Ann M. Hoppel

Once upon a time, the average internal medicine or family practice clinician (most often a physician) typically had about 10 patients who had been admitted to the hospital at any given time. This meant that in addition to seeing patients in the office, that clinician would spend at least part of his or her day—early morning, lunchtime, late night—doing rounds at the hospital. This arrangement, while necessary from a patient care perspective, was certainly not ideal.

For the clinician, a potentially inordinate amount of time could be spent on travel (particularly in the event of an unforeseeable glitch, such as a traffic jam or flat tire)—time that could not be spent with patients in either setting. Patients, by the same token, were seeing their trusted, established clinician once per day—and as everyone knows, lab results and acute events do not conveniently arrive or occur on a schedule. A patient whose tests were ordered in the morning but whose results did not arrive until afternoon might have to wait to be discharged until the following morning—a fact that would make neither the patient nor the hospital happy.

Out of this conundrum, about 10 years ago, hospitalists were born. These clinicians—actually, groups of clinicians—maintain their entire practice within a hospital and coordinate care for patients who are admitted from the emergency department or from outpatient settings.

NPs and PAs can make excellent additions to these teams, but even clinicians who don’t want to branch into hospital medicine should be aware of the role hospitalists play. After all, as Lynne M. Allen, MN, ARNP, a member of the Non-Physician Provider Committee of the Society of Hospital Medicine, says, “They’re taking care of your patient when your patient is most ill.”

A Growing Field
Hospital medicine is one of the fastest-growing specialties in the United States. The Society of Hospital Medicine (SHM) estimates that more than 28,000 hospitalists are currently practicing. That number does not include PAs and NPs, since hospitalist encompasses only physicians. According to the 2008 census by the American Academy of Physician Assistants (AAPA), more than 400 PAs work in hospital medicine. The corresponding number of NPs is not readily available.

Experts suggest the number of hospitalists could increase to 40,000; even so, workforce shortages are anticipated. “There are seven hospitalist jobs for every hospitalist out there,” says Jeanette Kalupa, MSN, ACNP-BC, APNP, another member of SHM’s Non-Physician Provider Committee.

The very nature of hospital medicine makes it conducive to a variety of clinicians filling different roles within the team. “NPs and PAs can play a good role here, because they have a flexibility about their practice and what they do,” Allen says. “They can join a hospital practice and do general hospital medicine, just like the physicians can. Or sometimes, depending on what their specialty is, they can work in particular areas.”

Getting NP/PA Specific
Integrating PAs and NPs into hospital medicine can be challenging. For NPs in particular, licensing varies by state. Hospital bylaws also differ from place to place; some facilities do not have a mechanism for credentialing nonphysician clinicians. But the biggest challenge may be that “neither NPs or PAs have much opportunity to get any education or training in hospital medicine,” as Allen says.

“In my [acute care NP] curriculum,” Kalupa adds, “I went through all of the subspecialties, but I really had no internal medicine rotation. I did pulmonary, GI, renal, cardiology, cardiovascular surgery—but there was no generalist rotation for me.”

PAs tend to follow a more traditional medical model of education—but they still might not receive training specific to how to be a hospitalist. “It is almost essential to have individuals who are trained in all facets of hospital-based medicine, just as there are those who are trained in outpatient medicine,” says Kevin Friedel, MS, PA-C, of the Milton S. Hershey Medical Center in Hershey, Pennsylvania. “Traditionally, PA education focuses more on the rural outpatient setting, unless students are fortunate to be introduced to inpatient medicine during clinical rotations or request specific inpatient rotations.”

The lack of educational opportunities was the impetus for a five-day boot camp to be held this month by the SHM, AAPA, and the American Academy of Nurse Practitioners. “Certainly, it doesn’t replace education,” Kalupa says. “But it will give them an overview of the core competencies that have been identified for hospital medicine. People will have a certificate when they’re done, and then medical directors will feel that at least they’ve had a baseline orientation.”

Unique Setting, Skills
What’s so different about hospital medicine? The assessments, treatments, antibiotics … “It is different than taking care of someone in the outpatient setting,” Allen emphasizes. “It’s not just one practitioner taking care of one patient. It’s not you looking in their ear and saying, ‘You have an earache, here’s a prescription. Go home.’ It’s ‘Here is a patient who is very ill’—because we don’t admit patients to the hospital the way we used to—and you have to look at the entire patient.”

“We often serve as the ‘coordinator of all things medicine,’” Friedel says. “Hospital medicine seems to be ever-changing. We care for patients in every age range and from every specialty, serving as a primary service to many, as well as a consultant-based service to various subspecialties.”

The constant changes in practice are another reason the hospital medicine specialty was born. “It’s become extremely specialized in the hospital,” Kalupa says. “There are constant changes in practice and protocols, as well as translation of research that’s going from the bench to the bedside more quickly.”

“In the present day, the majority of practitioners find it difficult to master both areas [inpatient and outpatient],” Friedel observes, “and maintain competence and comfort in both realms.” 

Besides being well versed in the core competencies, a clinician who wants to pursue a career in hospital medicine needs certain inherent skills—fortuitously, those that NPs and PAs are often lauded for. The most important are the ability to be a team player and the ability to communicate effectively. In a hospital, it’s essential to work closely with everyone from floor staff, subspecialists, and surgeons to social workers, representatives from the utilization department, and even chaplains, to provide the best possible patient care.

“It is a group of people working to bring a patient into the hospital, give them the best care they can in the most effective manner—and cost does play into that—and then discharge them,” explains Allen. It’s also helpful to know whom you can call on for a favor when you really need it—such as a quick turnaround on an MRI.

NPs and PAs can contribute to the hospitalist team even if they are not strictly hospital based. For example, Allen works for Columbia Basin Hematology and Oncology in Washington State, primarily in the outpatient clinic. But she also makes rounds every day and does comanagement of her hospitalized oncology patients.

“I’m there to answer the hospitalists’ questions,” she says, “if they do not have that exact knowledge base. You know, ‘This patient is anemic and his platelet count is way down. Do we transfuse now?’ I can answer that.” Her counterparts in areas such as cardiology, pain management, and palliative care (to name a few) provide similar expertise.

Have You Talked to Your Hospitalist Today?
Communication is also important between providers and patients in the hospital. “You’re stepping into a case with a patient and family who may have an established relationship—sometimes for many, many years—with a physician outside the hospital,” Kalupa points out. “So you have to instill confidence in that family [since] their primary care physician is not going to be there.”

That fact—the reason for the hospitalist’s existence—is also the source of the biggest knock on the specialty: How can continuity of care be ensured when the clinician caring for the hospitalized patient may never have seen him or her before?

“They don’t know what their background is, what their medical history is,” Allen says. “Finding all of that out and making sure they have the correct information is really important.”

Kalupa is a program manager and acute care NP for Cogent Healthcare of Wisconsin, Aurora St. Luke’s Medical Center, Milwaukee, where a system is in place to address continuity concerns. Clinical care coordinators—usually RNs—identify the patient’s primary care provider.

“We send the PCPs faxes letting them know that their patients are here, and we make sure they get copies of discharge summaries,” Kalupa explains. “We also contact them with what we call ‘landmark events’ as far as catastrophic diagnosis, death—even if there’s something like discord among the family.” If patients allow it, follow-up appointments are scheduled before they leave the hospital.

Friedel acknowledges that “it can become difficult at times” to maintain contact, particularly with a clinician who is not affiliated with the hospital. But in the interests of patient care, it’s essential. “I find it best to simply make a phone call to communicate my thoughts and concerns to outside physicians,” he says. “I know it takes time out of everyone’s day to take more phone calls, but it is also greatly appreciated and keeps things on a more personal level.”

Continuity is a two-way street; primary care providers should familiarize themselves with who comprises the hospitalist program at their local facility. “They need to develop a relationship,” Allen says. “How are you going to communicate with each other? It shouldn’t be that you see a patient one day and that patient says, ‘Last week I was in the hospital for 10 days with bilateral pneumonia,’ and you as a practitioner are looking at him or her and thinking, ‘I had no clue.’”

The exchange of information stands to benefit the most important person in the equation: the patient. Hospitalists and primary care providers will each have a unique perspective on the situation, and the details that one clinician can share with another could lead to a solution to a patient’s problem—or even illuminate the fact that there is a problem.

As an example, Allen shares an anecdote about a hospitalist physician who once complained about how patients from an NP-run clinic in rural America were continually returning to his hospital. When asked if he had ever spoken with the NPs, the doctor paused, then admitted he hadn’t. Allen’s viewpoint is that the doctor may have given the patient instructions at discharge that were never passed along to the NPs—or perhaps the NPs knew something about the patient’s life in “the real world” that the hospitalist didn’t.

“Maybe the patient comes to the clinic because he’s poor and doesn’t have any money for meds,” she hypothesizes. “But the hospitalist sent him home on this really expensive antibiotic that he can’t afford to get filled. So he goes to the clinic, and they give him something different, because that’s all he can afford. And it doesn’t work as well.

“So how do we make that work? That’s a huge thing that we tend not to do—communicate with one another. Nine times out of ten, if you sit down and talk, you figure out, ‘Wow, that was a problem from this perspective.’ I mean, the goal of everybody is to give good care.”          

