Medicine's Turf Wars
Specialists without M.D.'s are pushing for more medical power. Are they ready--and are you?
Behind the claims about safety for patients, however, lurks the specter of self-interest on both sides. "It's a political and economic issue," says physician Richard Cooper, professor of medicine and health policy at the Medical College of Wisconsin. Physicians want to maintain control of care and the financial rewards that come with it. They don't want to be undercut in the market by less costly providers.
Indeed, rising healthcare costs are a huge factor for consumers, health insurers, states, and employers all looking for less costly alternatives. "Nonphysician providers continue to achieve enhanced stature," notes Andrew McKinley, an analyst for Health Policy Tracking Service in Falls Church, Va. "There is growing support for the concept that the public health is best served by the broadest access to primary care, along with the safe use of pharmaceuticals." And for many, that concept is best supported by clinicians who don't have medical degrees.
Playing it safe
The safety issue isn't just a "he said, she said" debate. Research has shown that many nonphysician providers perform safely, or at least as safely as physicians do, in their expanded roles. But that doesn't mean there's nothing to worry about. "In the main, it's been very safe," notes Cooper, "because roles have expanded commensurate with training and supervision." Cooper, who studies the enlarging roles of nonphysician clinicians and writes on quality and patient safety, adds that research, however, has not been done on leading-edge practices now being undertaken by some of these providers. "There are no outcomes on podiatrists doing amputations," and that's just one example, Cooper notes.
What research has established most notably is that an assortment of nurses with advanced training, including nurse practitioners and certified nurse midwives and other registered nurses with master's- or Ph.D.-level education, are safe. They relieve our pain during surgery, deliver our babies, treat our kids' asthma, care for our aging parents, and help alleviate the suffering of those with AIDS/HIV and other devastating conditions. More than 100 studies have examined, for example, the care delivered by nurse practitioners. "To my knowledge, there is not a single study showing negative impact of [nurse practitioner] practice on health," says Linda Aiken, director of the University of Pennsylvania's Center for Health Outcomes and Policy Research and a nursing professor. She adds that numerous studies of advanced practice nurses show the care they deliver is equal to or better than that delivered by physicians.
Robert Wise, vice president for standards and survey methods at the Joint Commission on Accreditation of Healthcare Organizations, the oversight group that inspects the nation's hospitals and healthcare facilities on quality and safety, says that "the critical issue here is not what they are allowed to do, but do they know what they can't do?" A wide scope of practice doesn't mean that a provider, physician or not, knows it all. They should refer patients to other clinicians when appropriate. "If they know what they can do and what they can't do, they are [most likely to be] a pretty safe practitioner."
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