Medicine's Turf Wars
Specialists without M.D.'s are pushing for more medical power. Are they ready--and are you?
You've probably noticed it at your own doctor's office, the subtle yet revolutionary changes in the way Americans receive their healthcare. The tipoff may have come when a physician assistant wrote your child a prescription instead of the pediatrician. If you've recently switched doctors, chances are you saw a nurse practitioner and not the primary-care physician listed on your health insurance card. Perhaps you live in a place where you can bypass the doctor and go directly to the pharmacist for immunizations. Or maybe you're one of the millions of patients directly spurring these changes, deliberately asking for these providers because you're fed up with your doctor, had to wait too long to see him, or simply couldn't afford it.
Nonphysician clinicians--nurse practitioners, nurse anesthetists, dentists, optometrists, chiropractors, and others--have become prominent health providers. Often working alongside doctors, well-trained, nonphysician clinicians provide frontline medical care to patients increasingly needing preventive care or monitoring for diabetes, congestive heart failure, and other chronic diseases. These new faces of American medicine are more willing to go to rural or inner-city areas and to work beyond the limited office hours typically kept by physicians. Minneapolis nurse practitioner May Hang, for instance, sees a wide variety of patients early mornings and nights at a Target store that houses her mini medical office, MinuteClinic. The clinic is designed to treat a limited set of common acute ailments, including ear, bladder, and sinus infections and strep throat. No appointments are necessary, and visits take only 15 minutes.
Yet as health professionals such as Hang have advanced into territory once held solely by doctors, a larger medical turf war has begun. The battles take place away from patients and are fought before state legislatures, the courts, and other venues as non-M.D. professions try to broaden their responsibilities even further. Oklahoma recently allowed optometrists to do limited surgery, podiatrists in California can perform partial foot amputations, and Idaho last year removed requirements of physician supervision over nurse practitioners and certified nurse midwives, giving them more freedom to practice. Nurse anesthetists in New Jersey have been lobbying for the same type of autonomy. And right now, psychologists in Tennessee are fighting for the right to write prescriptions--a battle the non-M.D.'s have already won in New Mexico and Louisiana.
Their primary weapons are the issues of access and patient safety. In Tennessee, for example, psychologists argue that patients must typically wait six weeks for an initial psychiatrist's appointment; low-income patients wait several months. The result is that many people don't get proper treatment, the psychologists contend. Roughly three quarters of the people in Tennessee who seek help for depression are treated by physicians with only limited training in mental disorders. Psychologists, who tout Ph.D.'s and many years of training, say they're better equipped than an internist or OB-GYN to prescribe drugs for emotional conditions.
Psychiatrists, not surprisingly, don't agree. "The cure to the access problem being proposed is worse than the disease," says Steven Sharfstein, president-elect of the American Psychiatric Association, adding that psychologists' proposed medical education equals a few weeks of what physicians get in medical school. "We need more psychiatrists, but I don't think the solution is to entitle or enable poorly trained physicians to provide a level of medical care that is potentially unsafe."
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