Once upon a time, the average internal medicine or family practice clinician (most often a physician) typically had about 10 patients who had been admitted to the hospital at any given time. This meant that in addition to seeing patients in the office, that clinician would spend at least part of his or her day—early morning, lunchtime, late night—doing rounds at the hospital. This arrangement, while necessary from a patient care perspective, was certainly not ideal.

For the clinician, a potentially inordinate amount of time could be spent on travel (particularly in the event of an unforeseeable glitch, such as a traffic jam or flat tire)—time that could not be spent with patients in either setting. Patients, by the same token, were seeing their trusted, established clinician once per day—and as everyone knows, lab results and acute events do not conveniently arrive or occur on a schedule. A patient whose tests were ordered in the morning but whose results did not arrive until afternoon might have to wait to be discharged until the following morning—a fact that would make neither the patient nor the hospital happy.

Out of this conundrum, about 10 years ago, hospitalists were born. These clinicians—actually, groups of clinicians—maintain their entire practice within a hospital and coordinate care for patients who are admitted from the emergency department or from outpatient settings.

NPs and PAs can make excellent additions to these teams, but even clinicians who don’t want to branch into hospital medicine should be aware of the role hospitalists play. After all, as Lynne M. Allen, MN, ARNP, a member of the Non-Physician Provider Committee of the Society of Hospital Medicine, says, “They’re taking care of your patient when your patient is most ill.”

A Growing Field
Hospital medicine is one of the fastest-growing specialties in the United States. The Society of Hospital Medicine (SHM) estimates that more than 28,000 hospitalists are currently practicing. That number does not include PAs and NPs, since hospitalist encompasses only physicians. According to the 2008 census by the American Academy of Physician Assistants (AAPA), more than 400 PAs work in hospital medicine. The corresponding number of NPs is not readily available.

Experts suggest the number of hospitalists could increase to 40,000; even so, workforce shortages are anticipated. “There are seven hospitalist jobs for every hospitalist out there,” says Jeanette Kalupa, MSN, ACNP-BC, APNP, another member of SHM’s Non-Physician Provider Committee.

The very nature of hospital medicine makes it conducive to a variety of clinicians filling different roles within the team. “NPs and PAs can play a good role here, because they have a flexibility about their practice and what they do,” Allen says. “They can join a hospital practice and do general hospital medicine, just like the physicians can. Or sometimes, depending on what their specialty is, they can work in particular areas.”

Getting NP/PA Specific
Integrating PAs and NPs into hospital medicine can be challenging. For NPs in particular, licensing varies by state. Hospital bylaws also differ from place to place; some facilities do not have a mechanism for credentialing nonphysician clinicians. But the biggest challenge may be that “neither NPs or PAs have much opportunity to get any education or training in hospital medicine,” as Allen says.

“In my [acute care NP] curriculum,” Kalupa adds, “I went through all of the subspecialties, but I really had no internal medicine rotation. I did pulmonary, GI, renal, cardiology, cardiovascular surgery—but there was no generalist rotation for me.”

PAs tend to follow a more traditional medical model of education—but they still might not receive training specific to how to be a hospitalist. “It is almost essential to have individuals who are trained in all facets of hospital-based medicine, just as there are those who are trained in outpatient medicine,” says Kevin Friedel, MS, PA-C, of the Milton S. Hershey Medical Center in Hershey, Pennsylvania. “Traditionally, PA education focuses more on the rural outpatient setting, unless students are fortunate to be introduced to inpatient medicine during clinical rotations or request specific inpatient rotations.”

The lack of educational opportunities was the impetus for a five-day boot camp to be held this month by the SHM, AAPA, and the American Academy of Nurse Practitioners. “Certainly, it doesn’t replace education,” Kalupa says. “But it will give them an overview of the core competencies that have been identified for hospital medicine. People will have a certificate when they’re done, and then medical directors will feel that at least they’ve had a baseline orientation.”

Unique Setting, Skills
What’s so different about hospital medicine? The assessments, treatments, antibiotics … “It is different than taking care of someone in the outpatient setting,” Allen emphasizes. “It’s not just one practitioner taking care of one patient. It’s not you looking in their ear and saying, ‘You have an earache, here’s a prescription. Go home.’ It’s ‘Here is a patient who is very ill’—because we don’t admit patients to the hospital the way we used to—and you have to look at the entire patient.”

“We often serve as the ‘coordinator of all things medicine,’” Friedel says. “Hospital medicine seems to be ever-changing. We care for patients in every age range and from every specialty, serving as a primary service to many, as well as a consultant-based service to various subspecialties.”

The constant changes in practice are another reason the hospital medicine specialty was born. “It’s become extremely specialized in the hospital,” Kalupa says. “There are constant changes in practice and protocols, as well as translation of research that’s going from the bench to the bedside more quickly.”

“In the present day, the majority of practitioners find it difficult to master both areas [inpatient and outpatient],” Friedel observes, “and maintain competence and comfort in both realms.” 

Besides being well versed in the core competencies, a clinician who wants to pursue a career in hospital medicine needs certain inherent skills—fortuitously, those that NPs and PAs are often lauded for. The most important are the ability to be a team player and the ability to communicate effectively. In a hospital, it’s essential to work closely with everyone from floor staff, subspecialists, and surgeons to social workers, representatives from the utilization department, and even chaplains, to provide the best possible patient care.

“It is a group of people working to bring a patient into the hospital, give them the best care they can in the most effective manner—and cost does play into that—and then discharge them,” explains Allen. It’s also helpful to know whom you can call on for a favor when you really need it—such as a quick turnaround on an MRI.

NPs and PAs can contribute to the hospitalist team even if they are not strictly hospital based. For example, Allen works for Columbia Basin Hematology and Oncology in Washington State, primarily in the outpatient clinic. But she also makes rounds every day and does comanagement of her hospitalized oncology patients.

“I’m there to answer the hospitalists’ questions,” she says, “if they do not have that exact knowledge base. You know, ‘This patient is anemic and his platelet count is way down. Do we transfuse now?’ I can answer that.” Her counterparts in areas such as cardiology, pain management, and palliative care (to name a few) provide similar expertise.

Have You Talked to Your Hospitalist Today?
Communication is also important between providers and patients in the hospital. “You’re stepping into a case with a patient and family who may have an established relationship—sometimes for many, many years—with a physician outside the hospital,” Kalupa points out. “So you have to instill confidence in that family [since] their primary care physician is not going to be there.”

That fact—the reason for the hospitalist’s existence—is also the source of the biggest knock on the specialty: How can continuity of care be ensured when the clinician caring for the hospitalized patient may never have seen him or her before?

“They don’t know what their background is, what their medical history is,” Allen says. “Finding all of that out and making sure they have the correct information is really important.”

Kalupa is a program manager and acute care NP for Cogent Healthcare of Wisconsin, Aurora St. Luke’s Medical Center, Milwaukee, where a system is in place to address continuity concerns. Clinical care coordinators—usually RNs—identify the patient’s primary care provider.

“We send the PCPs faxes letting them know that their patients are here, and we make sure they get copies of discharge summaries,” Kalupa explains. “We also contact them with what we call ‘landmark events’ as far as catastrophic diagnosis, death—even if there’s something like discord among the family.” If patients allow it, follow-up appointments are scheduled before they leave the hospital.

Friedel acknowledges that “it can become difficult at times” to maintain contact, particularly with a clinician who is not affiliated with the hospital. But in the interests of patient care, it’s essential. “I find it best to simply make a phone call to communicate my thoughts and concerns to outside physicians,” he says. “I know it takes time out of everyone’s day to take more phone calls, but it is also greatly appreciated and keeps things on a more personal level.”

Continuity is a two-way street; primary care providers should familiarize themselves with who comprises the hospitalist program at their local facility. “They need to develop a relationship,” Allen says. “How are you going to communicate with each other? It shouldn’t be that you see a patient one day and that patient says, ‘Last week I was in the hospital for 10 days with bilateral pneumonia,’ and you as a practitioner are looking at him or her and thinking, ‘I had no clue.’”

The exchange of information stands to benefit the most important person in the equation: the patient. Hospitalists and primary care providers will each have a unique perspective on the situation, and the details that one clinician can share with another could lead to a solution to a patient’s problem—or even illuminate the fact that there is a problem.

As an example, Allen shares an anecdote about a hospitalist physician who once complained about how patients from an NP-run clinic in rural America were continually returning to his hospital. When asked if he had ever spoken with the NPs, the doctor paused, then admitted he hadn’t. Allen’s viewpoint is that the doctor may have given the patient instructions at discharge that were never passed along to the NPs—or perhaps the NPs knew something about the patient’s life in “the real world” that the hospitalist didn’t.

“Maybe the patient comes to the clinic because he’s poor and doesn’t have any money for meds,” she hypothesizes. “But the hospitalist sent him home on this really expensive antibiotic that he can’t afford to get filled. So he goes to the clinic, and they give him something different, because that’s all he can afford. And it doesn’t work as well.

“So how do we make that work? That’s a huge thing that we tend not to do—communicate with one another. Nine times out of ten, if you sit down and talk, you figure out, ‘Wow, that was a problem from this perspective.’ I mean, the goal of everybody is to give good care.”          

Once upon a time, the average internal medicine or family practice clinician (most often a physician) typically had about 10 patients who had been admitted to the hospital at any given time. This meant that in addition to seeing patients in the office, that clinician would spend at least part of his or her day—early morning, lunchtime, late night—doing rounds at the hospital. This arrangement, while necessary from a patient care perspective, was certainly not ideal.

