General Public Lack of Awareness

Another result of the history deriving from our all-encompassing medical practice acts is the fact that the general public almost reflexively associates health care with physicians. Although nursing functions have existed for millennia, the formal development and legal recognition of APNs as a distinct professional group has occurred only in the past 40–50 years. Thus, though the public is increasingly familiar with provider titles such as nurse practitioner, nurse-midwife and nurse anesthetist, it is still “doctor” who “knows best.” As the prominent medical sociologist Eliot Freidson has noted, “health services” as understood in the United States “are organized around professional authority, and their basic structure is constituted by the dominance of a single profession [medicine] over a variety of other, subordinate occupations.”9 This construct, which underpins the continued centrality of “doctor” and “physician” in the popular culture, prevents the public from forming an accurate perception of the many and diverse types of essential health care providers and their spheres of competence. Instead, misperceptions are reinforced by mass media marketing messages—for example, those declaring that “only your doctor can prescribe” a drug, when, in fact, APNs in a majority of the states can and do legally prescribe that drug on their own license. Of course, this misperception is both the result of, and sustained by, laws that require a physician’s name to be listed on the label for a prescription written by an APN, or require a bill for APN services to be submitted in the physician’s name.

Of the three impediments to reform that I have identified, this lack of understanding on the part of the general public is clearly the most amorphous. It is a

ments on “Family Physicians Scope of Practice”:

“It is the position of the American Academy of Family Physicians (AAFP) that clinical privileges should be based on the individual physician’s documented training and/or experience, demonstrated abilities and current competence, and not on the physician’s specialty” (AAFP, 2010).

The American Medical Association (AMA) holds a similar position. Regarding clinical privileges, the 1998 AMA Policy Compendium states, “The accordance and delineation of privileges should be determined on an individual basis, commensurate with an applicant’s education, training and experience, and demonstrated current competence.” It also states that “[i]n implementing these criteria, each facility should formulate and apply reasonable non-discriminatory standards for the evaluation of an applicant’s credentials, free of anti-competitive intent or purpose” (AMA, 1998).

“AAFP strongly believes that all medical staff members should realize that there is overlap between specialties and that no one department has exclusive ‘rights’ to privileges” (AAFP, 2010).


He goes on to add that “[this] professional dominance is the analytical key to the present inadequacy of the health services.” Eliot Freidson, Professional Dominance: the Social Structure of Medical Care (1970). For an especially insightful analysis of the development of the cultural, economic, political, and social authority and dominance of the physician, and especially of organized medicine, see Starr (1982).

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