Marcus Welby, PA.

• Author: Workman, James
• Position: Physician's assistant

You're sitting at Popeye's with your sister, plowing through a bucket of fried chicken, when suddenly she begins to Sometimes the best doctor isn't a doctor at all choke on a gob of fat. Before your eyes, her face turns the color of a bruise. Fortunately, you do not panic. You're a registered nurse; you know the Heimlich maneuver like you know white oxfords. Wrapping your arms around her torso, you prepare to render a life-saving squeeze....

Stop right there, mister. You're technically breaking medical laws in at least 37 states.

According to rules of most states' medical boards, using the Heimlich hug involves both "diagnosis" and "treatment" of a patient. Thus, if you're not an M.D.-if you haven't successfully completed four years of med school-your maneuver could actually get you sued for malpractice. And it's not just the Heimlich. Thanks to the relentless credentialism and formidable power of American doctors, in some states you're technically required to have years of expensive, specialized schooling before you perform such IQ-strainers as CPR or a Pap smear.

As necessary as doctors are to the physical well-being of Americans, much of what we've been paying them to do could easily be done outside the Hippocratic realm by thousands of ready and willing professionals trained to provide basic health care to patients. From Canada to the Netherlands to the Soviet Union, nurse practitioners (NPs) and physician's assistants (PAs) have been successfully clamping valves, treating fevers, and doing mammograms for 20 years at a lower cost to patients than a visit to an M.D. Here in the United States-where, ironically, those professions were invented in the sixties-conservative estimates are that increased reliance on alternative practitioners would save us about $90 billion each year in medical costs alone. But as other countries embrace our savvy innovation as a routine aspect of medical protocol, U.S. doctors have successfully contained its money-saving potential through a sweet confluence of regulatory authority and financial self-interest. In short, doctors write the rules under which all other medical practitioners operate.

Here's how it works. Say you have a pimple on your nose and you'd like a professional to pop it. Under the District of Columbia's medical laws-scripted by a doctor-dominated committee-a pimple" is defined as a "blemish," and a "blemish" is defined as an illness. That means the only person legally capable of diagnosing and treating it is a doctor. By performing similar semantic gymnastics, the New Jersey Medical Society has blocked PAs from using relatively simple technologies like ultrasound and kidney dialysis equipment; the Massachusetts Medical Society has helped defeat new legislation that would allow pharmacists to offer free blood-pressure testing; and other states have prevented the expansion of alternative care practitioners' hospital privileges and their authority to prescribe drugs or authorize direct insurance reimbursements. And occasionally-as happened last year in Montana-doctors have even fought to put their competitors out of business.

Until the winter of 1990, six nurses from St. Peter's Hospital Hospice in rural Helena routinely administered care to terminally ill patients-care that included handing out painkillers in the night-time hours after the pharmacy had closed and the resident physicians had vanished. For their efforts, the six were prosecuted by the state attorney general's office and the Montana Professional Licensing Bureau on charges ranging from "gross negligence" to potential homicide. Legal barriers like these are one...