For the clinician, a potentially inordinate amount of time could be spent on travel (particularly in the event of an unforeseeable glitch, such as a traffic jam or flat tire)—time that could not be spent with patients in either setting. Patients, by the same token, were seeing their trusted, established clinician once per day—and as everyone knows, lab results and acute events do not conveniently arrive or occur on a schedule. A patient whose tests were ordered in the morning but whose results did not arrive until afternoon might have to wait to be discharged until the following morning—a fact that would make neither the patient nor the hospital happy.

Out of this conundrum, about 10 years ago, hospitalists were born. These clinicians—actually, groups of clinicians—maintain their entire practice within a hospital and coordinate care for patients who are admitted from the emergency department or from outpatient settings.

NPs and PAs can make excellent additions to these teams, but even clinicians who don’t want to branch into hospital medicine should be aware of the role hospitalists play. After all, as Lynne M. Allen, MN, ARNP, a member of the Non-Physician Provider Committee of the Society of Hospital Medicine, says, “They’re taking care of your patient when your patient is most ill.”

A Growing Field
Hospital medicine is one of the fastest-growing specialties in the United States. The Society of Hospital Medicine (SHM) estimates that more than 28,000 hospitalists are currently practicing. That number does not include PAs and NPs, since hospitalist encompasses only physicians. According to the 2008 census by the American Academy of Physician Assistants (AAPA), more than 400 PAs work in hospital medicine. The corresponding number of NPs is not readily available.

Experts suggest the number of hospitalists could increase to 40,000; even so, workforce shortages are anticipated. “There are seven hospitalist jobs for every hospitalist out there,” says Jeanette Kalupa, MSN, ACNP-BC, APNP, another member of SHM’s Non-Physician Provider Committee.

The very nature of hospital medicine makes it conducive to a variety of clinicians filling different roles within the team. “NPs and PAs can play a good role here, because they have a flexibility about their practice and what they do,” Allen says. “They can join a hospital practice and do general hospital medicine, just like the physicians can. Or sometimes, depending on what their specialty is, they can work in particular areas.”

Getting NP/PA Specific
Integrating PAs and NPs into hospital medicine can be challenging. For NPs in particular, licensing varies by state. Hospital bylaws also differ from place to place; some facilities do not have a mechanism for credentialing nonphysician clinicians. But the biggest challenge may be that “neither NPs or PAs have much opportunity to get any education or training in hospital medicine,” as Allen says.

“In my [acute care NP] curriculum,” Kalupa adds, “I went through all of the subspecialties, but I really had no internal medicine rotation. I did pulmonary, GI, renal, cardiology, cardiovascular surgery—but there was no generalist rotation for me.”

PAs tend to follow a more traditional medical model of education—but they still might not receive training specific to how to be a hospitalist. “It is almost essential to have individuals who are trained in all facets of hospital-based medicine, just as there are those who are trained in outpatient medicine,” says Kevin Friedel, MS, PA-C, of the Milton S. Hershey Medical Center in Hershey, Pennsylvania. “Traditionally, PA education focuses more on the rural outpatient setting, unless students are fortunate to be introduced to inpatient medicine during clinical rotations or request specific inpatient rotations.”

The lack of educational opportunities was the impetus for a five-day boot camp to be held this month by the SHM, AAPA, and the American Academy of Nurse Practitioners. “Certainly, it doesn’t replace education,” Kalupa says. “But it will give them an overview of the core competencies that have been identified for hospital medicine. People will have a certificate when they’re done, and then medical directors will feel that at least they’ve had a baseline orientation.”

Unique Setting, Skills
What’s so different about hospital medicine? The assessments, treatments, antibiotics … “It is different than taking care of someone in the outpatient setting,” Allen emphasizes. “It’s not just one practitioner taking care of one patient. It’s not you looking in their ear and saying, ‘You have an earache, here’s a prescription. Go home.’ It’s ‘Here is a patient who is very ill’—because we don’t admit patients to the hospital the way we used to—and you have to look at the entire patient.”

“We often serve as the ‘coordinator of all things medicine,’” Friedel says. “Hospital medicine seems to be ever-changing. We care for patients in every age range and from every specialty, serving as a primary service to many, as well as a consultant-based service to various subspecialties.”

The constant changes in practice are another reason the hospital medicine specialty was born. “It’s become extremely specialized in the hospital,” Kalupa says. “There are constant changes in practice and protocols, as well as translation of research that’s going from the bench to the bedside more quickly.”

“In the present day, the majority of practitioners find it difficult to master both areas [inpatient and outpatient],” Friedel observes, “and maintain competence and comfort in both realms.” 

Besides being well versed in the core competencies, a clinician who wants to pursue a career in hospital medicine needs certain inherent skills—fortuitously, those that NPs and PAs are often lauded for. The most important are the ability to be a team player and the ability to communicate effectively. In a hospital, it’s essential to work closely with everyone from floor staff, subspecialists, and surgeons to social workers, representatives from the utilization department, and even chaplains, to provide the best possible patient care.

“It is a group of people working to bring a patient into the hospital, give them the best care they can in the most effective manner—and cost does play into that—and then discharge them,” explains Allen. It’s also helpful to know whom you can call on for a favor when you really need it—such as a quick turnaround on an MRI.

NPs and PAs can contribute to the hospitalist team even if they are not strictly hospital based. For example, Allen works for Columbia Basin Hematology and Oncology in Washington State, primarily in the outpatient clinic. But she also makes rounds every day and does comanagement of her hospitalized oncology patients.

“I’m there to answer the hospitalists’ questions,” she says, “if they do not have that exact knowledge base. You know, ‘This patient is anemic and his platelet count is way down. Do we transfuse now?’ I can answer that.” Her counterparts in areas such as cardiology, pain management, and palliative care (to name a few) provide similar expertise.

Have You Talked to Your Hospitalist Today?
Communication is also important between providers and patients in the hospital. “You’re stepping into a case with a patient and family who may have an established relationship—sometimes for many, many years—with a physician outside the hospital,” Kalupa points out. “So you have to instill confidence in that family [since] their primary care physician is not going to be there.”

That fact—the reason for the hospitalist’s existence—is also the source of the biggest knock on the specialty: How can continuity of care be ensured when the clinician caring for the hospitalized patient may never have seen him or her before?

“They don’t know what their background is, what their medical history is,” Allen says. “Finding all of that out and making sure they have the correct information is really important.”

Kalupa is a program manager and acute care NP for Cogent Healthcare of Wisconsin, Aurora St. Luke’s Medical Center, Milwaukee, where a system is in place to address continuity concerns. Clinical care coordinators—usually RNs—identify the patient’s primary care provider.

“We send the PCPs faxes letting them know that their patients are here, and we make sure they get copies of discharge summaries,” Kalupa explains. “We also contact them with what we call ‘landmark events’ as far as catastrophic diagnosis, death—even if there’s something like discord among the family.” If patients allow it, follow-up appointments are scheduled before they leave the hospital.

Friedel acknowledges that “it can become difficult at times” to maintain contact, particularly with a clinician who is not affiliated with the hospital. But in the interests of patient care, it’s essential. “I find it best to simply make a phone call to communicate my thoughts and concerns to outside physicians,” he says. “I know it takes time out of everyone’s day to take more phone calls, but it is also greatly appreciated and keeps things on a more personal level.”

Continuity is a two-way street; primary care providers should familiarize themselves with who comprises the hospitalist program at their local facility. “They need to develop a relationship,” Allen says. “How are you going to communicate with each other? It shouldn’t be that you see a patient one day and that patient says, ‘Last week I was in the hospital for 10 days with bilateral pneumonia,’ and you as a practitioner are looking at him or her and thinking, ‘I had no clue.’”

The exchange of information stands to benefit the most important person in the equation: the patient. Hospitalists and primary care providers will each have a unique perspective on the situation, and the details that one clinician can share with another could lead to a solution to a patient’s problem—or even illuminate the fact that there is a problem.

As an example, Allen shares an anecdote about a hospitalist physician who once complained about how patients from an NP-run clinic in rural America were continually returning to his hospital. When asked if he had ever spoken with the NPs, the doctor paused, then admitted he hadn’t. Allen’s viewpoint is that the doctor may have given the patient instructions at discharge that were never passed along to the NPs—or perhaps the NPs knew something about the patient’s life in “the real world” that the hospitalist didn’t.

“Maybe the patient comes to the clinic because he’s poor and doesn’t have any money for meds,” she hypothesizes. “But the hospitalist sent him home on this really expensive antibiotic that he can’t afford to get filled. So he goes to the clinic, and they give him something different, because that’s all he can afford. And it doesn’t work as well.

“So how do we make that work? That’s a huge thing that we tend not to do—communicate with one another. Nine times out of ten, if you sit down and talk, you figure out, ‘Wow, that was a problem from this perspective.’ I mean, the goal of everybody is to give good care.”          

An international expert panel assembled by three leading diabetes organizations has recommended the use of the A1C assay for the diagnosis of diabetes. In its report, the committee states its hope that the recommendation “will serve as a stimulus” to the discussion of appropriate screening for and diagnosis of this prevalent metabolic condition.

