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Marcus Welby, PA.

You're sitting at Popeye's with your sister, plowing through a bucket of fried chicken, when suddenly she begins to Sometimes the best doctor isn't a doctor at all choke on a gob of fat. Before your eyes, her face turns the color of a bruise. Fortunately, you do not panic. You're a registered nurse; you know the Heimlich maneuver like you know white oxfords. Wrapping your arms around her torso, you prepare to render a life-saving squeeze....

Stop right there, mister. You're technically breaking medical laws in at least 37 states.

According to rules of most states' medical boards, using the Heimlich hug involves both "diagnosis" and "treatment" of a patient. Thus, if you're not an M.D.-if you haven't successfully completed four years of med school-your maneuver could actually get you sued for malpractice. And it's not just the Heimlich. Thanks to the relentless credentialism and formidable power of American doctors, in some states you're technically required to have years of expensive, specialized schooling before you perform such IQ-strainers as CPR or a Pap smear.

As necessary as doctors are to the physical well-being of Americans, much of what we've been paying them to do could easily be done outside the Hippocratic realm by thousands of ready and willing professionals trained to provide basic health care to patients. From Canada to the Netherlands to the Soviet Union, nurse practitioners (NPs) and physician's assistants (PAs) have been successfully clamping valves, treating fevers, and doing mammograms for 20 years at a lower cost to patients than a visit to an M.D. Here in the United States-where, ironically, those professions were invented in the sixties-conservative estimates are that increased reliance on alternative practitioners would save us about $90 billion each year in medical costs alone. But as other countries embrace our savvy innovation as a routine aspect of medical protocol, U.S. doctors have successfully contained its money-saving potential through a sweet confluence of regulatory authority and financial self-interest. In short, doctors write the rules under which all other medical practitioners operate.

Here's how it works. Say you have a pimple on your nose and you'd like a professional to pop it. Under the District of Columbia's medical laws-scripted by a doctor-dominated committee-a pimple" is defined as a "blemish," and a "blemish" is defined as an illness. That means the only person legally capable of diagnosing and treating it is a doctor. By performing similar semantic gymnastics, the New Jersey Medical Society has blocked PAs from using relatively simple technologies like ultrasound and kidney dialysis equipment; the Massachusetts Medical Society has helped defeat new legislation that would allow pharmacists to offer free blood-pressure testing; and other states have prevented the expansion of alternative care practitioners' hospital privileges and their authority to prescribe drugs or authorize direct insurance reimbursements. And occasionally-as happened last year in Montana-doctors have even fought to put their competitors out of business.

Until the winter of 1990, six nurses from St. Peter's Hospital Hospice in rural Helena routinely administered care to terminally ill patients-care that included handing out painkillers in the night-time hours after the pharmacy had closed and the resident physicians had vanished. For their efforts, the six were prosecuted by the state attorney general's office and the Montana Professional Licensing Bureau on charges ranging from "gross negligence" to potential homicide. Legal barriers like these are one reason why, in many areas of the United States, PAs and NPs are almost as rare as Asian elephantiasis.

If that means unnecessarily high medical costs for absurdly simple procedures, patients ought to rise up in anger: I want my Pap smear for $30, not $60! So why don't they? In a theoretical, meritocratic America, you rise if you demonstrate competence, regardless of your surname or your skin color or the gloss of your credentials. In the real America, we forgive our teachers' subliteracy as long as they have teaching certificates in their files. Similarly, we tend to believe that almost all medical treatment necessarily involves highly trained, highly paid doctors, even when the average Boy Scout-let alone an amply trained nurse practitioner-could pop the same zit, do the same Heimlich, or apply the same splint. Our acceptance of credentialism explains why, when physicians assert that alternative care providers diminish the quality of care, we don't look at the evidence or our options. We just pull out our wallets.

Relief stitchers

On an average day, Mark Helgeson, the only full-time health practitioner in tiny Eagle Bend, Minnesota, sets fractures, checks blood pressure, treats rashes and respiratory infections, stitches cuts, and prescribes drugs. His patients don't seem to mind that he's neither a doctor nor a nurse. Instead, he's a fully licensed member of a relatively new breed of medical worker: the physician's assistant.

Helgeson and his 20,000 fellow PAs nationwide are graduates of a two-year medical training program; most of them have had to pass a national certifying exam, and all of them work under the supervision of a doctor who can be as near as the same office or as far as 50 miles away. According to Congress's Office of Technology Assessment (OTA), PAs are fully qualified to perform up to 80 percent of the duties commonly done by physicians, from taking medical histories and conducting physical exams to providing emergency care and even performing minor surgery. NPs often perform similar functions but are generally not permitted to diagnose illnesses. NPs, who must also work under the supervision of a doctor, require four years of training-training offered by such fly-by-night operations as Yale-and most have prior nursing experience. (Credentialists take note: Ivy League medical schools also train PAs.)

