Diversity and consistency: the challenge of maintaining quality in a multidisciplinary workforce

Non-physician clinicians have become prominent providers of patient services within the practice of medicine. They include nurse practitioners and clinical nurse specialists, physician assistants, the alternative and complementary disciplines (chiropractic, naturopathy and acupuncture), mental health providers (psychologists, clinical social workers, counsellors and therapists) and specialty disciplines (optometrists, podiatrists, nurse anaesthetists and nurse-midwives). Although these various disciplines have differing histories and philosophic frameworks, which create distinctive approaches to patient care, they have shared a struggle to obtain recognition and autonomy through state licensure, to expand their state-granted practice prerogatives and to achieve broader reimbursement from third-party payers and managed care. Most entered into a growth spurt beginning in the early 1990s. All now provide care that not only overlaps that of physicians but that complements and supplements that care. The central question is, how does their care contribute to quality? The evidence thus far shows that non-physician clinicians throughout the range of disciplines can produce high-quality outcomes under particular circumstances. However, the strongest body of evidence is derived from care that is at the least complex end of the clinical spectrum or that is provided under the umbrella of physicians. Unfortunately, few studies have critically examined the outcomes of non-physician clinicians at the leading edge of their practice prerogatives and under conditions that are free of physician oversight. Thus, while the principle that they can deliver high quality care within the practice of medicine is unequivocally true, more research is needed to test this principle under conditions of greater clinical complexity and autonomy, and, pending the results of such research, caution must be exercised in applying this principle too broadly.