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American Medical Association's Council on

ment can and will stretch the [nurse practi-

Medical Education found that the peer-

tioner's] knowledge and competence beyond

that of the basic education level."21

reviewed studies "almost uniformly conclude

The Indian Health Service (the federal

that . . . a non-physician clinician . . . can provide

an acceptable level of care."17 The Council did

health program for American Indians and

note that some observers find serious flaws in

Alaska Natives) grants clinical and prescribing

the literature, including small samples, lack of

privileges to physician assistants on the basis of

control subjects, and failure to control for dif-

education, training, experience, and current

competence.22 Relatively flexible scopes of prac-

ferences in the severity of illness treated by

tice enable physician assistants to alleviate

physicians and nonphysician clinicians. Never-

workforce shortages as they emerge. According

theless, physician groups are unable to point to

to the American Academy of Physician Assist-

studies showing worse health outcomes with

ants, about 20 percent of PAs change jobs annu-

mid-level clinicians. That may be the most per-

ally, often moving across specialties.23

suasive evidence that the quality of care provid-

Despite the progress made in incorporat-

ed by nonphysician clinicians is on a par with

ing mid-level clinicians, licensing and scope-

that provided by physicians.

of-practice rules still restrict providers' ability

to employ medical professionals to their full

The Need for Workforce Flexibility

competence. Licensing restricts nurse practi-

The flexibility to employ mid-level clinicians

tioners and other mid-level clinicians whose

in new ways is an essential part of making med-

competence exceeds the legislatively imposed

ical care more affordable. As Harvard Business

scope of practice.

School professor Clay Christensen and his col-

leagues explain, "Many of the most powerful

innovations that disrupted other industries did

The Politics of

so by enabling a larger population of less-

Medical Licensing

skilled people to do in a more convenient, less-

expensive setting things that historically could

Groups representing mid-level profes-

be performed only by expensive specialists in

centralized, inconvenient locations."18

sionals are currently threatening to erode

Such disruption is already taking place in

what little workforce flexibility exists. Like

medicine. According to public health researcher

physicians in the early part of the 20th cen-

and American Thoracic Society executive direc-

tury, lobbying groups of mid-level clinicians

tor Stephen Crane, "Fifty years ago . . . medicine

are working to secure legislation that would

was as much an art as a science. We've been able

allow them to stake a claim to specific areas

to codify a lot of that knowledge. That allows us

of practice, excluding all others from provid-

to teach what's going on in a shorter period of

ing services in those areas. In addition, many

Licensing

time and to delegate that to others to per-

clinician groups are lobbying to increase edu-

restricts nurse

form."19

cation requirements for new entrants to their

Hospitals and other providers use what

field. When government issues licenses to

practitioners and

workforce flexibility exists to determine the

medical professionals, it creates a regulatory

other mid-level

tasks a particular mid-level clinician may per-

apparatus that organized clinicians can

clinicians whose

form.20 As their skills develop, mid-level clin-

manipulate to increase their incomes.

icians are given greater responsibility and

competence

autonomy. Thus the effective delineation of

Is More Education Always Better?

exceeds the

their scopes of practice occurs outside the

Mid-level medical professions have been

legislatively

licensing process, and largely at the point of

successful in increasing the amount of educa-

care. Tracy Klein, a clinical instructor of med-

tion required to obtain a license. For example,

imposed scope

icine at the Oregon Health and Sciences

states increasingly require new NPs to obtain a

of practice.

University, writes, "Experience and environ-

master's degree. All states require physical ther-

4