Since the birth of their professions in the sixties, tens of thousands of PAs and NPs have safely and efficiently plied their trade across the country. But they tend to practice in places where doctors don't want to. As the Department of Health and Human Services reported last year, many places-rural communities, inner-city neighborhoods, prison facilities, and nursing homes-would have little or no access to quality health care were it not for PAs.

One reason that prisons and poor and rural neighborhoods rely on alternative practitioners is that they're consistently cheaper than doctors. Take, for example, the office visit, Pap smear, and mammogram recommended annually for many women. Those simple procedures, which cost on average $227 from a private physician, average $193 with a PA. Not much difference, until you figure that if roughly 70 million women over the age of 20 saved this each year, a total of $2.3 billion would be saved on one set of routine procedures.

Which doctors?

But are alternative practitioners as good as doctors? That's the issue the medical establishment has raised for two decades to keep the Mark Helgesons in Eagle Bend instead of on the Upper East Side.

The established physician furrows his brow, shakes his head, and begins, patiently, to explain. While alternative care may sound nice, there are still quite a few (ahem) concerns:

>"We have concerns," Dr. William Jacott, a family physician and member of the American Medical Association (AMA) recently told The New York Times, "that in some cases physician's assistants are providing care that they are not really qualified to provide."

>-Want a second opinion? Dr. Daniel Ein, president of the D.C. Medical Society, also has "concerns that there are areas of medicine which require lots of knowledge of how things work, and cases where nurse practitioners with independent practices are just not equipped, nor trained, to perform."

>.How about a third? While an AMA spokesman concedes that more than 80 percent of physical complaints could be cared for by nonphysicians, he voices "concerns about the 20 percent of physical complaints which do require intervention. Some can be very serious, and to discriminate between minor and dangerous takes a physician years to master."

These, of course, are legitimate concerns-ones shared by patients. No one wants some presumptuous second-tier health worker staring into his belly and wondering if the bladder is the little green organ or the large brown one, no matter how much money be is saving. While an NP could be trained to do most of the tests performed by, say, an allergist, he probably shouldn't be making decisions as to what those tests mean. And as physicians' organizations are quick to tell you, some alternative practitioners don't know their place. How about the Palm Springs midwife who dropped a patient in the midst of labor on the doorstep of a physician? Or the San Diego midwife who waited more than 24 hours this summer before turning her patient's complicated pregnancy over to a hospital for an immediate caesarean?

The patient who turns to alternative health care may indeed take risks. But so, for that matter, does the patient who checks into a hospital. Which risk is greater? Answering that question requires a somewhat less anecdotal approach.

The bleached white coats remind us that every physician is also a scientist. Most scientists would agree that for a hypothesis to stand it must be checked and rechecked in a gamut of tests and by a rigid analysis of data. So, does any research support the worry that patients are ill-served by PAs and NPs? Well, admits the AMA spokesman, no. In fact, the Congressional Budget Office summarized dozens of studies to conclude: "Nurse practitioners have performed as well as physicians with respect to patient outcomes, proper diagnosis, management of specialized medical conditions, and frequency of patient satisfaction." That was in 1979. A 1986 OTA report concluded that patients were even more satisfied with NPs than with M.D.s, since nurse practitioners appeared to have better communication, counseling, and interviewing skills than physicians. Another U.S. government-funded study conducted by the RAND Corporation found that patients treated by alternative care providers received more bedside care and spent fewer days in the hospital. A follow-up survey found that nonphysician practitioners provided more medical attention, monitored drugs more closely, and signed medical orders more promptly.

Is there, then, evidence, as doctors Jacott and Ein assert, that a PA or NP might try to provide care for which he or she was not properly trained? Again, government and academic studies have found that alternative care providers tend to know the limits of their practice and refer cases beyond them to physicians. "It's like an ongoing, progressive marriage," says Mark Helgeson. "Both the physician's assistant and the doctor gradually decide how much he or she can do. Just like with interns."

The AMA and state medical societies also worry that alternative practitioners might abuse prescription privileges. But researchers have concluded, to the contrary, that nonphysicians "are more likely than physicians to explain why medications are administered and what side effects are possible," and they are more reluctant than M.D.s to use unproven medication when it is not absolutely necessary.

