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."
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."
Safety studies have played a major role in the mother of all turf battles, which has been waged between those two professions, anesthesiologists and nurse anesthetists, who ensure that, every year, more than 26 million Americans feel no pain when they go under the knife. In general, anesthesia is extremely safe (only one death occurs for every 250,000 times it's administered, a dramatic improvement since the early 1980s, when two deaths occurred per 10,000 anesthetics administered). And 65 percent of all anesthesia care is delivered by certified registered nurse anesthetists, critical-care nurses with a graduate degree in anesthesia, who train for several years in order to sit for certification. Medicare has long recognized their qualifications and reimbursed them for their services. The two professions are extremely courteous to one another when individuals meet in an operating room.
But that courtesy masks a fierce dispute raging between the American Society of Anesthesiologists and the American Academy of Nurse Anesthetists. One part of this row involved nurse anesthetists' wanting to be paid for services rendered in hospitals and surgical centers without physician supervision. It has been left up to each state to allow--or disallow--that care without physician oversight.
To date, 12 mostly rural states have said there's no need for docs. The states have been swayed by safety data on anesthesia providers. "If there is a difference, the studies to date have not shown that," says Cooper.
Now the battle has shifted to doctors' offices. Florida has been the flashpoint. During the late 1990s, the number of office-based surgeries--largely lucrative cosmetic surgery operations--in the state skyrocketed. The practice wasn't well regulated, office facilities often lacked emergency care, and there were a number of highly publicized deaths.
"Office surgery is like the Wild West; it's the last frontier," says Rebecca Welch, president of the Florida Society of Anesthesiologists. While there are no data showing that CRNA s have trouble providing safe anesthesia in office settings, Welch says, "we feel like we are the experts" with a medical school background. Florida's state medical board apparently agreed and created standards for office-based surgeries that insisted anesthesiologists had to supervise CRNA s.
Nurse anesthetists felt the impact immediately. Victor Ortiz, a CRNA from Davie, Fla., says that right after the supervision rule took effect in 2002, "70 percent of my income got swept away." Why? Most surgeons concluded it wasn't economical or necessary to have both an anesthesiologist and a CRNA in their office. "[The medical board] was saying you're unsafe . . . but you read unbiased studies, and they show that you are safe. This was about control and turf," Ortiz says. So Ortiz sued the state medical board. Last summer, a Florida appellate court ruled the board overstepped its bounds with the anesthesiologist supervision rule, a decision affirmed last month by the Florida Supreme Court. "I'm elated," Ortiz says.
Now, another anesthesia battle is shaping up in New Jersey. The Garden State has passed an office-based-supervision rule similar to the one recently knocked down in Florida. It goes into effect in February. Local nurse anesthetists are gearing up for a court challenge, and they hope the outcome will be similar to Florida's as well.
Power of the pad
The right to write prescriptions is the subject of another skirmish. The psychologists pushing for prescribing privileges in Tennessee and five other states will point to the gains they've made in New Mexico in 2002 and Louisiana last year, perhaps their best evidence and best way to assure doubters that they know what they are doing. In New Mexico, for example, psychologists have to take 450 hours of classes in psychopharmacology and other sciences, as well as log years of supervision and collaboration with physicians in order to prescribe. Advocates will also be holding up a Department of Defense experiment that followed the patients of 10 psychologists trained to prescribe medications, a demonstration that ran from 1991 to 1997 with program graduates going on to prescribe medications in conjunction with other kinds of therapy to active and retired members of the military and their families. The federal government and outside evaluators concluded the psychologists were indeed trained to provide safe pharmacological care. But psychiatrists argue about the results anyway. They say that the DOD training was more comprehensive than the training specified in legislation pushed in the states.
But Elaine LeVine, a Las Cruces psychologist, who helped persuade New Mexico's Legislature to give her colleagues prescribing privileges, says far from endangering her patients by writing them prescriptions, her patients will do better when she can choose their meds. She has no problems with psychiatrists--when enough of them are available for patients. It's physicians without mental health training but with a prescription pad who give her pause. While a patient may see his primary-care provider for only very short visits, she notes, psychologists' patients may spend an hour a week in therapy.
