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No Doctor? No Problem!
Managed care may have made it harder than ever to get time with an M.D., but personal medical attention hasn’t disappeared. Two new groups of providers are helping to fill the gap.
November 1999
by Magaly Olivero
Magaly Olivero wrote about the reorganization of the Undergraduate Career Services Office in the October issue of the Yale Alumni Magazine.
For generations, the image of American medical care was molded by Norman Rockwell’s paintings of kindly physicians making house calls on old folks, and television scenes of Marcus Welby ministering to croupy kids. Such rosy scenes have long since been obscured by the impersonality of managed care. But in the process, many Americans may not have noticed that one-on-one medical attention is making a comeback. It’s just that some of the people most involved in providing it don’t put M.D. after their names on the prescription forms.
As the health-care environment in America has evolved over the past 30-odd years, two groups of providers have been quietly transforming the way patients are treated. They are nurse practitioners and physician assistants (sometimes known as physician associates), and their numbers and impact are growing dramatically. Trained in the skills of diagnosis and treatment, NPs and PAs can handle much of the load that general practitioners used to account for and today’s medical specialists are often too busy to deal with. They are also trained to recognize problems that exceed their expertise and refer them to the appropriate physician. But perhaps most important, they can help bring a personal touch back to a profession that many feel has become too bureaucratic and mechanical. These professionals are transforming urgent-care centers, emergency rooms, community health centers, school-based clinics, and health maintenance organizations across the land. “Ten years ago, there were about50 institutions that trained PAs,” says Elaine E. Grant, assistant dean for Yale’s Physician Associate Program. “Now, there are 116 nationwide.”
Nowhere is the evolution more apparent than at Yale, where the School of Nursing and the School of Medicine have pioneered the training of NPs and PAs, and the Yale Health Plan, which was the first health maintenance organization in Connecticut, has made extensive use of them in looking after Yale students and employees. And the phenomenon is growing. The PA program last spring graduated its first class with a master of medical science degree. And in response to growing demand, Yale this fall created an oncology nurse practitioner master’s specialty.
The origins of these increasingly influential professions go back to the mid-1960s, when physicians and educators alike recognized that there was a growing shortage and uneven distribution of primary-care physicians, especially in rural and inner-city areas. Eugene Stead, a doctor at the Duke University Medical Center in North Carolina, is often credited with developing the physician assistant concept. Stead realized that a large percentage of his own cases did not require the care of a fully trained physician like himself, at least in the early stages, and that with a group of people looking after minor ailments, he could concentrate on the acute cases. In search of a solution, Stead approached Duke’s School of Nursing about offering advanced training to nurses. But Stead’s medical model did not appeal to the nursing administrators. So Stead turned his attention to the substantial numbers of men and women who had served as medical aides with the military during the Vietnam War. They had received intensive training during their service, but with few exceptions had no chance to use their skills in civilian life.
Largely as a result of the efforts of Stead and his like-minded colleagues, thousands of physician assistants are today licensed to practice the sort of medicine Stead originally envisioned. They are trained to diagnose and treat ailments, but they also can prescribe medication and order and interpret diagnostic tests. Graduation from an accredited program such as Yale’s, and passage of a national certifying exam, are required for state licensure. About 52 percent of the country’s physician assistants are involved in primary care, with the remaining involved in internal medicine, emergency care, and other specialties.
Nurse practitioners operate on a somewhat different model. They are registered nurses with advanced educational preparation who provide nursing and medical services, emphasizing health education and disease prevention, as well as diagnosis and management of acute and chronic diseases. According to Nanette Alexander, the president of the Connecticut Nurse Practitioner Group Inc., the history of the NP specialty is similar to that of PAs, but different in significant ways. Many of the first nurse practitioners in the country were midwives and registered nurses with advanced training in pediatrics who were assigned to care for underserved populations.
Today, pediatrics still accounts for a major portion of nurse practitioner work. A teddy bear mobile hangs in the office of Jane Milberg, a nurse practitioner in pediatrics at the Yale Health Plan, as she goes about her work. “I knew from the start that I wanted to be in pediatrics,” says Milberg, who has cared for children for two decades. “I see pediatrics as the launching pad for your whole lifetime,” she says. “You can lay the foundation for good habits and well-being—traits children can carry with them for the rest of their lives.”
Milberg, a biology and chemistry major with a doctorate in pharmacology, was conducting animal research for several years when she decided she would rather work with people. As a nurse practitioner, Milberg could combine her interest in science with her desire to “help people stay healthy and well.” She enrolled in Yale’s nurse practitioner program and began working at the Yale Health Plan right after graduation.
