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NATIONAL HARBOR, Md. -- Delegates for the American Medical Association (AMA) continued to clash over scope-of-practice protections during the interim meeting of the House of Delegates on Tuesday.

Certain AMA delegates want the association to develop model legislation stating that all emergency departments require the "real-time, on-site presence of a physician" and "on-site supervision of non-physician practitioners" by a "licensed physician with training and experience in emergency medical care whose primary duty is dedicated to patients seeking emergency medical care in that emergency department." Others worry doing so could have unintended consequences for access in rural areas.

Jordan Warchol, MD, MPH, a delegate from Nebraska who spoke on behalf of the Rural Health Caucus and North Central Medical Conference, requested that the policy statement be referred back to the AMA's Board of Trustees for study, echoing the recommendation of the AMA's reference committee.

"As an emergency physician, I also want emergency physicians to staff emergency departments," she said. But in rural America, there's "significant tension" between maintaining physicians' scope of practice and providing access to healthcare.

While some argue it's "hyperbole" to say that scope-of-practice legislation will close emergency departments, she noted, "I promise you it is not hyperbole."

Warchol argued that the requirement of an on-site emergency physician at emergency departments in rural areas "would bankrupt our hospitals and close them, significantly decreasing access to care."

Pino Colone, MD, a delegate from the Michigan State Medical Society and the author of the draft policy, said his delegation had worked with others to craft language to address the concerns around rural hospital closures and called for the policy to be adopted and not referred.

At some point in the debate, Hilary Fairbrother, MD, MPH, a delegate for the American College of Emergency Physicians (ACEP), who supported the concept of model scope-of-practice legislation and opposed referral introduced amendment language calling for the draft policy to include "appropriate consideration for limited rural exceptions."

"Emergency departments in rural and urban areas around the country have replaced physicians with physician extenders," Fairbrother said. "Patients are undifferentiated, disproportionately vulnerable, and often critically ill. Please, let's pass this aspirational policy."

However, Catherine Schneider, MD, a delegate from Vermont who was speaking on her own behalf, said the amendment was "vague."

"Since half of the population and hospitals are rural in this country, I think that we need to be very clear that this resolution is a ... significant hardship for the hospitals," she said.

Erick Eiting, MD, MPH, also a delegate for ACEP and speaking on its behalf, supported the new language.

He shared that his father had visited an emergency room in rural Wisconsin at his urging, after his mother told him over the phone that his father's blood pressure was 80/40 mm Hg.

When it became clear that his father wasn't getting appropriate care or "the right answers" from the physician assistant at the emergency room, Eiting, a medical director of an emergency department in New York City, asked to speak to the attending physician. Eiting said he was told "that person is not available."

Eiting's father was admitted to the hospital, diagnosed with sepsis, and almost died.

"If you are billing yourself as an emergency department, you had better have a physician there. This is a quality issue ... We need to stand with scope of practice," he said to applause from the room.

Ultimately, the policy was referred back to the AMA's board in a vote of 333-224.

Correction: A previous version of this story stated that the resolution called for a licensed emergency physician in every emergency department. The resolution actually requires a "licensed physician with training and experience in emergency medical care."

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