As the two professions debate the finer points, Carmen Catizone, who has seen a lot of prescription pads, chuckles. Catizone, executive director of the National Association of Boards of Pharmacy, has seen many professionals duke it out over nonphysician prescribing privilege, including his own group. Pharmacists used to only make and hand out medications but today have authority to vaccinate patients in 37 states and can prescribe "morning after" emergency contraception in California, New Mexico, Alaska, and a handful of other places. Pharmacist prescribing generally is authorized under collaborative agreements with physicians but also allows pharmacists to monitor patients' ongoing conditions.
In the late 1960s and 1970s, the prescription battle was waged between M.D.'s and doctors of osteopathy. Today, like M.D.'s, D.O.'s have unlimited, independent prescribing authority in every state. In the early 1980s, optometrists battled ophthalmologists for the privilege. Now, optometrists can prescribe at least some eye-related medications in every state. Physician assistants, a profession devised by physicians to work under their supervision, had a much easier time in the early 1990s obtaining the ability to write prescriptions under the auspices of M.D.'s. Nurse practitioners have gotten some level of prescribing privileges in most states. Such battles cool as few significant problems are found and as more states grant a particular profession prescribing privileges. Instead, organized medicine focuses on preventing professions just starting to seek prescribing authority from getting it.
Knife fights
Even mightier than the prescription pen, when it comes to medical practice, is the sword--actually, the scalpel. And fights are breaking out around the nation over whether non-physicians can wield one. Such fights, often fought in the absence of quality data, are among the feistiest around--and some of the most difficult for patients who need to choose which hand will do their surgery.
One such hand could belong to Richard Joseph. He finished his residency in 1977. He started out in trauma surgery, rebuilding faces mangled by car accidents and violence in Jacksonville, Fla. Eventually, he got permission from Jacksonville's Baptist Medical Center to perform face-lifts as well. Now, his private practice includes face-lifts, eyelid surgery, Botox injections, and the occasional impacted wisdom tooth. Joseph is an oral surgeon, or, more properly, an oral and maxillofacial surgeon, a dental school graduate, and he's never been to medical school.
Oral surgeons are increasingly getting involved in doing cosmetic surgery. In a world of unhappy doctors and insurance hassles, cosmetic surgery looks like a good place to be. Oral surgeons are, technically, dentists. But they do at least four more years of training after dental school, when they learn to cut open, sew up, and improve the appearance of faces and necks, and they say they are just as qualified as plastic surgeons to do cosmetic surgery. Much of the facial trauma in the nation is handled by oral and maxillofacial surgeons; hospitals designated as Level I and Level II trauma centers are required to have one around to deal with facial injuries. And oral surgeons don't do the things you usually associate with dentists. Oral and maxillofacial surgeon Mark Steinberg, who teaches at Loyola University Medical Center in Chicago, says he hasn't filled a cavity in 25 years.
Plastic surgeons, for their part, go through medical school and several years of training in general surgery and plastic surgery. Oral surgeon training just doesn't match up, says Scott Spear, a plastic surgeon at Georgetown University Hospital and the president of the American Society of Plastic Surgeons. He and his colleagues insist that their concern is only for patient safety and good surgical results; predictably, oral surgeons shoot back that plastic surgeons just want to keep others off their lucrative turf.
State regulations that define dentistry have been the arena for the plastic surgeons' and oral surgeons' dust-ups. At issue is the American Dental Association's 1997 definition, which states that dentistry includes work on "the oral cavity, maxillofacial area and/or the adjacent and associated structures."
That is so ambiguous as to be useless, scoffs Bill Seward of the American Society of Plastic Surgeons. "The jaw is connected to the neck, which is connected to the torso. You can drive a Mack truck through that hole." He claims the "adjacent and associated structure" language gives oral surgeons the right to do breast augmentations, abdominal liposuction, or anything else they want, but oral surgeons point out that the definition also says they're only supposed to do work within the scope of their training.
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
This story appears in the January 31, 2005 print edition of U.S. News & World Report.