While she specializes in pediatrics, Milberg believes strongly in taking care of the medical, social and psychological needs of the entire family, not just the child coming in for an office visit. “No one grows in isolation,” she says, “that’s why you treat the child and the family.” That means helping children and parents get through “major family stages,” whether it’s the birth of a sibling, divorce, or the cry of independence from a teenager. Helping each family member cope with the stresses and changes taking place affects the overall health of the entire family. That’s also why patient education plays such a key role. “Our goal is to empower children and parents with enough information so they can make informed decisions and take charge of their bodies,” says Milberg.
But nurse practitioners increasingly work in a variety of other settings with people of all ages, and, like physician assistants, they too can prescribe medication and order and interpret diagnostic tests. Patient education and counseling are a major part of their activities. Yale’s program offers master’s degrees in many specialties including acute care, gerontology, adult care, oncology, and psychiatric mental health.
Reasons for the growth of each profession reflect the changes taking place in health care. Economic pressures exerted by managed care are forcing providers to look for ways to provide cost-effective, high-quality treatment to more patients. The use of physician assistants and nurse practitioners, who earn considerably less than physicians, provides a way for health-care organizations and private practices to continue providing care while keeping costs downs. According to Moreson Kaplan, medical director of the Yale Health Plan, relying on nurse practitioners and physician assistants represents a “more efficient use of people and resources,” because, as Stead recognized at Duke, many cases do not require the expertise and extensive training of a physician.
The emphasis on preventive care and patient education also helps to keep medical costs down, while assisting patients to more effectively manage their own health-care needs. Studies show that nurse practitioners are more likely to suggest lower-cost approaches—such as lifestyle changes—to deal with a particular health problem, rather than automatically prescribing medication. “It’s the difference between prescribing a pill for heartburn and talking to the patient about cutting back on the many Big Macs he eats,” says Nanette Alexander.
The holistic, family-centered approach to medicine embraced by nurse practitioners also streamlines the health-care delivery system and increases continuity of care by reducing the number of providers a patient requires. Says Paula Milone-Nuzzo, associate dean for Academic Affairs at the School of Nursing, “We look at the entire needs of the person—physical, mental, social, and spiritual. We don’t just treat the medical problem.”
The complexity of today’s health-care environment, as well as the acceleration in medical research and technology, has forced this more team-oriented approach to health care. Says John Dailinger, a physician assistant in orthopedics with the Yale Health Plan: “It’s nice to look with nostalgia to the days of the local general practitioner who took care of all your needs. But that’s not true nowadays, and anyway, it’s not really the best way to provide care in today’s environment. Medicine has grown so that nobody can do it all or do it better than a group of people with special and general skills who work together.”
There is another practical side to the growth in the population of NPs and PAs. As the number of applicants entering medical school decreases, many hospitals face the challenge of providing adequate numbers of residents and interns. Physician assistants and nurse practitioners provide a powerful alternative to fill these critical roles. Many physician assistants work in urgent care and surgery, while many nurse practitioners are concentrating on acute care. “There is a great need to have caregivers around the clock in hospital settings,” says Alexander.
Patients who may feel alienated by today’s complex medical system often appreciate the extra attention they receive from nurse practitioners and physician assistants. In general, these professionals are more apt to spend time with patients, helping them to understand their medical condition, make lifestyle changes, and navigate the health-care delivery system. Some patients inevitably feel short-changed when they are seen by someone who does not have an M.D., degree. But Dailinger thinks the positive aspects of the NP and PA alternatives outweigh the negatives. “Good medicine should leave people feeling that they have been taken care of, not processed,” he says.
For all the emphasis on team play, philosophical differences sometimes put physician assistants and nurse practitioners at odds. And despite their prevalence in numerous health-care settings, some physicians remain skeptical or even suspicious of practicing medicine with people who do not share their own training. But few would deny the benefits offered by the expansion of the care-giving cadre. Physician assistants, trained according to a medical model, actually work “under the supervision” of physicians, and tend to be more oriented toward curing a problem once it has emerged. Nurse practitioners, on the other hand, are educated using a nursing model and, according to the Connecticut Nurse Practice Act, practice in a “collaboration” with physicians that emphasizes avoiding or minimizing the problem before it becomes serious.
Needless to say, competition for jobs, as the health-care market becomes tighter, is another potential point of friction. And some physicians chafe at having their earning potential reduced by lower-paid professionals who may intercept cases that might otherwise have been billed at an M.D.’s higher rates.
