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| Diagnosis Dilemma |
| Columns - On the Web | ||||||||
| Written by Stuart Gitlow, MD | ||||||||
| Wednesday, 11 April 2007 | ||||||||
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Some months ago within this column, we briefly tried to distinguish
between medical and non-medical treatment of patients with addiction.
What are the differences, we asked, between treatment provided by
physicians and treatment provided by non-physicians. Many of you wrote
that you felt all of us are working together to achieve a goal of
abstinence and recovery, that you essentially support the concept of a
multidisciplinary team in which each participant brings something
valuable and useful to the table. Indeed, the medical field has over
the past years embraced this concept through what the physicians in a
somewhat narcissistic manner refer to as physician extenders.
On the one hand, physicians embrace the multidisciplinary team concept as it brings greater value to patients, but on the other hand they find themselves growing resentful and concerned as an increasing percentage of the treatment takes place outside their offices. As a result, physicians have been working to clearly define their scope of practice, often in parallel with other professions actively working along the same lines of thought. As the American Medical Association (AMA) put it in Health Trends 2006, “The scope of practice of non-physician providers continues to expand. States have granted a wide range of prerogatives to non-physician providers.” These prerogatives have been noted as “encompassing levels of care that can be categorized as routine general care.” Part of the issue is, of course, economic. There is a percentage of the healthcare dollar that is being used to fund actual healthcare. This percentage has been whittled away in recent years, with increasing percentages going to administrative overhead, third parties that didn’t even exist decades ago, government oversight, technological and pharmacological advances, and the greater expenses required for longer periods of end-of-life care. The remaining small fraction of the healthcare dollar has then been divided among an ever-increasing number of professionals indicating that they have expertise in treatment of any given illness. So in part, we have physicians trying to retain what has traditionally been the source of their income stream; and we have other professionals trying to gain access to this income stream. There is also the argument that physicians are trying to protect their patients by ensuring a high quality of medical care at the same time that others are suggesting that their quality of care is at least equivalent. How does all this play out in the addiction treatment field? Here, physicians have for the most part ignored those with the disease; the majority of treatment for addiction takes place outside physician’s offices and fellowship programs in addiction psychiatry go unfilled each year. Addictive disease is therefore one of the few illnesses in which the typical community standard does not reflect treatment-by-physician. The AMA passed new policy in November stating that the act of diagnosing a patient represents part of the practice of medicine. This policy arose, in fact, with issues that are totally outside addiction and mental health, stemming in part from lab test interpretation issues. In the past, when the AMA has declared some activity to be the practice of medicine, laws and regulations have changed in response. For example, several years ago, the AMA created new policy indicating that medical expert testimony represents the practice of medicine. As a result, medical experts are now required to hold state licensure in some states where they might have otherwise testified without such a license. They are now held to standards by that state’s medical licensing board that might not have otherwise been applicable. And they can be held accountable where previously they could not have been. Rather than simply providing opinion, the legal standard for expert testimony, they are now practicing medicine. The AMA policy on medical expert testimony does not apply to, say, social workers. If a social worker provides testimony, such testimony would represent social work expertise, not medical expertise. However, the AMA policy on diagnosis applies to all. If any non-physician sees a patient and formulates a medical diagnosis (e.g. cocaine dependence), that individual has now practiced medicine without a license – at least according to the AMA’s new policy. Depending upon the extent to which state medical boards adopt this new policy, and depending upon the degree to which these boards cooperate with the equivalent licensing board for other professions — such as those for psychologists, nurses, and social workers — and further depending upon the degree to which liability coverage providers accept this new policy, non-physician clinicians could find themselves in turbulent waters with respect to the diagnostic process. Interestingly, in some states, if a medical licensing board receives a complaint of a non-physician clinician practicing medicine, the board will refer the complaint to the clinician’s oversight board for action. It is then up to the nursing board or social work board to make a determination as to whether the individual is acting outside the allowable scope of practice. Physicians are beginning to recognize that this has led to significant erosion of what they can uniquely offer since other license boards are expanding their allowable scope of practice. I expect that changes will be called for by the physician community over the coming years. Solutions to the diagnosis policy could range from the provision of physician oversight for all diagnostic activities to the development of new diagnostic manuals for other professions. There would then be a social work diagnosis or a psychological diagnosis in addition to the medical diagnosis, a problematic solution at the least. The AMA works on policy issues through its House of Delegates meetings in June and November. There could easily be amendments offered by way of resolutions to that body. Do you have ideas as to what might be a workable solution? Send me an email at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it and let’s see if we can figure out a rational approach. Note: Dr. Gitlow is Chair of the Alcohol & Health Task Force of the American Medical Association. This column represents his personal opinion and does not imply any position or policy taken by the AMA.
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