SCOPE OF PRACTICE
Scope of Practice : Cost of Care Implications
by TOM JAMES , MD
The American health care system is a complex organism . The roots of the system are very much predicated upon altruism for the care of individual patients . However , there are multiple forces that exert pressures on this health delivery system so that it now looks very little as it did at the time that Benjamin Franklin opened Pennsylvania Hospital in 1751 . Among these forces of change are cultural expectations , institutional racism , the explosion of medical knowledge … and economic pressures . It is the intent of this article to focus on just one sliver of these economic pressures , that of the loss of professional boundaries . Most people in this country have a stereotypic understanding of the roles of physicians , dentists , nurses and physical therapists . As with so many other cultural expectations in the post-World War II era , the roles of physicians – family doctors or specialists – were fairly clearly understood .
Prior to the Flexner Report , schools of medicine did not have consistency in education or their approach to medicine . The Flexner Report led to a standardized approach to medical education and a greater degree of reliability in the skills of physicians . As a result of a consistent curriculum , medical education led to better patient outcomes . But the number of medical students graduating each year was proportionately outpaced by the growth of the population . There has been consensus that there is a need for greater access to affordable health care services . The response from multiple-sector “ social engineers ” has been to increase the number of professionals such as advanced practice registered nurses ( APRNs ), physician assistants ( PAs ) and a whole entourage of behavioral health paraprofessionals . These planners indicated that these various professionals are less expensive to educate and to employ and can complete their degrees in less time than medical or osteopathic physicians . They reason that at a population level , these mid-level providers can manage the routine health care services . They anticipate that physicians are needed only for more complicated diagnoses or procedures . These health system-focused groups point to China and developing countries as proof that populations don ’ t need as many physicians .
Certainly in some instances , these health system advocates seemed to have written off patients misdiagnosed because a lesser trained professional failed to consider significant elements in the history , physical or laboratory tests that should alter patient management . There are cultural expectations in this country that are different from those in China or in developing countries . The American expectation is for more personalized service , especially
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