But what impact would this recommendation—if widely implemented—have on primary care practice? And will it be widely implemented, as has largely been assumed? As Sandra Drozdz Burke, PhD, APRN, CDE, BC-ADN, a member of the board of directors of the American Association of Diabetes Educators, points out, “It’s a report. And nothing is going to be done about it until after the constituent groups have a chance to review it and make some decisions…. We generally don’t change practice based on an article. 

The Case for A1C
Currently, the standard for the diagnosis of type 2 diabetes is a fasting plasma glucose (FPG) of 126 mg/dL or higher or a random oral glucose tolerance test (OGTT) of more than 200 mg/dL. While these tests have been validated, endorsed, and standardized, they provide a snapshot of a patient’s glycemic control—and not in entirely “real world” conditions. 

The FPG test requires the patient to fast for at least eight hours prior to testing. Besides that inconvenience, there are also variances in FPG. “If you’re fasting, you haven’t been challenged for an extended period,” says Scott Urquhart, PA-C, President of the American Society of Endocrine PAs, who practices at Diabetes and Thyroid Associates in Fredericksburg, Virginia. “And the day-to-day variation is roughly 12%. So a patient could be at 112 one day and 98 the next. They were ‘prediabetic,’ and now they’re not.”

For the OGTT, patients must consume 75 grams of sweet drink in five minutes. “Most of us can’t even consume that,” Urquhart points out. By his calculation, the preparation is equivalent to drinking a 20-ounce bottle of soda in five minutes. “That gives you an indication of why it’s often called a glucose stress test—it is quite stressful. And is that a fair comparison to how most people consume daily calories? The answer is, probably not. So maybe that uncovers too many people who wouldn’t be facing that challenge every day.”

By contrast, the A1C assay, as the expert panel notes, “can be obtained at any time [and] requires no patient preparation.” Besides ease of use, a more important argument in favor of the A1C assay for diagnosis of diabetes is the fact that it provides a long-term overview of a patient’s glycemic state.

“It doesn’t give a one-day look at the blood sugar,” says Geralyn R. Spollett, MSN, ANP, CDE, an adult nurse practitioner and Associate Director of the Yale Diabetes Center. “It’s an accumulation of two to three months’ averaging of blood sugar. Hopefully, it would catch those patients who come in and their blood sugar looks OK that day but for whom there is some kind of symptomology suggestive of diabetes.”

A Matter for Debate
One prevailing theory is that these benefits might encourage clinicians to use the A1C assay, resulting in the identification of more patients who are currently diabetic but unaware of it. Statistics indicate that approximately 25% of persons in the United States with type 2 diabetes are undiagnosed.

“It very well could be that this is a nice alternative to what we’re already doing,” Burke says, “since what we’re already doing is only capturing 75% to 80% [of diabetes cases].”

But can the health care system accommodate those additional patients, who will require treatment not only for their glycemic issues but also for comorbidities such as hypertension and dyslipidemia?

“This is going to help us catch those that need to be diagnosed,” Urquhart says. “But are we going to be able to handle the 50% [of diabetic patients] who aren’t being managed properly now, and then throw these [new cases] on top of them?”

It’s one of many debating points that the recommendation has raised. The committee acknowledges that the A1C assay will not be an accurate measure for patients with hemoglobinopathies; will providers always know which patients have such traits? While some assay methods can correct for these factors, will clinicians—particularly in primary care—have access to them?

Other questions relate to A1C values and how clinicians will interpret them. Burke, who is vice-chair of the Older Adults Working Group of the National Diabetes Education Program, points out that there are not currently age-specific A1C targets. “Even though we know that A1C increases with age, they’re still recommending a universal target of 6.5% as a diagnostic value,” she says. “Is that going to give us false-positives in some populations?”

At a more basic level, what does that 6.5% mean? “If you look at a mean average for A1C, 6% is around 130 mg/dL and 7% is around 165 mg/dL, ” Spollett says. “If people are diagnosed between 6% and 6.5%, they’re going to be called ‘at risk.’ So I think there will be some confusion about what those numbers mean and how to interpret them.”

Better Screening Needed
For now, the questions are theoretical. Until it is widely adopted, so is the recommendation. (The American Diabetes Association has assembled a task force to review the report and may issue its own commentary by the end of the summer.) But the discussion the report has generated provides an opportunity to focus attention on the problem of diabetes in this country.

“Even though we’re improving, we’re still not at a point where we can say that most of our patients have achieved really good control,” Burke adds. “So, using the A1C more appropriately to guide clinical decision-making in terms of medication management, referral to educators or dietitians—a paper like this really brings that into very clear relief.”

The consensus among Burke, Spollett, and Urquhart seems to be that clinicians simply are not screening enough for diabetes. “It still isn’t as widely known as the other screenings for cancer and heart disease,” Spollett says. “Even if it’s not [with] the A1C, clinicians should be screening patients appropriately and really asking the questions that patients need to hear about their weight gain and their exercise and sedentary level.”

“An A1C is just a number,” as Urquhart says. “That number corresponds to other things that are going on in the body. We need to tackle those things, all the different entities of dyslipidemia and hypertension and glucose and obesity.”

An international expert panel assembled by three leading diabetes organizations has recommended the use of the A1C assay for the diagnosis of diabetes. In its report, the committee states its hope that the recommendation “will serve as a stimulus” to the discussion of appropriate screening for and diagnosis of this prevalent metabolic condition.

But what impact would this recommendation—if widely implemented—have on primary care practice? And will it be widely implemented, as has largely been assumed? As Sandra Drozdz Burke, PhD, APRN, CDE, BC-ADN, a member of the board of directors of the American Association of Diabetes Educators, points out, “It’s a report. And nothing is going to be done about it until after the constituent groups have a chance to review it and make some decisions…. We generally don’t change practice based on an article. 

The Case for A1C
Currently, the standard for the diagnosis of type 2 diabetes is a fasting plasma glucose (FPG) of 126 mg/dL or higher or a random oral glucose tolerance test (OGTT) of more than 200 mg/dL. While these tests have been validated, endorsed, and standardized, they provide a snapshot of a patient’s glycemic control—and not in entirely “real world” conditions. 

The FPG test requires the patient to fast for at least eight hours prior to testing. Besides that inconvenience, there are also variances in FPG. “If you’re fasting, you haven’t been challenged for an extended period,” says Scott Urquhart, PA-C, President of the American Society of Endocrine PAs, who practices at Diabetes and Thyroid Associates in Fredericksburg, Virginia. “And the day-to-day variation is roughly 12%. So a patient could be at 112 one day and 98 the next. They were ‘prediabetic,’ and now they’re not.”

For the OGTT, patients must consume 75 grams of sweet drink in five minutes. “Most of us can’t even consume that,” Urquhart points out. By his calculation, the preparation is equivalent to drinking a 20-ounce bottle of soda in five minutes. “That gives you an indication of why it’s often called a glucose stress test—it is quite stressful. And is that a fair comparison to how most people consume daily calories? The answer is, probably not. So maybe that uncovers too many people who wouldn’t be facing that challenge every day.”

By contrast, the A1C assay, as the expert panel notes, “can be obtained at any time [and] requires no patient preparation.” Besides ease of use, a more important argument in favor of the A1C assay for diagnosis of diabetes is the fact that it provides a long-term overview of a patient’s glycemic state.

“It doesn’t give a one-day look at the blood sugar,” says Geralyn R. Spollett, MSN, ANP, CDE, an adult nurse practitioner and Associate Director of the Yale Diabetes Center. “It’s an accumulation of two to three months’ averaging of blood sugar. Hopefully, it would catch those patients who come in and their blood sugar looks OK that day but for whom there is some kind of symptomology suggestive of diabetes.”

A Matter for Debate
One prevailing theory is that these benefits might encourage clinicians to use the A1C assay, resulting in the identification of more patients who are currently diabetic but unaware of it. Statistics indicate that approximately 25% of persons in the United States with type 2 diabetes are undiagnosed.

“It very well could be that this is a nice alternative to what we’re already doing,” Burke says, “since what we’re already doing is only capturing 75% to 80% [of diabetes cases].”

But can the health care system accommodate those additional patients, who will require treatment not only for their glycemic issues but also for comorbidities such as hypertension and dyslipidemia?

“This is going to help us catch those that need to be diagnosed,” Urquhart says. “But are we going to be able to handle the 50% [of diabetic patients] who aren’t being managed properly now, and then throw these [new cases] on top of them?”

It’s one of many debating points that the recommendation has raised. The committee acknowledges that the A1C assay will not be an accurate measure for patients with hemoglobinopathies; will providers always know which patients have such traits? While some assay methods can correct for these factors, will clinicians—particularly in primary care—have access to them?

Other questions relate to A1C values and how clinicians will interpret them. Burke, who is vice-chair of the Older Adults Working Group of the National Diabetes Education Program, points out that there are not currently age-specific A1C targets. “Even though we know that A1C increases with age, they’re still recommending a universal target of 6.5% as a diagnostic value,” she says. “Is that going to give us false-positives in some populations?”

At a more basic level, what does that 6.5% mean? “If you look at a mean average for A1C, 6% is around 130 mg/dL and 7% is around 165 mg/dL, ” Spollett says. “If people are diagnosed between 6% and 6.5%, they’re going to be called ‘at risk.’ So I think there will be some confusion about what those numbers mean and how to interpret them.”

Better Screening Needed
For now, the questions are theoretical. Until it is widely adopted, so is the recommendation. (The American Diabetes Association has assembled a task force to review the report and may issue its own commentary by the end of the summer.) But the discussion the report has generated provides an opportunity to focus attention on the problem of diabetes in this country.