These findings should be especially reassuring these days, as acute, low-tech health care becomes a more central part of medicine. Fitness awareness, improved sanitation, and a higher standard of living mean that people are living longer; the flip side is that they're also taking longer to die. Problems that come with old age and chronic illness require a different kind of treatment-treatment that PAs and NPs are well positioned to supply. Yet despite the demographic imperative, organized medicine-whether the AMA, the state medical licensing associations, or simply the physicians on a hospital board-continues to thwart the expansion of alternative health care: an effort that may have more to do with competition than quality of care. Medical monopoly

In 1961, the Journal of the American Medical Association (JAMA) took a bold and farsighted action: calling for PAs to help compensate for physician shortages by providing reasonably priced care to large populations with unmet medical needs. Today, as health care costs eat up 12 percent of our GNP and more than 37 million Americans have no health insurance, JAMA's 30-year-old argument is even more compelling. But the doctors themselves have changed their tune. Over the years, alternative practitioners have found themselves repeatedly blocked by subtle and not-so-subtle barriers: refused hospital privileges, denied prescription rights, forbidden insurance repayment, consumer agency investigations, arrests, and court litigation. All the barriers stem from a single source: American medical licensing laws.

Historically, these laws were enacted with the patient's needs in mind, ensuring that only qualified physicians provided treatment to the sick. Fair enough. But as competition increased, so did conflict of interest. Physician-dominated boards-not consumer advocates or elected officials were charged with setting, lobbying for, and enforcing the medical licensing rules that affect all levels of health practitioners. Thus today doctors essentially control medical information, medical fees, and medical insurance company payment policies. They can, with little effort, close out competitive programs.

For instance, throughout the sixties and seventies, when the Mendocino area of Northern California was populated by hippies, artists, and marijuana farmers, the to inexpensive local midwives for medical care, birthing, and postnatal advice. With a rise in property values, a wealthier set moved in. By the mid-eighties, when physicians discovered they could set up profitable practices in the area, the California Medical Society began to enforce its medical laws, drive out the less expensive midwives, and replace them with the ob-gyn physicians who work there today.

Self-serving actions like these have united alternative practitioners in opposition in recent years. Despite intensive AMA lobbying, Congress passed laws under the Omnibus Budget Reconciliation Acts of 1986 and 1990 that allow direct repayment to alternative practitioners. But this in no way revolutionized the practice. The AMA still opposes direct payment to PAs and NPs by Medicare, and the two groups find it next to impossible to get the nation's largest insurer, Blue Cross/Blue Shield (physician-controlled), to repay. "Sure, [our practice] may now be legal," says Susan Wysocki, director of the Nurse Practitioners Association in Washington, D.C. "But if insurance companies won't pay or reimburse you for something's not worth it to perform independent health care."

The medical fraternity also uses its rules to curtail prescription-writing authority and hospital privileges. A few years back, the Ohio attorney general had to file an antitrust suit against the Joint Commission on Accreditation of Hospitals to pry open hospital privileges for nonphysicians. While prescription restrictions have been loosened in some geographic regions-mainly in states such as Montana and Minnesota with large rural populations-there are still large parts of the country where PAs and NPs are prevented from prescribing medications, and the AMA continues to oppose granting privileges in these areas.


The AMA's push for tight "regulation" of alternative practitioners comes, ironically, from one of the most conservative constituencies in the country. As a group, doctors looked on with approval as the Reagan-Bush administrations undercut regulatory oversight in banking, real estate, and the environment. They nod to vague rhetoric about "empowerment" for consumers and a healthy "free-market" economy. And yet, when talk of deregulation swings around to health care-an idea promising competition for services, lower prices, and increased consumer access in areas where care is scarce-the market panacea becomes a bitter pill. Ironically, though, medical care is one area in which modified deregulation that opens up the medical realm to regulated alternative practitioners will yield real financial returns without real human cost. In fact, it might even have real human benefit for the millions of Americans who opt out of basic medical treatment-especially preventive care-because they have neither money nor insurance.

This sort of limited deregulation could free America's highly trained physicians from many routine and time-consuming tasks, allowing them to concentrate on serious cases and complex diagnoses. What it won't do is put doctors out of business. Instead, it will provide greater accessibility to health care at a lower social cost.

The forces of demographics, technology, and economics all demand alternatives to the venerable and expensive M.D. Only medical boards-and our collective lack of imagination-stand in the way. In England, Canada, and across Northern Europe, consumers already comprehend that making a good splint doesn't require $120,000 worth of specialized training. As the cost of health care continues to soar, it's time to reclaim an American innovation and allow it to start healing at home.
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Title Annotation:physician's assistant
Author:Workman, James
Publication:Washington Monthly
Date:Jan 1, 1992
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