
For instance, the standard PPE form distributed by the American
Academy of Family Physicians, American Academy of Pediatrics,
American College of Sports Medicine, American Medical Society
for Sports Medicine, American Orthopaedic Society for Sports
AB 1992
Page 7
Medicine, and American Osteopathic Academy of Sports Medicine
and used by the California Interscholastic Federation (CIF) for
high school sports utilizes a questionnaire but also requires a
full physical exam. The full physical exam includes medical and
musculoskeletal tests.
The medical tests include detections of abnormalities in lymph
nodes, abdomen, lungs, and for males, genitourinary system
(genitals), among others. The musculoskeletal tests include the
spine, elbows, knees, shoulders, and other joint and functional
tests. Therefore, while many practitioners may have the
training or competence to perform the exam, not all
practitioners have the legal scope of practice to perform the
full range of tests described on the form.
MDs are able to perform physical exams because the physician's
and surgeon's license permits all medical practice. PAs are
able to perform physical exams because they can perform medical
services under MD supervision and authorization under a
delegation of services agreement.
Nurse Practitioner Scope of Practice. According to the Board of
Registered Nursing (BRN), the state licensing board for nurses,
an NP is a RN who has additional training and skills in physical
diagnosis, psycho-social assessment, and management of
health-illness needs in primary health care. In California, RNs
and NPs are permitted to perform nursing functions which are
carved-out from the practice of medicine.
In order to perform medical services outside of the legal scope
of nursing, the RN or NP must operate in accordance with
standardized procedures or protocols (SPPs). SPPs are written
authorizations to perform specified medical services developed
in collaboration with a licensed MD within a medical setting,
such as a hospital or medical group.
AB 1992
Page 8
However, state law also specifies some nursing functions that do
not require standardized procedures, such as physical and mental
assessment, disease prevention and restorative measures,
performance of skin tests and immunization techniques, and
withdrawal of blood, as well as authority to initiate emergency
procedures. As a result, due to the additional training in
primary care, the legal scope of NPs likely includes the
physical examinations described under this bill. It would be up
to the NP and the supervising physician (if applicable) to
determine whether the NP is competent in each situation.
Naturopathic Doctor Scope of Practice. State law defines
"naturopathy" as a noninvasive system of health practice that
employs natural health modalities, substances, and education to
promote health. "Naturopathic medicine" is defined as a
distinct and comprehensive system of primary health care using
naturopathy for the diagnosis, treatment, and prevention of
human health conditions, injuries, and disease.
According to California Naturopathic Medicine Committee, NDs are
trained as primary care practitioners for all conditions
utilizing alternative and complementary therapies. While
treatment approaches differ between NDs and MDs, state law
authorizes NDs to order and perform physical and laboratory
examinations for diagnostic purposes, including physiological
function tests. They may also prescribe scheduled drugs under
SPPs developed with a supervising physician.
Because NDs are authorized to perform full physicals and the PPE
forms do not require the practitioner to treat the observed
ailments, the PPEs appear to fall within the legal scope of NDs.
Again, the individual ND would determine whether performing the
exam falls within the ND's individual competence of practice.
AB 1992
Page 9
Chiropractic Scope of Practice. According to the California
Board of Chiropractic Examiners (BCE), "Chiropractic is a health
care profession that emphasizes the power of one's own body to
heal itself, without the use of drugs or surgery. The practice
of chiropractic focuses on the relationship between structure
(primarily the spine) and function (as coordinated by the
nervous system), and how that relationship affects one's
health."
However, the exact scope of a DC is unclear. Under the
California Chiropractic Initiative Act, a DC may practice
chiropractic in the State of California as taught in
chiropractic schools or colleges. However, there is no
definition of "as taught in chiropractic schools." As a result,
California courts have held that schools and colleges may not
change the meaning of the word "chiropractic" or change the
curriculum to authorize a DC to practice anything taught in the
schools (People v. Fowler (1938, Cal App Dep't Super Ct)).
