Wednesday, November 3, 2010

"Practice At Top Of License" - The Newest Phrase in Dog Whistle Politics

The Disease Management Care Blog remains fascinated - if irritated - by the lingering pestilence of "dog whistle" politics. Readers may recall that this is the use of otherwise innocent sounding rhetoric that conveys deeper meaning that is only "audible" to a tuned-in constituency. So, when the DMCB announces that it supports cinematic art that explores the impermanence of life, the clued-in DMCB spouse quickly discerns this is really all about watching vulgar zombie movies.

One juicy health care dog whistle that's emerging is the phrase "practice at the top of license" as applied to non-physician professionals. To most people, this is interpreted to mean that nurses, pharmacists, optometrists, podiatrists and other health professionals should be able to care for patients at a level commensurate with their training and local State law. Ask an attuned and politically savvy nurse, pharmacist, optometrist or podiatrist what that really means, and you'll get a different answer: this means that they should be able to independently take care of and prescribe treatments for patients without doctor oversight.

Not much seems to be actually written about this (for example), which leads the DMCB to think that only makes it more deniable. It has certainly heard that phrase from many speakers at many conferences on the topic of primary care, access, manpower, patient centered medical homes and accountable care organizations.

This isn't going to be a small issue. Other than the eternally irksome topic of the Medicare sustainable growth rate, there is probably no other issue that is more likely to vex the organized physician groups. For the latest example of this, contrast the Institute of Medicine Report Brief on The Future of Nursing (the phrase here is a similar dog whistle "practice to the full extent of their education and training") with the response of the American College of Physicians: "Physicians and nurses complete training with different levels of knowledge, skills, and abilities that are complementary but not equivalent."

The DMCB appreciates both sides of the issue, which may be suitable for a future post. The important issue here, however, is that the same dog whistle contagion that infected reform ("cover all Americans" really being interpreted as the government option, "provider efficiency" meaning economic credentialing of doctors and the "Patient Bill of Rights" meaning "please forgive us for passing this ugly bill") continues to cheapen what should be an ongoing, open and civil health care debate that brings credit to our Republic.

The next time the DMCB hears the term, it's going to call the speaker out. The topic deserves to be examined in the light of day.

Image from Wikipedia


GlassHospital said...

You can fool some of the people some of the time, but you clearly can't fool the DMCB wife.

Bradley Dean Stephan said...

Yes, I like the "dog whistle" adjective and it is certainly apt, here. But, I would also contend that an astute and opened-minded physician, who is living under a shared-risk, accountable health program contract, would heartily concur with the "top of the license" sentiment, as his or her financial responsibility can now be partially assumed by a lower-cost professional.

Jaan Sidorov said...

Hey bradleydean: I ran the dog whistle past another nurse, and she agreed with me too.

It will be interesting to see how physicians in physician-owned practices will cooperate with ACOs that use the dog whistle to posture their primary care networks.