Collaboration seen as key to the future

Only through working together with nonphysician practitioners can medicine maintain its preeminence and avert the spread of nonscientific alternatives, says futurist Jeffrey C. Bauer, PhD.

By Bonnie Booth, amednews staff. Feb. 7, 2000.

AMA Executive Vice President E. Ratcliffe Anderson Jr., MD, is fond of telling leaders of physician specialty groups that the time has come to circle the wagons and shoot outward at the enemy -- not inward at each other.

Only then, he says, can organized medicine realize its full potential.

But futurist Jeffrey C. Bauer, PhD, believes that organized medicine needs to widen that circle even further and rethink its idea of who the enemy is, if it is to win 21st-century health care battles.

"The biggest battle is going to be between scientific and nonscientific healers," said Dr. Bauer, a nationally recognized health care futurist. He shared this theory with the leaders of organized medicine during a speech he gave late last year. "I told them 'Please rethink the idea that the enemies are other scientific people.' "

And while asking nurse practitioners, nurse anesthetists, pharmacological PhDs and others viewed by some physicians as encroachers onto the practice of medicine to add their wagons to the circle is a sea change in thinking, Dr. Bauer said the AMA -- indeed all of organized medicine -- must face some cold, hard facts about the new century. As a futurist for 25 years who describes himself as a strong supporter of organized medicine, Dr. Bauer may be the best person to help physicians swallow this new medicine.

"Arguably, I am a very strong defender of allopathic and osteopathic medicine," said Dr. Bauer, who is a former full-time teacher and administrator at the University of Colorado Health Sciences Center. "Throughout the 20th century, nobody knew more than physicians: No one had better access, more training or better experience. They deserved to be at the top of triangle."

That position, often used as an argument for keeping other science-based providers at bay, is no longer defensible, he said, because advanced-practice nurses, physical therapists and pharmacists are trained at the same academic health centers that are training physicians.

"I am trying to open the mind of AMA leaders to collaboration with scientific competitors," he said. "The core challenge facing the AMA is to regain leadership of the defenders of scientific principles. Doing that means being willing to recognize that other people trained side by side [with physicians] can have the same skills."

Collaboration yes, independence no

He offers a gloomy scenario for organized medicine if it doesn't adopt a more collaborative stance.

"It risks being peripheral to what's happening in health care as acupuncturists, herbalists, etc. become trusted and gain the ear of patients and legislators," he said. "If all those people continue to do what they've done in state legislatures, and organized medicine becomes less in touch with people's attitudes and allows them to forget scientific foundations, they are opening a big wide hole for alternative medicine to march through."

Leaders of organized medicine groups traditionally concerned with scope-of-practice issues point out that they are not against collaboration with nonphysician health care providers -- to a point. They do take issue, however, with the idea of independent practice for nonphysicians.

"The American Society of Anesthesiologists is not against nurse anesthetists," said Ronald McKenzie, DO, the president of ASA, who practices at the Mayo Clinic in Rochester, Minn. "The key is supervision. Where we disagree with the organized nurse anesthetists is in the area of independent practice for advanced-practice nurses. We are very much opposed to that."

Supervision is also key to the American Academy of Family Physicians giving its support to nonphysician practitioners.

"We certainly believe in supporting evidence-based medicine," said AAFP President Bruce Bagley, MD, of Albany, N.Y. "Anybody who is practicing that and doing a good job is fine with us. That includes physician assistants and nurse practitioners, as long as a physician is head of the care team."

Alternative medicine is not the enemy

Dr. Bagley said he does not agree with the wholesale labeling of alternative medicine as "the enemy."

"Traditional medicine to a great extent ignores the belief system of many patients," he said. "As a physician, my belief system has to do with medications, and I can tell you to take them and it will make you feel better. But if you believe having someone stick needles in you will make you better, I cannot totally ignore that."

He added that there are cases in which acupuncture, under controlled trials, has been shown to work, giving it some evidence base.

In a sense, the plethora of medical advice and options now available through a wide variety of sources has contributed to decreasing physician preeminence, Dr. Bauer said. But it also may be that plethora of information and patients' need to know the bogus from the credible that will help physicians maintain their leadership role.

"There has been an explosion of the knowledge base, and physicians are going to maintain leadership by knowing how to find and interpret information," he said. Any physician will admit there's just too much to know now. The issue for the future is to become a competent searcher of that knowledge base and to work closely with patients who just two to three years ago could not access this information.

"Organized medicine can re-establish its credibility by making itself the source for making sure consumers get the best information," he continued. "If they don't, they will be further marginalized."

He said the AMA's new Web partnership with several specialty societies is a step in the right direction.

"The AMA could lose out if it doesn't position itself in the e-commerce world," Dr. Bauer said. "It they don't establish a meaningful position, I could see more physicians being loyal to a drkoop.com, WebMD, Medscape or Healtheon. Professional associations have to look at the e-commerce dimensions of being a leader in their field."

But he doesn't envision the people behind those Web sites providing the leadership that the AMA can.

"While I have good things to say about those competitors, they aren't a force in my mind that can go out there and coalesce all of the scientifically trained practitioners," Dr. Bauer said. They are not going to go out and do the good things that the AMA has done, defending science, trying to improve diversity, helping to define cultural competence."

Dr. Bauer, who is a senior fellow at the Center for the New West in Denver, also participates in studies of advances in medical science and technology and their impact on the delivery of health services, both nationally and internationally. He is a senior vice president of the Southfield, Mich.-based Superior Consultant Group.