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The right to exercise independent medical judgment separates physicians from nonphysician personnel. This is a statutory distinction; the right to practice medicine is defined and granted by the state government. That is, the state may restrict acts of medical practice to physicians, allow them to be performed by other medical personnel, or forbid anyone to perform certain of them. States follow a common path and define medical practice functionally. Physicians are defined according to what they are given the exclusive right to do--for example, performing a procedure, writing a prescription, or making a diagnosis. A functional definition, however, does not define the practice of medicine sufficiently clearly to establish which acts can be delegated and which cannot.

In medicine, independently observable phenomena are called signs, as distinguished from symptoms, which are reported by the patient. Much of medicine is practiced on the assumption that these objective phenomena can be categorized and measured as accurately by nonphysician personnel as by physicians. This is certainly true of phenomena such as blood pressure and temperature, which can be measured and recorded unambiguously by nonphysician, or even lay, personnel. But if the phenomena being observed are not easily quantified, the training and biases of the observer begin to affect the consistency of the observations. Medicine contributes further to this ambiguity by using terms of diagnosis interchangeably with terms of description. For example, hypertension is both a disease process and the state of having a higher than normal blood pressure.

Making observations often involves the exercise of medical judgment. When a medical care provider examines a patient's throat, the provider must decide whether the throat displays objective signs of illness. This is simple in extreme cases of raging tonsillitis, but in more ambiguous cases, the provider must exercise judgment to decide whether the patient's throat should be recorded as normal or diseased. These expert observations blur the distinction between objective information and medical decision making. Physicians may delegate the task of making expert observations to nonphysician personnel, but the delegating physician retains responsibility for the accuracy of the observations. Physicians should not delegate diagnostic or therapeutic decisions that require analysis beyond the application of the rules in a strict protocol.

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