During the past decade, many primary care physicians have discovered that much of their work can be done quite well by nonphysicians. Consequently, there has been a steady growth of training and employment opportunities for nonphysician clinicians (a generic term for physicians' extenders, physicians' assistants, and nurse practitioners). Although the nonphysician clinician usually works under the supervision of a physician, two thirds of the patient contacts in the primary care setting may be managed without directly involving a physician.1,2 In some states, a patient contact managed by a nonphysician clinician is reimbursed by third parties for the full fee customarily charged by a physician, implying that society places the same value on certain diagnostic and therapeutic services, regardless of the training of the direct provider of the service. Since this implicit societal judgment may have considerable effect on health care costs, the quality of these services as provided by
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