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State and federal laws governing the delegation of authority to nonphysician personnel are much more restrictive than medical practice would indicate. These laws include medical practice acts, state and federal controlled substances laws, administrative rules governing protocol-oriented quality assurance activities, and laws and regulations limiting physician reimbursement for work performed by nonphysician personnel. Physician extenders resist these rules because their training creates the expectation that they will be able to operate as autonomous professionals. Physicians tend to overdelegate authority because it allows them to have more patients go through offices. However, this natural reaction to the pressure to deliver cost-effective medical care can compromise the quality of medical care if the PEs are not carefully managed through direct supervision and formal protocols.

The most probable consequence of improperly delegating authority to nonphysician personnel is a medical malpractice lawsuit. The general legal rule is that a physician may delegate authority but not responsibility to nonphysician personnel. Physicians always remain legally liable for the actions of personnel under their control. (See the section on employment in Chapter 6.) This keeps the insurance rates for nonphysician personnel artificially low, masking the real risks of improper delegation.

Improper delegation of authority is grounds for limiting or terminating a physician's license, although very few boards of medical examiners enforce the rules against improper delegation of authority or unauthorized practice of medicine by nonphysician personnel. This is expected to change as the federal government pressures the states to improve the regulation of medical practice. The most likely enforcement action will come from the state board of pharmacy, the federal Drug Enforcement Administration, or the Health Care Financing Administration. These agencies can recommend that action be taken against the physician's license, but they are more likely to bring a civil or criminal prosecution against the physician.

Aggressive delegation of authority is a symptom of deeper philosophical problems in medical care delivery. Some groups oppose physician-dominated medical care in favor of quasi-scientific schools of natural healing. Some PEs strive for greater autonomy, reflecting expectations garnered in training programs. Employers and others seeking to lower the cost of medical care assume that using PEs more will be cheaper than relying on physicians. Most sympathetically, advocates of reducing restrictions on delegation of authority point to the potential benefit to rural communities.

There is little evidence that the extensive use of autonomous PEs (as opposed to supervised PEs working off proper protocols) reduces the cost or increases the availability of medical care. In most practices, PEs are used to allow physicians to spend more time on costly procedures and less on routine, inexpensive patient evaluation. The systems that have the most difficulty in supervising PEs are those that use several PEs to each physician in one office. These are nearly always urban or suburban practices. Rural practices cannot generate the patient flow to support practices with several PEs per physician.

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