rhinoplasties, and eyelifts.44
assistants, Mississippi was the last state to
allow physician assistants to practice.36
Those groups that oppose broader scope
Clinician groups that fail to achieve their
for nonphysician clinicians call for extensive
goals through legislative means have found a
review by policymakers of scope-of-practice ini-
second avenue to reform: working with state
tiatives. For example, the guidelines set by the
regulatory boards to alter scope-of-practice
Federation of State Medical Boards calls for a
rules. Because it is expensive for physician
"verifiable need" for the proposed change,
groups to challenge board decisions in court,
along with a review of the "details, rationale,
this path to scope-of-practice expansion is
growing.45 However, it is not always successful.
and ethics of any proposals to bypass licensing"
In 2008 a Texas appeals court ruled that the
and "the implications for other practitioners,
and the effect on patient safety."37 That stan-
Texas State Board of Podiatric Medical Exam-
dard would present a formidable barrier to
iners went beyond its power in 2001 when it
reform. It is noteworthy that the Federation's
expanded podiatrists' scope of practice. The
desire for evidence runs in only one direction.
appeals court determined that such a change
would need to come from the state legislature.46
The Federation only demands evidence of the
With all of these efforts, the concern for
patient-safety effects of proposed expansions of
Licensing and
consumers is that licensing requirements and
scope-of-practice rules. It does not call for evi-
scope-of-practice
scope-of-practice determinations will reflect
dence that the existing limits on midlevel clini-
the political power of various clinician lobbies
cians' scopes of practice enhance patient safety.
laws give
rather than the patient's interest in affordable,
There is no such evidence.
the medical
quality care. For example, physician assistants
Today's turf battles include a wide range
professions con-
now have prescribing authority over controlled
of issues. Here are some examples:
· Optometrists seek to expand their scope
drugs in 36 states, yet Alabama, Florida,
siderable control
Kentucky, and Missouri still do not allow
over whether
of practice to include surgical proce-
physician assistants to prescribe any controlled
substances.47 As of 2001 physician assistants
dures traditionally limited to ophthal-
other professions
· Physical therapists want to be able to
mologists.38
and nurse practitioners had parallel duties in
may compete
many facilities in Louisiana, yet nurse practi-
with them.
treat patients without a physician's pri-
tioners were allowed to write prescriptions,
· Physician-anesthesiologists seek to limit
or diagnosis.39
whereas physician assistants were not.48 Such
outcomes are more likely the result of power
the scope of practice of nurse anes-
politics than variation in the competence of
· The American Medical Association op-
thetists.40
physician assistants across states.
Licensing and scope-of-practice laws give
poses assessment and diagnosis of clinical
the medical professions considerable control
and laboratory data by PhD clinical lab
over whether other professions may compete
· Medical societies in California and
scientists.41
with them. That frequently slows the spread
of affordable care. Consumers are worse off if
Idaho amended naturopaths' scope of
licensure and scope of practice laws unneces-
practice to require physician supervi-
sarily limit access to care.
· In Missouri, certified professional mid-
sion or collaboration.42
What Value Does
wives aspire to work independent of
· Despite physicians' concerns about safe-
physician collaboration.43
Licensing Add?
State licensing boards' duties include
ty, California decided to expand the
checking the credentials of medical profes-
scope of practice for oral and maxillofa-
sionals, disciplining errant practitioners, and
cial surgeons to include elective facelifts,
6