One-sided arguments

When I read the debate “Should prescribing authority be shared with nonphysicians,”1,2 I was disappointed to see unilateral statements by 2 different professionals without either acknowledging health system limitations or addressing the concerns of both sides. Historically, and not only in Canada, this debate evolved from government policies developed because of a lack of physicians in some areas, work-related strain of practising physicians in others, and inadequate financial remuneration for health care providers. In fact these issues are present even today. At the same time, the nursing profession was actively trying to evolve from a purely clinical to an academic discipline, thus expanding its scope of knowledge and practice. To resolve physician shortages, governments therefore came up with a less expensive solution that was widely supported by the nursing community—the establishment of independent nurse practitioners who could replace or assist physicians in specific areas, such as surgical assistance, anesthesia, and primary care. In recent years, debate over prescribing privileges has expanded beyond nurse practitioners and physician assistants to pharmacists, who are also considered able to perform different procedures and prescribe medications within their scope of practice.

This issue is widely debated outside the physician community as well. Before addressing the main question we need to see what drives this debate on each side. Nurses and other paramedical professionals might be interested in expanding their prescribing ability to limit the need for physician supervision, and pharmacists could be interested in bypassing intermediaries when renewing chronic medications to minimize their historical dependence on prescribers. Physicians, who are under pressure to relinquish their sole right to prescribe to other medical professionals, are facing multiple dilemmas: Should anyone else prescribe? Who should be allowed to prescribe? What are they allowed to prescribe? Who will want to prescribe in the future? How much will it affect physicians in the future (specifically primary care physicians)?

First of all, let’s ask the question correctly. It is no longer an issue of if other medical professionals should prescribe but rather who among them should prescribe and what their scope of practice should be. It is a fact that nurse practitioners are here to stay and contribute to the provision of primary and specialized care in many underserviced areas and collaborative teams. Other health professionals, such as chiropractors, physiotherapists, and respiratory technicians, have specialized medical education and therefore do not have enough knowledge of other medical disciplines to be able to prescribe. Pharmacists have broad knowledge of medications and their indications, but don’t have the knowledge necessary to diagnose or monitor multisystem diseases. Further, pharmacists have exclusive rights to sell medications, which creates a conflict of interest and presents ethical issues with respect to prescribing or advising patients on medication; therefore, they should not be allowed to prescribe. This conflict of interest is even evident now when pharmacists actively advise on over-the-counter medications for the common cold, despite the fact that such medications have been described as having no benefit.3

In summary, it is clear that the trend in health care is to expand the scope of practice of different medical professions; however, in the rush of cutting corners and saving money many issues might be overlooked. Therefore, governments should consult with physicians’ associations before making decisions about whether to expand the scopes of practice of other medical professionals.

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