Medicine's Turf Wars
Specialists without M.D.'s are pushing for more medical power. Are they ready--and are you?
Yet despite the plastic surgeons' objections, 16 states have adopted the ADA's definition, and several others also give permission for oral surgeons to do any procedures they have the training and credentials to do--which could include cosmetic surgery.
A patient who wants cosmetic surgery by a qualified surgeon--oral or any other--is bound to be a little confused. But there are some common-sense checks to make. Check to see if the surgeon is board certified, for example, and how many of the procedures the doctor does in a year. If the surgeon has hospital privileges to do your procedure, that's an indication that his or her peers think he or she is qualified.
In another cutting-edge battle, organized medicine has gone on the warpath in Oklahoma, the only state that allows optometrists to do laser and nonlaser eye surgeries. The state was apparently swayed by the access argument, specifically Oklahoma's greater supply of optometrists than ophthalmologists. Last year, ophthalmologists tried to overturn the law authorizing the scope of optometry practice, charging that it gave optometrists too much surgical authority. The challenge didn't quite work out. Instead, Oklahoma's Legislature and governor clarified optometrists' practice boundaries, allowing these nonphysicians to continue scalpel surgery around the eyelids and lashes and other eye-related surgeries. "It was politically motivated, and they picked a fight and it backfired on them," says Stillwater, Okla., optometrist David Cockrell, who is president of the Oklahoma Board of Examiners in Optometry.
These battles, without good information with which patients can make good choices, have many people concerned. "Unless we drastically change course, patients will see a much more fragmented system, and it will be more difficult to know whom to see and the quality of care they deliver," says Robert Phillips Jr., director of the Robert Graham Center, a policy center sponsored by family physicians looking at primary-care and quality issues. The course change that Phillips recommends is more collaboration and less conflict. He notes that the widening responsibilities allied health professionals are getting shouldn't leave them isolated from physicians. Most nurse practitioners, physician assistants, and others gaining more practice authority still work collaboratively and harmoniously with physicians. In fact, one thing physicians and allied health clinicians agree on is that a team approach to care is best for patients.
This spring, the Federation of State Medical Boards--a group that monitors physicians' licenses and practices--plans to release a document designed to help healthcare regulatory bodies and legislatures to make better-informed decisions on scope of practice changes. One would expect the FSMB document to boost the physician side in the turf battles, but FSMB P resident and CEO James Thompson, M.D., won't show his hand. Thompson does say that he believes calls from the Institute of Medicine to forge more collaborative relationships are getting the attention of physicians, and he expects to see that trend continue over the next five to 10 years.
Calls for collaboration are all very well, but many observers think that stronger intervention is needed. Market forces--in other words, money or the lack of it--are going to continue to draw primary-care physicians away from patients and draw allied health professionals in to take their places. "The system of medicine is pushing people to the edges of their competence," says the Medical College of Wisconsin's Cooper. "Is this a crisis? No, it's not a crisis. But is the system pushing nonphysicians to the limit of their capability? I think so."
With Helen Fields
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