Commentry on “The Changing Medical Division of Labor”

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IN the 40 years since the establishment of The Journal of Ambulatory Care Management, much has changed in health care and the health care workforce. Organizational consolidation across previously freestanding institutions and autonomous office-based medical practices has resulted in a shift in more power to executive management and a loss of power for physicians (Pool, 1991). New occupations in health care have exploded, and many of the “allied” health care professions, including psychologists, pharmacists, and physical therapists, have increased their educational qualifications to the doctorate level, thus broadening their scope of practice and recognition by insurers for direct billing of their professional fees. There is less and less public policy support for physicians' territorial claims over all medical work, and more interest in all health care professionals working to the top of their licenses, thus returning greater value to consumers.
Nurses have fared particularly well in the changing medical division of labor, substantially expanding their sphere of influence, scope of practice, economic welfare, and public and professional stature. Nurses have been ranked highest among the professions in honesty and ethics for 15 consecutive years by the Gallup Poll (Norman, 2016). The loss of autonomy of physicians due to organizational consolidation has accrued to the benefit of nurses, and they have not ceded much authority to the multiplicity of health care occupations that have proliferated over the past several decades. Indeed, nurses are the most likely nonphysicians to lead team care delivery models, take on executive managerial responsibilities in service delivery organizations including in some of the nation's leading hospitals, and to be represented in leadership roles in public policy and private sector health care–related organizations. Besides physicians, nurses are the only health care professionals with the expertise to care for the full range of patient conditions in health services, including the most seriously ill and the well, and every problem in between, and manage almost the full range of technological and pharmacologic treatments. Nurses' broad interests and education position them well for changing trends in population health including chronic illnesses, aging, lifesaving care for very low-birth-weight infants, and more humane options for care at the end of life. They are good team players, value interdisciplinary care, are interested in keeping patients well and helping the chronically ill manage their conditions. Because there is less perceived social distance between nurses and their patients than is the case with physicians and patients, nurses often have a better understanding of patients' wishes at critical junctures of life transitions from birth to death that occur largely in medical settings.
While nurses have long been positioned by their interests, education, and skill sets to expand their influence in the evolving medical division of labor, it was the enactment of Medicare in 1965 that profoundly altered the professional trajectory of American nursing. Universal health insurance for older adults in combination with generous Medicare “cost plus” reimbursement increased demand for health care and produced a substantial increase in good jobs for graduate nurses, especially in hospitals that had long been staffed largely by student nurses and assistive personnel. The accompanying federal National Nurse Training Act to prevent a nurse shortage leveraged an expansion in baccalaureate and graduate nursing education, including advanced clinical training for nurses in primary care, thus giving nurses the formal education to qualify for advanced clinical and managerial roles (Lynaugh, 2008). Pay increases following the introduction of Medicare set the pace for future earnings, with nurses today earning 40% more than those in the general economy with comparable education (Glied et al., 2015).

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