“Even though we’re improving, we’re still not at a point where we can say that most of our patients have achieved really good control,” Burke adds. “So, using the A1C more appropriately to guide clinical decision-making in terms of medication management, referral to educators or dietitians—a paper like this really brings that into very clear relief.”

The consensus among Burke, Spollett, and Urquhart seems to be that clinicians simply are not screening enough for diabetes. “It still isn’t as widely known as the other screenings for cancer and heart disease,” Spollett says. “Even if it’s not [with] the A1C, clinicians should be screening patients appropriately and really asking the questions that patients need to hear about their weight gain and their exercise and sedentary level.”

“An A1C is just a number,” as Urquhart says. “That number corresponds to other things that are going on in the body. We need to tackle those things, all the different entities of dyslipidemia and hypertension and glucose and obesity.”

An international expert panel assembled by three leading diabetes organizations has recommended the use of the A1C assay for the diagnosis of diabetes. In its report, the committee states its hope that the recommendation “will serve as a stimulus” to the discussion of appropriate screening for and diagnosis of this prevalent metabolic condition.

But what impact would this recommendation—if widely implemented—have on primary care practice? And will it be widely implemented, as has largely been assumed? As Sandra Drozdz Burke, PhD, APRN, CDE, BC-ADN, a member of the board of directors of the American Association of Diabetes Educators, points out, “It’s a report. And nothing is going to be done about it until after the constituent groups have a chance to review it and make some decisions…. We generally don’t change practice based on an article. 

The Case for A1C
Currently, the standard for the diagnosis of type 2 diabetes is a fasting plasma glucose (FPG) of 126 mg/dL or higher or a random oral glucose tolerance test (OGTT) of more than 200 mg/dL. While these tests have been validated, endorsed, and standardized, they provide a snapshot of a patient’s glycemic control—and not in entirely “real world” conditions. 

The FPG test requires the patient to fast for at least eight hours prior to testing. Besides that inconvenience, there are also variances in FPG. “If you’re fasting, you haven’t been challenged for an extended period,” says Scott Urquhart, PA-C, President of the American Society of Endocrine PAs, who practices at Diabetes and Thyroid Associates in Fredericksburg, Virginia. “And the day-to-day variation is roughly 12%. So a patient could be at 112 one day and 98 the next. They were ‘prediabetic,’ and now they’re not.”

For the OGTT, patients must consume 75 grams of sweet drink in five minutes. “Most of us can’t even consume that,” Urquhart points out. By his calculation, the preparation is equivalent to drinking a 20-ounce bottle of soda in five minutes. “That gives you an indication of why it’s often called a glucose stress test—it is quite stressful. And is that a fair comparison to how most people consume daily calories? The answer is, probably not. So maybe that uncovers too many people who wouldn’t be facing that challenge every day.”

By contrast, the A1C assay, as the expert panel notes, “can be obtained at any time [and] requires no patient preparation.” Besides ease of use, a more important argument in favor of the A1C assay for diagnosis of diabetes is the fact that it provides a long-term overview of a patient’s glycemic state.

“It doesn’t give a one-day look at the blood sugar,” says Geralyn R. Spollett, MSN, ANP, CDE, an adult nurse practitioner and Associate Director of the Yale Diabetes Center. “It’s an accumulation of two to three months’ averaging of blood sugar. Hopefully, it would catch those patients who come in and their blood sugar looks OK that day but for whom there is some kind of symptomology suggestive of diabetes.”

A Matter for Debate
One prevailing theory is that these benefits might encourage clinicians to use the A1C assay, resulting in the identification of more patients who are currently diabetic but unaware of it. Statistics indicate that approximately 25% of persons in the United States with type 2 diabetes are undiagnosed.

“It very well could be that this is a nice alternative to what we’re already doing,” Burke says, “since what we’re already doing is only capturing 75% to 80% [of diabetes cases].”

But can the health care system accommodate those additional patients, who will require treatment not only for their glycemic issues but also for comorbidities such as hypertension and dyslipidemia?

“This is going to help us catch those that need to be diagnosed,” Urquhart says. “But are we going to be able to handle the 50% [of diabetic patients] who aren’t being managed properly now, and then throw these [new cases] on top of them?”

It’s one of many debating points that the recommendation has raised. The committee acknowledges that the A1C assay will not be an accurate measure for patients with hemoglobinopathies; will providers always know which patients have such traits? While some assay methods can correct for these factors, will clinicians—particularly in primary care—have access to them?

Other questions relate to A1C values and how clinicians will interpret them. Burke, who is vice-chair of the Older Adults Working Group of the National Diabetes Education Program, points out that there are not currently age-specific A1C targets. “Even though we know that A1C increases with age, they’re still recommending a universal target of 6.5% as a diagnostic value,” she says. “Is that going to give us false-positives in some populations?”

At a more basic level, what does that 6.5% mean? “If you look at a mean average for A1C, 6% is around 130 mg/dL and 7% is around 165 mg/dL, ” Spollett says. “If people are diagnosed between 6% and 6.5%, they’re going to be called ‘at risk.’ So I think there will be some confusion about what those numbers mean and how to interpret them.”

Better Screening Needed
For now, the questions are theoretical. Until it is widely adopted, so is the recommendation. (The American Diabetes Association has assembled a task force to review the report and may issue its own commentary by the end of the summer.) But the discussion the report has generated provides an opportunity to focus attention on the problem of diabetes in this country.

“Even though we’re improving, we’re still not at a point where we can say that most of our patients have achieved really good control,” Burke adds. “So, using the A1C more appropriately to guide clinical decision-making in terms of medication management, referral to educators or dietitians—a paper like this really brings that into very clear relief.”

The consensus among Burke, Spollett, and Urquhart seems to be that clinicians simply are not screening enough for diabetes. “It still isn’t as widely known as the other screenings for cancer and heart disease,” Spollett says. “Even if it’s not [with] the A1C, clinicians should be screening patients appropriately and really asking the questions that patients need to hear about their weight gain and their exercise and sedentary level.”

“An A1C is just a number,” as Urquhart says. “That number corresponds to other things that are going on in the body. We need to tackle those things, all the different entities of dyslipidemia and hypertension and glucose and obesity.”

When Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, talks about her trip to Cambodia with Arizona-based Peacework Medical Projects, her enthusiasm is infectious. 

“It was amazing,” she says of the two weeks she spent as an international medical volunteer in January 2009. “We were very well received, and I think by the time we left, we all wanted to go back. And I believe the community would welcome us back.”

Segal-Gidan is such an eager participant that when she says, “You should come with us next time!” even a nonclinician who fears camping is at least a bit tempted to sign on. Perhaps her experiences, and those of other clinicians, will encourage readers to contribute their professional skills to a worthwhile project.

A Sustainable Model
Peacework Medical Projects (not to be confused with Peacework International) is the creation of Pamela Burwell, MS, PA-C, a woman for whom volunteering has never been a choice; it’s always been something she just does. Her efforts in Ghana and Honduras earned her the 2008 Humanitarian PA of the Year award from the American Academy of Physician Assistants; this year, she added Cambodia to the list of places Peacework visits.

When Segal-Gidan began looking for an organization to volunteer with, she had a list of criteria: it had to be PA-friendly, short-term, and not religiously or politically affiliated. As she says, “The list got pretty narrow pretty fast.” But when she found Peacework Medical Projects on the Web and began corresponding with Burwell, she sensed that she’d found a winner.

“[Pam] works well with the local resources, which is very important, and she’s very respectful of the culture,” Segal-Gidan says. “It wasn’t like, ‘We’ve got the answers and we’re going to come and solve your problems.’ She goes in with the idea of ‘I’m going to see what we can do to help you.’”

Around the same time that Burwell launched Peacework in January 2000, criticism of short-term medical missions began to appear in the medical literature. Editorials and essays in journals such as BMJ and JAMA questioned whether these efforts actually do more harm than good and how clinicians can expect to treat chronic illnesses in a single visit. There have also been queries about whether such “medical tourists” cause disruptions and strain the local communities they purport to help.

Burwell understands the criticism but has worked to develop a sustainable model that integrates as much as possible with the local infrastructure. She has a five-page document outlining the process of putting a project together, from identifying needs and host country nationals with whom to collaborate, to assembling teams of health care providers for the trip. And she never, ever takes a team to a location she hasn’t vetted herself on what she calls her “scouting trips.”

“I think the big—and rightful—complaint about short-term projects is that you go in, you drop a bunch of medicine, and you leave,” acknowledges Burwell. “The way I try to combat that is to create long-term commitments in a given area, and I build health education into the program.”

Focus on Education
Each Peacework volunteer carries about 70 pounds of medications into a country (a fact that slightly concerned Segal-Gidan, until she realized Burwell had done her homework with the Cambodian authorities to ensure that no one would be detained at Customs). Even so, Burwell’s commitment to health education means those medicines “are simply the carrot on the stick that brings so many people to us,” as Burwell says.

Once patients arrive at the Peacework clinic, the focus becomes health education. “We want them to understand the relationship between their own behaviors with personal hygiene and clean water and their own good health,” Burwell says. “We’re not going there and treating long-term diabetes or hypertension. We can treat those things in the short term but more importantly, teach people how not to get them in the first place.”

