Nonphysician Clinicians in the Health Care Workforce

To the Editor: Dr Cooper and colleagues¹ explore some of the trends of nonphysician clinicians (NPCs) and their march to increase their scope of practice, but stop short of analyzing what impact this "high degree of autonomy" will have on patient care. While much can be learned through hindsight, the public cannot afford to have the medical community take a wait-and-see attitude in this matter.

As president of the American Society of Anesthesiologists, our organization and I have substantial experience with efforts by certified registered nurse anesthetists (CRNAs) to expand their scope of practice. The stated intention of CRNAs, to be able to practice independently of any medical supervision, should make it clear to physicians in primary care and specialty practices alike that many "nonphysician clinicians do not aspire merely to complement physicians," as Drs Grumbach and Coffman noted in their Editorial.² If NPCs want to improve patient care, as they claim, why are some of them so intent on severing all ties with physicians who bring medical expertise and judgment to the table?

By limiting their data collection to only NPC organizations, Cooper et al¹ reported information that is, at best, biased and, at worst, totally inaccurate. For example, it is not true that CRNAs have the authority to practice independent of physicians in 18 states or that they have prescriptive authority in 9 states. A thorough review of all relevant statutes and regulations governing anesthesia delivery in the 50 states and the District of Columbia³ reveals that only 1 state, New Hampshire, allows CRNAs to practice without any physician involvement, and only New Hampshire and the District of Columbia give prescriptive authority to CRNAs.

As part of its lobbying efforts, the American Association of Nurse Anesthetists promotes these inflated figures, basing them solely on nursing regulations and ignoring the mandates of medical acts, hospital regulations, and controlled-substance laws. Furthermore, the American Association of Nurse Anesthetists refuses to acknowledge physician collaboration requirements; collaboration, to them, makes nurse anesthetists equal to physicians and is what they consider to be independent practice. This is, of course, a ludicrous and dangerous assumption. Despite the characterization by Cooper et al, anesthesia delivery is not "routine" or "less complicated care," but, in fact, involves critical care medicine requiring physician participation.

Nonphysician clinicians have much to offer if they are willing to accept the limitations of their training and abilities to deliver patient care. But it is time to draw the line on so-called practice prerogatives being sought by some NPCs. Those who wish to practice medicine should do so by education, not legislation. As a practicing physician with more than 30 years of experience, turf has never been important to me. What is important is the safety and welfare of patients. If physicians do not fight for what is in the patient's best interest, who will?