Tuesday, May 1, 2012

Boundaries: Who Shall Prescribe, Order Procedures, Perform Procedures, Provide Prevention, Promote Wellness,  and  Care for the Sick?
The Great Spirit knows no boundaries, nor will his red children acknowledge any.
Tecumseh(1768-1813), American Indian Chief, message to Joseph Brennan message to President James Madison (1810)
The boundaries between health care and medicine are more and more  vague and shadowy.
Through my broad experience as a nurse, physician, and medical administrator, it has become clear that the most influential factors in the health of my patients are not primarily addressed within the walls of the health delivery system.
Bonnie Zell, MD, Principal, Zell Community Health Studies, San Francisco, “For Health Reform Success, Context Matters,”  Prescription for Excellence, Spring, 2012

May 1, 2012 -  It’s May Day – a traditional holiday in many countries , a holiday  for International Workers,  and the name for a distress signal among radio and IT communicators.
For me, it’s a day to discuss the distressing situation of  boundaries  between health and disease and those who control and patrol those boundaries.  

Boundaries of Health and Disease
As anybody with any sense of context knows,  the boundaries are vague and shadowy.   What and who determines the boundaries between health and disease, between premature death and a long and healthy life, free of disease until near the end? 

Five Factors
What follows  are five  factors that determine  who shall live and who shall die and when and how (M. McGinnis, P. Williams-Russo, JR Knickman. “The Case for More Active Policy Attention to Health Promotion,” Health Affairs,  Volume 21, Number 2, pages 78-93, 2002). 
--Behavior patterns  40%

-    --Genetic predisposition  30%

·         --Social circumstances  15%

·         --  Medical care  10%

·       --  Environmental exposure  5%


These factors overlap.  Most are outside the jurisdiction and control of physicians.   Most occur outside hospital and physician office settings.  
By rewarding a grant of $1 million to Health Leaders, Inc., a Boston-based health organization, the Physicians Foundation, a non-profit representing 17 state and country medical societies,  has begun  to cross the boundaries of care.  Health Leaders has created “health desks,” in  medical clinics and hospitals, manned by college volunteers,  most of whom are seeking health care careers,  that allows physicians to “prescribe” access to essential social services like access to food stamps, at home medical advice, job training, medical transportation, and housing.   
But beyond this type of activity and being part of organizations providing  nursing and other professional services to patients in their homes and at work, there is little physicians can do to alter behavioral patterns, genetic predispositions, social circumstances, and environmental hazards.

Scope of Practice
This bring to scope of practice issues. Historically, physicians have had a dominant role in prescribing drugs, ordering procedures, performing procedures, and otherwise caring for the sick.  However, with looming physician shortages,  expanding  care to millions more Medicare and Medicaid recipients,  more intensive training of other health professionals, and health reform with more government programs to promote population health , doctor dominance is receding and boundaries of who shall care for the sick are shifting. 
Scope of practice is a terminology used by national and regional licensing boards for various professions to define procedures, actions, and process permitted for a licensed individual.   The scope of practice is limited to what the law allows for specific education and experience and specific demonstrated competence.   Each specific jurisdiction has laws,  licensing bodies, and regulations to design requirements and training and define scope of practice.
In the present state of flux in  health reform – with concern over escalating costs,  exploding use of health information technologies,  massive government intervention into practices, more public use of alternative care practitioners,  and  fear of widespread physician shortages,  scope of practice issues have surfaced and raised fundamental questions. 

Questions of Scope of Practice
Should pharmacists, naturopaths,   nurse practitioners,   physician assistants,  psychologists,  optometrists, and other medical paraprofessionals be allowed to prescribe and perform procedures?   Should chiropractors have the right to order imaging procedures? And if so, how much and under what circumstances? 
These are not easy issues to resolve.   The issues often depend on the lobbying and financial clout of those professions seeking to expand their scope of practice. 
Tweet:  As physician shortages grow and pressures mount to reform, expand, and improve health care, other health professionals are expanding their scope of practice.

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