“If we can teach someone to keep their water clean, it might decrease their chances of being ill 10 times a year,” says Shelley Vaughn, RN, BSN, who is currently enrolled in the family nurse practitioner track at Northern Arizona University.

Something as simple as a five-minute discussion might be enough to improve someone’s life and health; this is part of what keeps Vaughn, who has participated in three Peacework projects in northern Honduras, going back. For example, Hondurans drink a lot of coffee, which contributes to their high blood pressure levels. “Even helping them to understand that if they only had one cup of coffee a day, instead of that being their only beverage all day long,” Vaughn says, might make a difference in preventing or controlling hypertension.

Along with the education, clinicians deliver a sense of respect to the people they treat. Burwell and Vaughn have seen the fruits of that respect in Honduras. After eight years at a location in the northern part of the country, Burwell actually ended her project there (and is preparing to scout a site in southern Honduras) because the people Peacework helped serve have arranged to bring in a government doctor and nurse each month. They have also received a grant from an organization called World Vision to help with their educational needs.

“Now, I can’t say Peacework did all of that,” Burwell says, “but we were there every year, and we convinced these people that they mattered enough for us to show up every year.”

The Good and The Sad
Participation in international medical work is, of course, more complex than just providing health education. For every heartwarming story, there is a heartbreaking one, and clinicians may come away feeling conflicted about how much good they’re doing. Segal-Gidan witnessed both extremes while in Cambodia.

The heartbreaker was the young woman in her last trimester of pregnancy with her eighth or ninth child. She appeared on the second clinic day and was diagnosed with preeclampsia. The Peacework volunteers brought in the local physician to try to convince the woman to go to the nearest hospital, which was about 10 miles away and accessible by public transportation. As Segal-Gidan discovered, the hospital may not have been geographically inaccessible, but for this patient, it was financially inaccessible; her understanding was that the patient would not have to pay for care, but there was an admission fee just to be seen at the hospital.

“I don’t remember the sum, but it wasn’t something that seemed astronomical to us—but to her it was,” she recalls. “And we could not give her the money. Financially, we could, but if we did that … we couldn’t do it for everybody. So that was really difficult.”

Vaughn has been confronted by poverty in Honduras, where she visited a community of about 70 families living in a garbage dump, in huts constructed from plastic egg crates and anything else that comes to hand. “It’s not that they can’t go to a doctor; they can, but it costs money,” she says. “The small amount of money that it costs might be a month’s salary for them. So [health care] is not going to come first. What comes first is trying to put food on the table.”

Burwell acknowledges “it can be rough” but also points out that Americans have something to learn from the quiet dignity and resourcefulness with which people in less affluent countries respond to unfortunate circumstances. “We see the end result of disease that has gone undetected and uncared for. We see congenital defects in children that will not be repaired,” she says. “But what we also see are families who take care of these unfortunate babies, caring for them with such love and in some cases such faith.”

Segal-Gidan, in fact, found some of her patients in Cambodia to be downright inspiring. In particular, there was the man with a spinal cord injury who came to the clinic in a wheelchair, accompanied by his wife and children. Segal-Gidan, who works in a rehab hospital with spinal cord injury patients in the United States, was amazed by the man’s condition. He had no bedsores. He needed to be catheterized for bladder care, but his wife had taught herself how to do that and boiled the tubing that they received once or twice a year for that purpose.

“They could come and teach some people here how to be resourceful,” Segal-Gidan says. “His legs were atrophied; it clearly took a lot of effort from his family to keep him in the condition he was in. And they just did it. It was quite inspiring.”

Many Reasons to Give
Professional and spiritual rejuvenation, in addition to a desire to “do good,” are some of the reasons clinicians may want to consider medical volunteer work. For many, it’s a reminder of why they went into health care in the first place.

“I see a lot of primary care providers who are burnt out about the way medicine is practiced here in the US,” Burwell observes. “They feel up against the paperwork, up against the litigation threat, up against the greed that happens in medicine today. And they forget their original, very good reasons for becoming a doctor or a nurse or a PA.”

For Segal-Gidan, volunteering with Peacework represented a return to her roots. “I chose to go to PA school with the idea that I was going to go and work in the Third World. But when I graduated, the world was not ready for PAs,” she says with a laugh. In the meantime, “life kind of intervened,” and she has followed a much different path—although she’s always had it in mind to pursue that original goal.

Segal-Gidan went to Cambodia with a mix of anticipation and anxiety. She specializes in geriatrics here in the US; Cambodia, because of the atrocities committed by the Pol Pot regime in the 1970s, is a very young country, population-wise. But she found that the health care providers Burwell had assembled truly functioned as a team and did not divide up patients based on their own Western knowledge base.

“What I do [in the US] is take care of people’s dementia; what was I going to do [there]?” she recalls thinking. “But your basic skills stay with you. I could still diagnose otitis media in a kid.”

Vaughn is at the other end of the career spectrum—in fact, part of her interest in becoming an FNP is to contribute more not only here in the US but also in Honduras. As a nurse, she currently handles triage or pharmacy at the Peacework clinics but says, “I would really like to be able to treat the family as a group. Maybe once I’m the clinician, I’ll be able to offer a little more education. That to me is what matters the most.”

Besides feeling that helping the community—at home or abroad—“is part of our responsibility in the health care profession,” Vaughn’s main reason for giving back is her appreciation for the resources available in the US. At the time of her first Peacework trip, Vaughn was a single mom with two young sons who used her nursing sign-on bonus to participate in the project.

“I know that because of the resources we have here, I was able to change what was going on in my life,” she says. “Without those resources, I probably would still be working a $5- or $6-an-hour job and not be able to have what I have now. So I felt the need to share how my life has changed.”

Burwell says volunteers need to be realistic about what they can accomplish on a short-term medical trip. “The very few less-than-satisfied volunteers I’ve ever had were those who had romanticized the projects to the point where they really thought they were going to be saving lives every day and they were going to be welcomed almost like heroes,” she recounts. “And you don’t see change every day, you don’t save lives every day, any more than you do at work here.” (Her list of questions that potential volunteers should ask can be found in the box.)

And while Burwell, Vaughn, and Segal-Gidan come across as pretty extraordinary (not that they’ll tell you so; all three are remarkably humble), “Everybody has something to give,” Segal-Gidan says. “You learn more than you give, but you’re able to give a little, too."

When Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, talks about her trip to Cambodia with Arizona-based Peacework Medical Projects, her enthusiasm is infectious. 

“It was amazing,” she says of the two weeks she spent as an international medical volunteer in January 2009. “We were very well received, and I think by the time we left, we all wanted to go back. And I believe the community would welcome us back.”

Segal-Gidan is such an eager participant that when she says, “You should come with us next time!” even a nonclinician who fears camping is at least a bit tempted to sign on. Perhaps her experiences, and those of other clinicians, will encourage readers to contribute their professional skills to a worthwhile project.

A Sustainable Model
Peacework Medical Projects (not to be confused with Peacework International) is the creation of Pamela Burwell, MS, PA-C, a woman for whom volunteering has never been a choice; it’s always been something she just does. Her efforts in Ghana and Honduras earned her the 2008 Humanitarian PA of the Year award from the American Academy of Physician Assistants; this year, she added Cambodia to the list of places Peacework visits.

When Segal-Gidan began looking for an organization to volunteer with, she had a list of criteria: it had to be PA-friendly, short-term, and not religiously or politically affiliated. As she says, “The list got pretty narrow pretty fast.” But when she found Peacework Medical Projects on the Web and began corresponding with Burwell, she sensed that she’d found a winner.

“[Pam] works well with the local resources, which is very important, and she’s very respectful of the culture,” Segal-Gidan says. “It wasn’t like, ‘We’ve got the answers and we’re going to come and solve your problems.’ She goes in with the idea of ‘I’m going to see what we can do to help you.’”

Around the same time that Burwell launched Peacework in January 2000, criticism of short-term medical missions began to appear in the medical literature. Editorials and essays in journals such as BMJ and JAMA questioned whether these efforts actually do more harm than good and how clinicians can expect to treat chronic illnesses in a single visit. There have also been queries about whether such “medical tourists” cause disruptions and strain the local communities they purport to help.

Burwell understands the criticism but has worked to develop a sustainable model that integrates as much as possible with the local infrastructure. She has a five-page document outlining the process of putting a project together, from identifying needs and host country nationals with whom to collaborate, to assembling teams of health care providers for the trip. And she never, ever takes a team to a location she hasn’t vetted herself on what she calls her “scouting trips.”

“I think the big—and rightful—complaint about short-term projects is that you go in, you drop a bunch of medicine, and you leave,” acknowledges Burwell. “The way I try to combat that is to create long-term commitments in a given area, and I build health education into the program.”

Focus on Education
Each Peacework volunteer carries about 70 pounds of medications into a country (a fact that slightly concerned Segal-Gidan, until she realized Burwell had done her homework with the Cambodian authorities to ensure that no one would be detained at Customs). Even so, Burwell’s commitment to health education means those medicines “are simply the carrot on the stick that brings so many people to us,” as Burwell says.

Once patients arrive at the Peacework clinic, the focus becomes health education. “We want them to understand the relationship between their own behaviors with personal hygiene and clean water and their own good health,” Burwell says. “We’re not going there and treating long-term diabetes or hypertension. We can treat those things in the short term but more importantly, teach people how not to get them in the first place.”

