If the Association of American Medical Colleges' prediction comes true— that the nation's physician shortage will grow from about 25,000 today to about 150,000 in 15 years—who will treat the millions more people who will have health coverage for the first time under health reform?
Some of this care is almost certain to come from non-physician providers expanding their education and scope of practice, a push that's either a battle or a gentle nudge to a greater or lesser degree in every state and many medical professions nationwide.
"In my view, what we're seeing is a kind of an evolution of most of the professions moving toward an expansion of their scope of practice," says Stephen Collier, director of the Office of Health Professions Education and Workforce Development at the University of Alabama at Birmingham. Collier sees it not so much as health professions waging a turf battle, but a change taking place because health reform laws are demanding we rethink public policy.
"It's a kind of a natural thing as [the U.S. healthcare system] tries to provide more services," he says.
Clearly physician groups may be vehemently opposed to expanded purviews of other health professions, saying that subordinate health providers don't have the necessary training and skill to diagnose and treat complex diseases. At the very least, a physician needs to be in the room or immediately available.
But the move is on to fight that attitude—out of necessity, many professional trade organizations say. For example, advanced practice nurses are working for expanded ability to prescribe drugs, admit patients to hospitals, and practice in office settings with minimal or perhaps no physician oversight.
"They've gone to school for a minimum of six years, just about as long as physicians do," says Rebecca Patton, president of the American Nurses Association, who says that nurse practitioners are being increasingly employed by hospitals to do tasks that residents can no longer perform because of limits on their work hours.
Bernadine Healy, MD, former director of the National Institutes of Health, wrote in a recent U.S. News and World Report article that nurses "have broken the bounds of their crisp white aprons to assume substantial authority," to treat "a wide range of common medical conditions and wield a prescription pen with virtually the same independence as any MD."
The country simply lacks "sufficient primary care doctors to attend to the growing ranks of aging baby boomers and patients of all stripes who increasingly demand support with wellness and disease prevention," she wrote.
Many organized health professions are taking steps to work without physician oversight, something that is important in rural and underserved areas where physician recruitment continues to lag.
Nurse anesthetists are a good example. In 15 states, they now have the ability to be federally reimbursed when they administer anesthesia to Medicare patients without physician supervision, despite objection from the American Medical Association and many state physician groups.
Nurse practitioners seek the ability to set up office practices and, if needed, admit their patients to a hospital without a physician's okay.
Physician assistants, physical therapists, respiratory therapists, and many others also are hoping to expand their ability to practice without being directly observed by another provider. For example, dental hygienists in many states are hoping to work not only in different locations than dentists, but patients would make appointments with them for routine cleaning—not with the dentist—unless they needed follow-up care for dental disease.
In California, efforts are underway to give psychologists the right to prescribe certain medications, perhaps with oversight from a physician such as a psychiatrist.
Podiatrists' purview varies from state to state, but in many parts of the country they seek expanded scope of practice so they can operate not just from the ankle down, but up to the knee, something that is frowned upon or prohibited in many states now.
Optometrists no longer just prescribe eyeglasses and correct vision. Now in many states, especially rural areas, they diagnose and treat glaucoma and retinal diseases, and sometimes screen for thyroid irregularities and endocrine imbalances that manifest in the eye. In some communities, they routinely take blood pressure readings, advise on diet and exercise and treat diabetes.
Pharmacists seek to be able to give vaccinations against influenza and pneumonia in their clinics.
And chiropractors seek to perform manipulation procedures on their patients while they are under anesthesia.
Linda Whitney, interim executive director of the Medical Board of California, says much of the concern about physicians needing to oversee what other health practitioners do under their supervision is alleviated with expanded use of telemedicine.
"Now that we have telemedicine, you may have even better oversight if you think you may need to have that supervision," Whitney says.
Collier says that much of this expansion is coming at the same time that health sciences education is undergoing change. Audiologists now receive clinical doctorate degrees and nurses seek special training in oncology, midwifery, gerontology and neonatal care.
Surely there will be turf wars and the battlegrounds may get ugly. But if there aren't going to be enough physicians, who will provide this care?
Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached at cclark@healthleadersmedia.com.