Turf Battles

April 1, 2005

Non-physicians are encroaching on physician domain

"Who Needs Doctors?" screams the cover of a recent issue of U.S. News & World Report.

According to the news magazine that circulates to 2 million readers, "Your future physician might not be an MD -- and you may be better off."

Challenges to your domain as an MD are not new. Optometrists and nurse practitioners are two groups of nonphysicians that are winning limited prescribing rights. And nonphysicians of various types are making inroads in other areas that were once the sole discretion of physicians.

More change is coming. And U.S. News says that's all for the better.

There's a convergence of factors going on here. Technology has made it easier, and in some cases, cheaper for nonphysicians to do procedures that previously only physicians could perform.

Meanwhile, payers are pressuring you to spend less time with patients by keeping reimbursement flat year after year, or providing increases too paltry to keep up with inflation, forcing you to see more patients to make up the difference.

So while it's not your fault, patients complain that they don't get the care they deserve.

Waiting to fill this unmet need is a growing army of nonphysicians.

The average wait for a first appointment for a psychiatrist in some markets is six weeks. Not the case with psychologists. As the demand for mental health treatment grows, psychologists are only too happy to help. Now, though, they are demanding the authority to prescribe medications in addition to providing talk therapy. They've already won the right in New Mexico and Louisiana and are fighting for it in other states.

Is this a good idea for patients? Probably not. At least half of mentally ill patients who require medication have comorbidities that require other types of medication. How well does a psychologist understand drug interactions, especially when one or more of the drugs is for something other than a mental illness?

Such questions have prompted at least two psychologist groups to publicly oppose prescribing privileges. But the debate rages, as psychologists and psychiatrists continue to fight each other.

And so it goes: California podiatrists now perform partial foot amputations. Filling cavities is passe for many oral surgeons who now focus on higher paying cosmetic surgery.

For many years, Florida's nurse anesthesiologists worked in hospitals alongside physician anesthesiologists. Then surgeries migrated to outpatient centers. The nurses litigated all the way to the Florida Supreme Court to maintain the right to do their thing without an anesthesiologist supervising them. The Florida Society of Anesthesiologists argued that an MD should be present to protect patients' health. But the doctors lost.

Physicians have successfully stopped some assaults, most recently in California and Virginia.

But there are likely to be more battles. Unlike medical malpractice, which could be resolved by Congress, these jurisdictional fights will be fought state by state. 


Public opinion increasingly supports loosening restrictions on nonphysicians, according to a host of surveys. Busy people want someone to help them -- at a time that's convenient for them and at a low cost.

Where will it end? What about quality of care?

Nonphysicians have developed research to refute claims that only a physician can safely provide certain services. Undoubtedly, as more services are "outsourced" away from physicians, there will be more data to examine.

And politicians would love nothing more than to meet the growing need for health services with lower-priced alternatives.

If your area of practice comes under assault, be prepared: determine whether the challenge is worth fighting. If it is, work with your state medical society and specialty organizations to develop the research to halt the intrusion. Don't be bashful: explain your position to your patients, colleagues, the media, and state lawmakers. Patients need to understand why a trained MD can provide better quality of care than a nonphysician.

Yes, this is another challenge to the physician domain. But challenges can be checked and your patients' care protected.