“If we can teach someone to keep their water clean, it might decrease their chances of being ill 10 times a year,” says Shelley Vaughn, RN, BSN, who is currently enrolled in the family nurse practitioner track at Northern Arizona University.

Something as simple as a five-minute discussion might be enough to improve someone’s life and health; this is part of what keeps Vaughn, who has participated in three Peacework projects in northern Honduras, going back. For example, Hondurans drink a lot of coffee, which contributes to their high blood pressure levels. “Even helping them to understand that if they only had one cup of coffee a day, instead of that being their only beverage all day long,” Vaughn says, might make a difference in preventing or controlling hypertension.

Along with the education, clinicians deliver a sense of respect to the people they treat. Burwell and Vaughn have seen the fruits of that respect in Honduras. After eight years at a location in the northern part of the country, Burwell actually ended her project there (and is preparing to scout a site in southern Honduras) because the people Peacework helped serve have arranged to bring in a government doctor and nurse each month. They have also received a grant from an organization called World Vision to help with their educational needs.

“Now, I can’t say Peacework did all of that,” Burwell says, “but we were there every year, and we convinced these people that they mattered enough for us to show up every year.”

The Good and The Sad
Participation in international medical work is, of course, more complex than just providing health education. For every heartwarming story, there is a heartbreaking one, and clinicians may come away feeling conflicted about how much good they’re doing. Segal-Gidan witnessed both extremes while in Cambodia.

The heartbreaker was the young woman in her last trimester of pregnancy with her eighth or ninth child. She appeared on the second clinic day and was diagnosed with preeclampsia. The Peacework volunteers brought in the local physician to try to convince the woman to go to the nearest hospital, which was about 10 miles away and accessible by public transportation. As Segal-Gidan discovered, the hospital may not have been geographically inaccessible, but for this patient, it was financially inaccessible; her understanding was that the patient would not have to pay for care, but there was an admission fee just to be seen at the hospital.

“I don’t remember the sum, but it wasn’t something that seemed astronomical to us—but to her it was,” she recalls. “And we could not give her the money. Financially, we could, but if we did that … we couldn’t do it for everybody. So that was really difficult.”

Vaughn has been confronted by poverty in Honduras, where she visited a community of about 70 families living in a garbage dump, in huts constructed from plastic egg crates and anything else that comes to hand. “It’s not that they can’t go to a doctor; they can, but it costs money,” she says. “The small amount of money that it costs might be a month’s salary for them. So [health care] is not going to come first. What comes first is trying to put food on the table.”

Burwell acknowledges “it can be rough” but also points out that Americans have something to learn from the quiet dignity and resourcefulness with which people in less affluent countries respond to unfortunate circumstances. “We see the end result of disease that has gone undetected and uncared for. We see congenital defects in children that will not be repaired,” she says. “But what we also see are families who take care of these unfortunate babies, caring for them with such love and in some cases such faith.”

Segal-Gidan, in fact, found some of her patients in Cambodia to be downright inspiring. In particular, there was the man with a spinal cord injury who came to the clinic in a wheelchair, accompanied by his wife and children. Segal-Gidan, who works in a rehab hospital with spinal cord injury patients in the United States, was amazed by the man’s condition. He had no bedsores. He needed to be catheterized for bladder care, but his wife had taught herself how to do that and boiled the tubing that they received once or twice a year for that purpose.

“They could come and teach some people here how to be resourceful,” Segal-Gidan says. “His legs were atrophied; it clearly took a lot of effort from his family to keep him in the condition he was in. And they just did it. It was quite inspiring.”

Many Reasons to Give
Professional and spiritual rejuvenation, in addition to a desire to “do good,” are some of the reasons clinicians may want to consider medical volunteer work. For many, it’s a reminder of why they went into health care in the first place.

“I see a lot of primary care providers who are burnt out about the way medicine is practiced here in the US,” Burwell observes. “They feel up against the paperwork, up against the litigation threat, up against the greed that happens in medicine today. And they forget their original, very good reasons for becoming a doctor or a nurse or a PA.”

For Segal-Gidan, volunteering with Peacework represented a return to her roots. “I chose to go to PA school with the idea that I was going to go and work in the Third World. But when I graduated, the world was not ready for PAs,” she says with a laugh. In the meantime, “life kind of intervened,” and she has followed a much different path—although she’s always had it in mind to pursue that original goal.

Segal-Gidan went to Cambodia with a mix of anticipation and anxiety. She specializes in geriatrics here in the US; Cambodia, because of the atrocities committed by the Pol Pot regime in the 1970s, is a very young country, population-wise. But she found that the health care providers Burwell had assembled truly functioned as a team and did not divide up patients based on their own Western knowledge base.

“What I do [in the US] is take care of people’s dementia; what was I going to do [there]?” she recalls thinking. “But your basic skills stay with you. I could still diagnose otitis media in a kid.”

Vaughn is at the other end of the career spectrum—in fact, part of her interest in becoming an FNP is to contribute more not only here in the US but also in Honduras. As a nurse, she currently handles triage or pharmacy at the Peacework clinics but says, “I would really like to be able to treat the family as a group. Maybe once I’m the clinician, I’ll be able to offer a little more education. That to me is what matters the most.”

Besides feeling that helping the community—at home or abroad—“is part of our responsibility in the health care profession,” Vaughn’s main reason for giving back is her appreciation for the resources available in the US. At the time of her first Peacework trip, Vaughn was a single mom with two young sons who used her nursing sign-on bonus to participate in the project.

“I know that because of the resources we have here, I was able to change what was going on in my life,” she says. “Without those resources, I probably would still be working a $5- or $6-an-hour job and not be able to have what I have now. So I felt the need to share how my life has changed.”

Burwell says volunteers need to be realistic about what they can accomplish on a short-term medical trip. “The very few less-than-satisfied volunteers I’ve ever had were those who had romanticized the projects to the point where they really thought they were going to be saving lives every day and they were going to be welcomed almost like heroes,” she recounts. “And you don’t see change every day, you don’t save lives every day, any more than you do at work here.” (Her list of questions that potential volunteers should ask can be found in the box.)

And while Burwell, Vaughn, and Segal-Gidan come across as pretty extraordinary (not that they’ll tell you so; all three are remarkably humble), “Everybody has something to give,” Segal-Gidan says. “You learn more than you give, but you’re able to give a little, too."

When Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, talks about her trip to Cambodia with Arizona-based Peacework Medical Projects, her enthusiasm is infectious. 

“It was amazing,” she says of the two weeks she spent as an international medical volunteer in January 2009. “We were very well received, and I think by the time we left, we all wanted to go back. And I believe the community would welcome us back.”

Segal-Gidan is such an eager participant that when she says, “You should come with us next time!” even a nonclinician who fears camping is at least a bit tempted to sign on. Perhaps her experiences, and those of other clinicians, will encourage readers to contribute their professional skills to a worthwhile project.

A Sustainable Model
Peacework Medical Projects (not to be confused with Peacework International) is the creation of Pamela Burwell, MS, PA-C, a woman for whom volunteering has never been a choice; it’s always been something she just does. Her efforts in Ghana and Honduras earned her the 2008 Humanitarian PA of the Year award from the American Academy of Physician Assistants; this year, she added Cambodia to the list of places Peacework visits.

When Segal-Gidan began looking for an organization to volunteer with, she had a list of criteria: it had to be PA-friendly, short-term, and not religiously or politically affiliated. As she says, “The list got pretty narrow pretty fast.” But when she found Peacework Medical Projects on the Web and began corresponding with Burwell, she sensed that she’d found a winner.

“[Pam] works well with the local resources, which is very important, and she’s very respectful of the culture,” Segal-Gidan says. “It wasn’t like, ‘We’ve got the answers and we’re going to come and solve your problems.’ She goes in with the idea of ‘I’m going to see what we can do to help you.’”

Around the same time that Burwell launched Peacework in January 2000, criticism of short-term medical missions began to appear in the medical literature. Editorials and essays in journals such as BMJ and JAMA questioned whether these efforts actually do more harm than good and how clinicians can expect to treat chronic illnesses in a single visit. There have also been queries about whether such “medical tourists” cause disruptions and strain the local communities they purport to help.

Burwell understands the criticism but has worked to develop a sustainable model that integrates as much as possible with the local infrastructure. She has a five-page document outlining the process of putting a project together, from identifying needs and host country nationals with whom to collaborate, to assembling teams of health care providers for the trip. And she never, ever takes a team to a location she hasn’t vetted herself on what she calls her “scouting trips.”

“I think the big—and rightful—complaint about short-term projects is that you go in, you drop a bunch of medicine, and you leave,” acknowledges Burwell. “The way I try to combat that is to create long-term commitments in a given area, and I build health education into the program.”

Focus on Education
Each Peacework volunteer carries about 70 pounds of medications into a country (a fact that slightly concerned Segal-Gidan, until she realized Burwell had done her homework with the Cambodian authorities to ensure that no one would be detained at Customs). Even so, Burwell’s commitment to health education means those medicines “are simply the carrot on the stick that brings so many people to us,” as Burwell says.

Once patients arrive at the Peacework clinic, the focus becomes health education. “We want them to understand the relationship between their own behaviors with personal hygiene and clean water and their own good health,” Burwell says. “We’re not going there and treating long-term diabetes or hypertension. We can treat those things in the short term but more importantly, teach people how not to get them in the first place.”

