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· Psychiatric/Mental Health

· Gerontology

The Importance of

Mid-Level Clinicians

Nonphysician clinicians have made signifi-

In addition to nurse practitioners, ad-

cant inroads in the practice of medicine,

vanced practice nurses include clinical nurse

despite opposition from the American Medical

specialists, certified nurse midwives, and

Association and state medical associations. By

nurse anesthetists.

2004, there were more than 240,000 advanced

Despite the primary care emphasis in their

practice nurses6 and 60,000 physician assis-

education, many physician assistants work in

tants7 working in the United States, compared

specialty practices. The American Academy of

with about 800,000 active physicians.8 These

Physician Assistants lists numerous specialty

two professions did not exist prior to the

practices, as follows. None of these specialties

1960s.9 Medicare and Medicaid, which togeth-

are specifically licensed by the states.14

· Allergy and Immunology Medicine

er account for nearly half of all health care

· Oncology

spending in the United States,10 routinely

· Cardiology

reimburse nonphysician clinicians, including

· Otolaryngology

physical therapists, audiologists, optometrists,

By most

· Dermatology

podiatrists, nurse anesthetists and many oth-

· Orthopedic Surgery

accounts,

ers, for a variety of tasks.

· Emergency Medicine

Today, 23 states permit nurse practition-

the quality of

· Psychiatry

ers to practice independent of physician over-

· Gastroenterology and Hepatology

services

sight or collaboration; the remaining states

· Radiology

do not.11 Most states allow nurse practition-

consumers get

· Nephrology

ers and physician assistants to prescribe con-

from nonphysi-

· Rheumatology

trolled substances.12 Though no states allow

· Neurosurgery

cian clinicians is

physician assistants to practice independent-

· Pediatrics

ly, it is not uncommon for physician assis-

at least on par

· Obstetrics and Gynecology

tants to have relative autonomy, conferring

· Surgery

with what they

with a supervising physician as necessary.

· Occupational Medicine

would get from

Specialization is increasingly common

among mid-level clinicians. For example,

a physician.

nurse practitioners training at the University

Mid-Level Clinicians and Quality

of California, San Francisco, may choose

By almost all accounts, the quality of ser-

from a wide variety of specialties, as listed

below: 13

vices consumers get from nonphysician clini-

· Acute Care

cians is at least on par with what they would

· Midwifery/Women's Health

get from a physician performing the same ser-

· Acute Care Pediatrics

vices. Dozens of peer-reviewed studies com-

· Occupational and Environmental Health

pare outcomes in situations where patients are

· Adult Nursing

treated by a physician, a physician assistant, or

· Oncology

an advanced practice nurse. Outcomes appear

· Cardiovascular

similar15--an important factor, considering

· Pediatrics

that nonphysician clinicians can provide many

· Advanced Community Health

services at a much lower cost. There is also evi-

· Neonatology

dence that teams of clinicians outperform

· Critical Care/Trauma

individual physicians. (Many physicians who

· Perinatology

are accustomed to working in teams are happy

· Family Practice

with the collaboration.)16

A review of more than 50 studies by the

3