Tug-of-War Over Prescription Powers : Health: Pharmacists, nurses and other non-doctors want the authority to prescribe drugs. Others insist only physicians have the training to do so safely.

Many of California’s 7,000 optometrists would love to prescribe medications for patients with eye problems.

But, right now optometrists have to refer patients in need of prescription drugs to ophthalmologists. Likewise, nurse-midwives must turn to obstetricians, while psychologists turn to psychiatrists.

Increasingly, however, nurses, optometrists, psychologists, physician assistants and pharmacists are asking why they can’t perform this task without permission from medical doctors. They are seeking--and in some states winning--prescription privileges.

The trend concerns physicians, who fear patients may be harmed and physicians may lose their identity as well as some income. But some observers say, like it or not, the emphasis on cost-effective primary care proposed by the Clinton task force on health reform favors using other professions to perform basic health-care functions like prescribing drugs.

Nurses, optometrists, psychologists, as well as pharmacists and physician’s assistants, contend that they can save precious health-care dollars if they can write prescriptions for basic illnesses and health problems, thereby saving a patient a trip to the doctor’s office.

“This is part of the larger debate on health-care reform,” says Joan Meehan, a spokeswoman for the American Nurses Assn., which is lobbying hard for some nursing specialties--such as nurse-midwives and nurse practitioners--to gain the privilege. “If you’re looking at increasing access to care and containing costs, allowing others to prescribe is a key part of that.”

At the California Medical Assn. in San Francisco, officials are gearing up for what they expect will be repeated challenges to prescription privileges, which they call the “defining” characteristic of MDs.

“This is an issue that will be getting a lot of attention,” says Vonnie Gurgin of the CMA.

But Gurgin says the fundamental question before state lawmakers will be: Can these other health professionals be as responsible and effective as physicians at the task?

“There is a paucity of research on this question, and that makes the issue problematic. There is a lot of anecdotal evidence. But that’s not scientific evidence.”

Although the challenge to prescription privileges has been met with great opposition by physicians in California, other states are doling out the prescription pads to non-medical doctors.

Besides medical doctors, podiatrists and dentists can prescribe drugs in all 50 states, says Tom Marra, a psychologist in Monterey who is a leader in the fight for prescription privileges. Optometrists in all but five states now have prescription privileges.

Nurses are quickly gaining ground, with 43 states now allowing nurse-practitioners to prescribe with varying degrees of autonomy. Some nurses in California have a limited prescription authority; they can write prescriptions for some medication as long as a physician’s name is printed on the prescription.

Nationally, pharmacists are also making a bid to prescribe a limited class of drugs. Florida, for example, allows pharmacists to prescribe certain drugs and other states are considering similar legislation.

Psychologists have not won the right to prescribe in any state, except for some authorized pilot studies. But the California Psychological Assn. will introduce a bill next year for the privilege. State optometrists, who have been unsuccessful in an attempt to pass such legislation this session, are also expected to keep trying.

In almost every case, supporters also argue if physicians are not providing care where it’s needed, such as in rural areas where there are gross shortages of doctors, other health professionals should be allowed to do so.

“If we’re going to provide quality care and there is no one else out there in rural America doing it, (legislators) are going to change the statutes to allow us to do that,” says Patrick H. DeLeon, an aide to Sen. Daniel Inouye (D-Hawaii).

But physicians say the argument is not about turf--it’s about what’s best for the public’s health.

Professionals such as optometrists and psychologists do not have enough training to effectively prescribe medications, physicians say. Even the training courses and extra graduate-level education these groups are proposing to learn pharmacology will be insufficient, say the MDs.

Each group goes through four years of graduate school. Optometrists contend that their education is sufficient. Ophthalmologists say their post-medical school years--internships and residencies--provide the best training for prescribing drugs.

“I think that you have to look at the distinctions in educational requirements,” says the CMA’s Gurgin. “There is an extraordinarily large difference. Physicians can make mistakes. That’s bad enough. What happens if people who aren’t as well-trained are put in positions that physicians are now?”

Physicians point to a recent Washington state study that showed patients treated by optometrists after cataract surgery fare worse than patients treated by ophthalmologists.

Physicians have training in all the body’s systems and can provide more comprehensive care. For example, says Gurgin, ophthalmologists might better understand how eye problems relate to certain diseases, such as diabetes.

“It’s always going to be a public-health argument: that we should not have prescription privileges because we did not go to medical school,” says DeLeon. “But prescription privileges is no big deal. It’s like learning how to use a desk-top computer.”

Others disagree. Some psychologists have resisted their profession’s move toward prescription privileges because of the complexity involved.

“People assume that prescribing psychotropic drugs for mentally ill people is a well-developed and scientifically based method of treatment. Well, that is not true,” says Victor D. Sanua, a New York psychologist who opposes the change.

Physicians also challenge the other health professions’ claims that they can provide services and prescriptions cheaper.

“My sense is any dollar savings would be temporary,” says Gurgin.

While California optometrists have been dealt a setback in their quest, psychologists say they are not discouraged. Leaders of both professions say it may take several years to win prescription privileges.

While optometrists sought prescription privileges for all optometrists, psychologists will be more conservative, seeking the privilege only for certain specialists, Marra says.

“We will recommend that significant training, education and supervision by MDs would be required before specially certified psychologists would be able to prescribe,” Marra says.

The shift toward viewing mental disorders as biologically based illnesses demands that psychologists learn how to use psychotropic medications--those used for mental disorders--to fully treat certain patients, they say.

Yet in one survey, only 17% of the prescriptions for psychotropic medications were written by psychiatrists. The remainder, says Marra, were written by MDs “with the least amount of training in mental health.”

Although California has been more conservative than other states in extending prescription privileges, one of the most convincing studies favoring the trend was carried out in California, DeLeon notes.

In the early 1980s the state Department of Health Planning and Development provided 16 to 95 hours of training to various health practitioners including nurses, physician’s assistants and pharmacists. These practitioners treated 1 million patients over three years, including prescribing drugs to half of them. The state concluded that they not only treated their patients very effectively and safely, but not using physicians saved about $2 million.

“The quality of care was excellent. The patient satisfaction rate was 98%,” says DeLeon. “People can learn this task very quickly and very well.”