Patients Seeking Empowerment Through Non-Medical Specialists

U.S. News and World Report recently reported on "the subtle yet revolutionary changes in the way Americans receive their healthcare," changes that have implications for integration of complementary and alternative medical therapies into hospitals and mainstream health care."

Examples include: patients seeing "a nurse practitioner and not the primary-care physician listed on your health insurance card;" or 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."

The article notes: "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."

The above list includes allied health providers such as nurses, and CAM providers such as chiropractors. These "new faces of American medicine" are more diverse than the old. But beyond expanded patient choices is a "larger medical turf war.... 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."

The recent battle over Florida's proposed chiropractic college reifies the notion of a 'turf war' and shows how broad the battleground can be.

"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."

The article observes that the "primary weapons" of allied health providers seeking expanded legal authority "are the issues of access and patient safety." These are the same arguments made for licensing and expanded scope of practice of many CAM providers--and they align as well with ethical arguments for greater patient autonomy.

Many skirmishes catalogued in the article include: presciption authority (psychologists vs. medical doctors); the right to do surgery (oral surgeons/dentists doing cosmetic surgery vs. plastic surgeons who are MDs); and anesthesia (nurse anesthetists vs. anesthesiologists). The piece concludes: "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." Given the data concerning patient visits to CAM providers, CAM should be considered a part of this market shift.

Reference: Gearon CJ. Medicine's Turf Wars: Specialists without M.D.'s are pushing for more medical power. Are they ready--and are you? US News and World Report. January 31, 2005 http://www.usnews.com/usnews/issue/050131/health/31turf.htm.