Nonphysician providers and limited-license practitioners: scope-of-practice issues.

The medical community recognizes that nonphysician providers are attempting to position themselves to assume larger, more independent roles in the new health care system. The American Medical Association (AMA) addressed this issue at its 1993 annual meeting of the house of delegates with the adoption of a resolution to study the role of mid-level practitioners. A report responding to the resolution was presented at the AMA's 1993 interim meeting of the house of delegates. The focus of the report was solely on the scope of practice of nurses; PAs were not included because they work under the supervision of physicians by law, and the American Academy of Physician Assistants has declared that it has no intention of seeking independent practice from physicians. The report reviews the qualifications and roles of a variety of APNs, and determines that "care by physicians does not equate to care delivered by nurses, allied health professionals, or nontraditional caregivers." It also states that substitution of physician care by nonphysicians raises questions of patient safety, competence of therapeutic decision, and fragmentation of care. The AMA report concludes that "physician care is based on cognitive and technical skills that are shaped by a unique education and experiences to form a foundation of clinical knowledge that allows physicians to decide what needs to be done across the wide variety of human maladies; that is irreplaceable by anyone with lesser training."