All parties, however, are quick to note that physician assistants and nurse practitioners are trained to seek advice from colleagues or physicians when faced with a case beyond their reach. And in most settings, they say, nurse practitioners, physician assistants, and physicians work together in harmony, keeping the needs of the patient as their top priority. “One of our strengths lies in our ability to recognize when we need assistance,” says Molly Meyer, a nurse practitioner in undergraduate medicine and oncology at the Yale Health Plan.
Dailinger downplays the issue of “turf wars” between physician assistants and nurse practitioners who may be vying for the same openings because, as he points out, there are “plenty of jobs to go around. There’s a great need for people to do general medicine.” He cites the Yale Health Plan as an example of an organization where members of all health-care fields work as colleagues to deliver high-quality health care to patients. “Some of my closest colleagues are nurse practitioners,” says Dailinger, who lectures on orthopedic medicine and other health-related issues at Yale. He often brings students in Yale’s physician associate and nurse practitioner programs together to “discuss their goals, training, and the roles they envision for themselves. Once they start talking, they discover they share many common bonds.”
Dailinger speaks with considerable authority, having come to his present position through a route that Duke’s Eugene Stead might have prescribed himself. Dailinger says he spent his undergraduate years “making fun of the pre-med majors,” and decided to become a high school teacher. But in 1970 he was drafted. “I had no problem with serving my country,” he says, “but I refused to bear arms. That’s why they began training me as a battlefield medic.” A nationwide shortage of operating room technicians led to Dailinger’s assignment—not to combat, but to the Presidio military complex in San Francisco caring for the wounded returning home.
Once his military term ended, Dailinger decided he wanted to remain in medicine, but the prospect of juggling medical school with a home life that by then included two children wasn’t appealing. Instead, he took a job as an operating room technician at Greenwich Hospital and soon learned about the physician assistant profession from a colleague. Dailinger graduated from Yale’s program in 1976 and joined the Yale Health Plan, specializing in orthopedics.
A close colleague of Dailinger’s at the YHP, Molly Meyer illustrates the subtle differences between the PA and nurse practitioner roles. Meyer has worked as a nurse practitioner with hundreds of Yale students and employees, including many of the University’s athletes and coaches, in addition to the oncology patients served by the YHP. It’s hard to keep up with Meyer, who juggles a multitude of duties, ranging from physical exams and treating medical ailments to helping patients manage their oncology treatment and comforting concerned parents. “I view myself as a primary caregiver and a traffic cop who helps connect people with the resources they need,” she says.
Meyer was one of four registered nurses selected by the Yale Health Plan when it began to provide on-the-job training for nurse practitioners. The program was the vision of then medical director Daniel “Pete” Rowe, who believed strongly in the nurse practitioner concept. Rowe turned to Kaplan, who was then a staff doctor in internal medicine, for assistance in developing the in-house program in conjunction with the Yale School of Nursing. The Yale Health Plan originally opened with two nurse practitioners, one a midwife and one in pediatrics, but couldn’t find any NPs in the field of adult medicine. “Rowe recognized the value of the expanded role of the nurse in treating clinical problems where the training of physicians was superfluous,” Kaplan says.
That recognition changed everything for Meyer, who had been working as a registered nurse for six months when she was tapped to receive the intensive training. “I was in the right place at the right time,” she says. “I consider myself to be incredibly lucky.” Like Dailinger, Meyer says she enjoys the collegial atmosphere at the Health Plan, and doesn’t hesitate to seek guidance from physicians and others if a case poses a challenge. Many colleagues turn to her as well. “Nurse practitioners have a tremendous amount of expertise to contribute for the betterment of the patient, whether as a member of a team or as an individual practitioner,” says Meyer.
The nursing field was also familiar territory for Thomas Brady, whose mother and sister are nurses, and whose father became a licensed practical nurse after working for 30 years as a butcher. Brady, too, was interested in health care, but he lacked what he calls the “inner flame” to become a doctor and wanted a career with “more of a medical model” than nursing. So after working for two years in research, he enrolled in Yale’s PA program and then joined the urgent-care team at the Health Plan. “I can honestly say that after eight years I thoroughly enjoy my work,” says Brady. “I don’t dread Monday mornings.”
Brady says he enjoys the interaction with patients, and the variety of cases that appear each day. But most of all, he says, he values the collegial relationship he shares with physicians and other health-care providers: “We all work together to figure out the puzzle that the patient presents.”  |
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