Instead, the scope of a DC is limited to what was understood and
defined when the initiative was enacted in 1922 (People v.
Mangiagli (1950, Cal App Dep't Super Ct)).
The BCE defines the scope of practice of a DC as having the
authority to manipulate and adjust the spinal column, other
joints of the human body, and to manipulate the related muscle
and connective tissue as required to perform the adjustment (16
CCR § 302). The authorization includes the diagnosis and
treatment of conditions related to the practice of chiropractic.
Despite the definition, it is still unclear what conditions fall
within the practice of chiropractic and there is no clear
delineation in state law-just that the practice of chiropractic
involves the non-invasive manipulation and adjustment of the
spine and all related diagnoses and treatments. Regardless, the
AB 1992
Page 10
definition is consistent with the meaning of the practice of
chiropractic under the initiative of 1922 (Tain v. BCE (2005,
Cal App 1st Dist), review denied, Tain v. BCE, (2005, Cal) and
the opinions of the Office of the Attorney General (59 Ops. Cal.
Atty. Gen. 420, 1976).
To further clarify, the BCE notes that DCs "receive extensive
training in chiropractic college regarding how to conduct
physical examinations (16 CCR § 331.12.2) and treat conditions
in a manner consistent with chiropractic methods and teachings
(16 CCR § 317)" (BCE letter to the Schools Insurance Authority,
October 2, 2014). The BCE also indicates that if an exam
reveals a problem outside of the DC's scope or competence the DC
must refer the patient to the proper practitioner. BCE
regulations state that it is unprofessional conduct if the DC
fails to affirmatively make the proper referral (16 CCR §
317(w)).
As a result, PPEs that involve the spinal column appear to be
within the legal scope of a DC. In addition, PPEs with general
questionnaires and forms with questions about an athlete's
medical history which are filed out or answered by the patient
may also be within a DC's legal scope of practice (many DCs have
patients fill out medical history forms). The individual DC
would have to determine whether the PPE in question was within
the DC's competence to practice and whether a referral is
needed.
Physical Examinations of Commercial Drivers. NPs and DCs are
also authorized to perform exams to certify various types of
drivers of motor vehicles under state and federal law. Because
NPs operate under SPPs, no additional qualification is necessary
(besides self-regulation for competence). DCs, however, must be
certified as a Certified Medical Examiner with the National
Registry of Certified Medical Examiners under the Federal Motor
Carrier Safety Administration (FMCSA) program. To be listed,
AB 1992
Page 11
medical examiners must complete training and successfully pass a
test on FMCSA's physical qualification standards.
The medical examiners perform medical examinations for
commercial motor vehicle drivers in interstate commerce. The
goal of the training is to ensure the medical examiners fully
understand the medical standards in the FMCSA regulations,
related guidance, and how they relate to the medical demands of
operating a commercial motor vehicle.
The exam for drivers appears to fall within the scope and
competence of an NP for the reasons stated above. It appears to
fall within the scope of a DC because driving involves the spine
and neck. However, the purpose of a PPE for school athletic
programs is different from that of the certification for ability
to drive a motor vehicle. Therefore, competence to perform the
motor vehicle exam is not necessarily suggestive of competence
to perform an interscholastic PPE.
Prior Related Legislation. AB 2143 (Williams), Chapter 269, of
2014, exempted DCs listed on the FMCSA registry from California
clinical laboratory requirements that are classified as waived
clinical laboratory tests under the federal Clinical Laboratory
Improvement Amendments of 1988 (CLIA) for the sole purpose of
completing the vehicle medical examination report, as specified.
The bill also required a DC who receives an abnormal finding,
to refer the applicant to the applicant's primary care MD.
AB 722 (Lowenthal), Chapter 160, Statutes of 2013, authorized
DCs to perform commercial drivers' license examinations if
registered as a Certified Medical Examiner with the FMCSA.
SB 1069 (Pavley), Chapter 512, Statutes of 2010, specified
various services and examinations that a PA could provide under
AB 1992
Page 12
a Delegation of Services Agreement, including a physical
examination that is required for participation in an
interscholastic athletic program, as specified.
