Definition of practice of medicine—A person is practicing medicine if he does one or more of the following:

  1. Offers or undertakes to diagnose, cure, advise or prescribe for any human disease, ailment, injury, infirmity, deformity, pain or other condition, physical or mental, real or imaginary, by any means or instrumentality;

  2. Administers or prescribes drugs or medicinal preparations to be used by any other person;

  3. Severs or penetrates the tissues of human beings.6

The breadth of definitions such as this was remarkable in itself, but the real mischief was accomplished through corresponding provisions making it illegal for anyone not licensed as a physician to undertake any of the acts included in the definition. The claim staked by medicine was thereby rendered not only universal but (in medicine’s own view) exclusive,7 a preemption of the field that was further codified when physicians obtained statutory authority to control the activities of other health care providers “so as to limit what they could do and to supervise or direct their activities” (Freidson, 1970). Not that long ago, for example, even registered professional nurses could not perform such basic tasks as taking blood pressure, starting an IV, or drawing blood unless under a physician’s “order.” Absent such a directive, they would have been deemed to be practicing medicine by “diagnosing” or “penetrating the tissues of human beings.” (The full reach of the latter provision is further illustrated by the fact that, well into the 1970s, only physicians were permitted to pierce ears.)

Present-day consequences: competence, authority, and the disjunction between “can” and “may” Even though some of the more striking manifestations of this “everything is medicine” approach have gone by the wayside, the authority to supervise or direct other providers, combined with the authority to “delegate” medical procedures and tasks to nonphysicians, persists to this day. It underpins the legislative infrastructure that continues to subvert even the best efforts to develop a rational, effective scheme that promotes the highest and best use of all trained providers, especially those—like APNs—who seek to practice to the full extent of their competencies. No matter what their training, experience, and abilities, as noted earlier, they are perpetually in the position of having to carve out tasks or functions from the all-encompassing medical scope of practice that still prevails in every state. And even after the carving out has been accomplished, it is often accompanied by mandatory physician supervision or collaboration. In this way, the pervasive medical practice acts “exert a gravitational force that


Rev. Code Washington §18.71.011 (1)-(3) (1993).


Sociologist Eliot Freidson has aptly characterized this statutory preemption as “the exclusive right to practice” (Freidson, 1970).

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