ARGUMENTS IN SUPPORT:
The California Chiropractic Association (sponsor) writes in
support, "The chiropractic scope of practice fully permits
pre-participation physical examinations. Since 1922, doctors of
chiropractic in California have been educated and licensed by
the State of California to serve as portal of entry/primary care
providers. After undergraduate study, chiropractic students
earn a four-year doctorate degree with classroom and laboratory
work in basic clinical sciences, physical examination, diagnosis
and differential diagnosis, x-ray and interpretation of
laboratory blood work and other treatment procedures. Clinical
education includes a year-long internship overseen by a licensed
doctor of chiropractic on patients with various clinical
presentations using manipulation as their primary clinical
procedure. Chiropractic doctors are required by law to refer
patients to another health care provider if a condition is
detected that is not a part of the chiropractic scope of
practice."
The Board of Chiropractic Examiners writes in support, "This
bill addresses an omission in existing law that precludes health
care providers, such as chiropractors, from providing a service
for which they are trained and qualified. Performing athletic
physicals is well within the scope knowledge and ability of the
chiropractic profession. Furthermore, doctors of chiropractic
are already authorized under state and federal law to perform
examinations more rigorous than athletic physicals to screen
patients for a variety of other purposes, such as driving
commercial vehicles and school buses.
AB 1992
Page 13
Finally, by allowing doctors of chiropractic, naturopathic
doctors, and nurse practitioners to provide athletic physicals,
this bill will make these physicals more accessible and
affordable to students, particularly those in lower income and
underserved communities."
ARGUMENTS IN OPPOSITION:
In opposition, the California Medical Association writes that
this bill "puts the health and safety of young athletes at risk
by authorizing chiropractors and naturopaths who lack the
appropriate education and clinical training to diagnose [Sudden
Cardiac Arrest] and other harmful conditions, to sign a form
that affirmatively states that no potentially adverse cardiac,
neurologic, or other harmful conditions exist. Another goal of
athletic physical examinations is for schools and school
districts to satisfy legal requirements; authorizing these
lesser training practitioners to sign athletic examinations may
increase their exposure to risk and liability.
Chiropractors and naturopaths are not educated to detect
cardiovascular causes and do not have a mandatory residency
requirement in order to acquire the appropriate clinical
training to do so. The ideal examiner for a young athlete is
the child's personal family physician or pediatrician who
already knows the child's health history and family history in
depth. "
POLICY ISSUES FOR CONSIDERATION:
This bill specifies that each practitioner may only perform the
PPE in compliance with the relevant licensing laws. Further,
each practitioner may already perform some of the PPEs, so this
bill does not appear to expand any scope. Therefore, this bill
AB 1992
Page 14
may not be necessary.
Further, because some of the practitioners listed under the bill
do not have a well-defined scope of practice, the wording of the
bill may make things more unclear. For example, as noted by the
BCE and shown through existing law relating to the certification
of drivers, it is within a DC's legal scope of practice and
competence to perform PPEs for interscholastic athletic programs
when the exam involves the spinal column and general questions
about a patient's medical history. However, the variation in
the depth of PPEs and the lack of delineation in a DC's scope of
practice and competence may result in some confusion among
athletes, practitioners, and school districts about which types
of PPEs can be performed in compliance with the DC's practice
act, initiative, and education.
Therefore, if this bill passes this Committee, the author may
wish to consider amending the bill to clarify the types of PPEs
the providers may perform or establish additional continuity of
care measures. Examples of potential amendments include
requiring the practitioners to develop simple SPPs with a
supervising MD or clarifying that schools may still choose which
providers are acceptable.
REGISTERED SUPPORT:
California Chiropractic Association (sponsor)
Board of Chiropractic Examiners
REGISTERED OPPOSITION:
AB 1992
Page 15
California Medical Association
Analysis Prepared by:Vincent Chee / B. & P. / (916) 319-3301