“If we can teach someone to keep their water clean, it might decrease their chances of being ill 10 times a year,” says Shelley Vaughn, RN, BSN, who is currently enrolled in the family nurse practitioner track at Northern Arizona University.

Something as simple as a five-minute discussion might be enough to improve someone’s life and health; this is part of what keeps Vaughn, who has participated in three Peacework projects in northern Honduras, going back. For example, Hondurans drink a lot of coffee, which contributes to their high blood pressure levels. “Even helping them to understand that if they only had one cup of coffee a day, instead of that being their only beverage all day long,” Vaughn says, might make a difference in preventing or controlling hypertension.

Along with the education, clinicians deliver a sense of respect to the people they treat. Burwell and Vaughn have seen the fruits of that respect in Honduras. After eight years at a location in the northern part of the country, Burwell actually ended her project there (and is preparing to scout a site in southern Honduras) because the people Peacework helped serve have arranged to bring in a government doctor and nurse each month. They have also received a grant from an organization called World Vision to help with their educational needs.

“Now, I can’t say Peacework did all of that,” Burwell says, “but we were there every year, and we convinced these people that they mattered enough for us to show up every year.”

The Good and The Sad
Participation in international medical work is, of course, more complex than just providing health education. For every heartwarming story, there is a heartbreaking one, and clinicians may come away feeling conflicted about how much good they’re doing. Segal-Gidan witnessed both extremes while in Cambodia.

The heartbreaker was the young woman in her last trimester of pregnancy with her eighth or ninth child. She appeared on the second clinic day and was diagnosed with preeclampsia. The Peacework volunteers brought in the local physician to try to convince the woman to go to the nearest hospital, which was about 10 miles away and accessible by public transportation. As Segal-Gidan discovered, the hospital may not have been geographically inaccessible, but for this patient, it was financially inaccessible; her understanding was that the patient would not have to pay for care, but there was an admission fee just to be seen at the hospital.

“I don’t remember the sum, but it wasn’t something that seemed astronomical to us—but to her it was,” she recalls. “And we could not give her the money. Financially, we could, but if we did that … we couldn’t do it for everybody. So that was really difficult.”

Vaughn has been confronted by poverty in Honduras, where she visited a community of about 70 families living in a garbage dump, in huts constructed from plastic egg crates and anything else that comes to hand. “It’s not that they can’t go to a doctor; they can, but it costs money,” she says. “The small amount of money that it costs might be a month’s salary for them. So [health care] is not going to come first. What comes first is trying to put food on the table.”

Burwell acknowledges “it can be rough” but also points out that Americans have something to learn from the quiet dignity and resourcefulness with which people in less affluent countries respond to unfortunate circumstances. “We see the end result of disease that has gone undetected and uncared for. We see congenital defects in children that will not be repaired,” she says. “But what we also see are families who take care of these unfortunate babies, caring for them with such love and in some cases such faith.”

Segal-Gidan, in fact, found some of her patients in Cambodia to be downright inspiring. In particular, there was the man with a spinal cord injury who came to the clinic in a wheelchair, accompanied by his wife and children. Segal-Gidan, who works in a rehab hospital with spinal cord injury patients in the United States, was amazed by the man’s condition. He had no bedsores. He needed to be catheterized for bladder care, but his wife had taught herself how to do that and boiled the tubing that they received once or twice a year for that purpose.

“They could come and teach some people here how to be resourceful,” Segal-Gidan says. “His legs were atrophied; it clearly took a lot of effort from his family to keep him in the condition he was in. And they just did it. It was quite inspiring.”

Many Reasons to Give
Professional and spiritual rejuvenation, in addition to a desire to “do good,” are some of the reasons clinicians may want to consider medical volunteer work. For many, it’s a reminder of why they went into health care in the first place.

“I see a lot of primary care providers who are burnt out about the way medicine is practiced here in the US,” Burwell observes. “They feel up against the paperwork, up against the litigation threat, up against the greed that happens in medicine today. And they forget their original, very good reasons for becoming a doctor or a nurse or a PA.”

For Segal-Gidan, volunteering with Peacework represented a return to her roots. “I chose to go to PA school with the idea that I was going to go and work in the Third World. But when I graduated, the world was not ready for PAs,” she says with a laugh. In the meantime, “life kind of intervened,” and she has followed a much different path—although she’s always had it in mind to pursue that original goal.

Segal-Gidan went to Cambodia with a mix of anticipation and anxiety. She specializes in geriatrics here in the US; Cambodia, because of the atrocities committed by the Pol Pot regime in the 1970s, is a very young country, population-wise. But she found that the health care providers Burwell had assembled truly functioned as a team and did not divide up patients based on their own Western knowledge base.

“What I do [in the US] is take care of people’s dementia; what was I going to do [there]?” she recalls thinking. “But your basic skills stay with you. I could still diagnose otitis media in a kid.”

Vaughn is at the other end of the career spectrum—in fact, part of her interest in becoming an FNP is to contribute more not only here in the US but also in Honduras. As a nurse, she currently handles triage or pharmacy at the Peacework clinics but says, “I would really like to be able to treat the family as a group. Maybe once I’m the clinician, I’ll be able to offer a little more education. That to me is what matters the most.”

Besides feeling that helping the community—at home or abroad—“is part of our responsibility in the health care profession,” Vaughn’s main reason for giving back is her appreciation for the resources available in the US. At the time of her first Peacework trip, Vaughn was a single mom with two young sons who used her nursing sign-on bonus to participate in the project.

“I know that because of the resources we have here, I was able to change what was going on in my life,” she says. “Without those resources, I probably would still be working a $5- or $6-an-hour job and not be able to have what I have now. So I felt the need to share how my life has changed.”

Burwell says volunteers need to be realistic about what they can accomplish on a short-term medical trip. “The very few less-than-satisfied volunteers I’ve ever had were those who had romanticized the projects to the point where they really thought they were going to be saving lives every day and they were going to be welcomed almost like heroes,” she recounts. “And you don’t see change every day, you don’t save lives every day, any more than you do at work here.” (Her list of questions that potential volunteers should ask can be found in the box.)

And while Burwell, Vaughn, and Segal-Gidan come across as pretty extraordinary (not that they’ll tell you so; all three are remarkably humble), “Everybody has something to give,” Segal-Gidan says. “You learn more than you give, but you’re able to give a little, too."

To most Americans, the sight of a soldier returning from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and being reunited with his or her family epitomizes a happy ending. After all, parents, spouses, and children, having sent their loved ones to serve in Afghanistan or Iraq, now have their heroes returned safely to them. Not every family has been so fortunate, and each reunion is a small victory, a moment to reflect on what has been lost since 2001—and to be grateful for what has not.

But sometimes the battle continues when the troops come home. It may be a very different battle—but then again, the conflicts in Iraq and Afghanistan represent a very different kind of war. What our soldiers have experienced in theatre, through extended and multiple deployments, often leaves them with lingering, not-so-obvious injuries. The effects of these psychological and emotional wounds, if they are not properly healed, impact not only the soldiers but also their families.

The Department of Veterans Affairs (VA) has been developing programs and services to meet soldiers’ physical and mental health needs, but not every OEF/OIF veteran is going to have ready access to a top-notch VA facility. Health care providers in non-VA settings may represent the only contact some soldiers and their families will have with the health care system.

“I think providers have the burden here, because they’re the ones that are going to be on the front lines, seeing these families,” says Peggy Anne Fisher McNulty, DrPH, CPNP, CFNP, RN, an Assistant Professor in the University of Hawaii at Manoa School of Nursing and Dental Hygiene, who served with the US Navy Nurse Corps for more than 30 years. “I think it’s going to be their mission to open that door and get families the help they need.”

Invisible Wounds
Last year, the RAND Corporation’s Center for Military Health Policy Research issued a report outlining the effects the current conflicts have had on soldiers. A confidential survey of almost 2,000 returned veterans indicated that nearly 19% met criteria for either posttraumatic stress disorder (PTSD) or depression, and nearly 20% reported experiencing a probable traumatic brain injury during deployment. An earlier report from the VA’s Special Committee on PTSD suggested that up to 20% of OEF/OIF veterans are “at risk for significant symptoms short of full diagnosis but severe enough to cause significant functional impairment.”

Beyond potential clinical diagnoses, soldiers’ lives in theatre are just much different from civilian life. Deployment has been described as a year-long adrenaline rush, filled with stressors, and soldiers are trained to have a battle mindset and focus on the mission.

“That frame of mind is hard to transition back from,” says Master Sergeant Christopher Pugh of the Community-Based Warrior Transition Unit of Massachusetts, an Iraq veteran who was preparing to redeploy when Clinician Reviews spoke with him. “For most soldiers who come off the plane, they’re not focused on battle mind or potential problems. They just want to get through the process and go home to their loved ones if possible. And that’s usually when the problems start arising.”

Readjustment issues can include difficulty dealing with crowds, loss of patience with certain individuals, and a lingering sense of urgency that others don’t feel. “You feel like if you need to get something done, it has to be done right away,” Pugh explains, “whereas it’s not as important to anyone else.”

But if left unaddressed, any of these underlying stressors could eventually manifest in the form of domestic, substance abuse, or gambling problems. According to a study published in JAMA last year, nearly 12% of soldiers report problems with alcohol on their postdeployment health assessment forms. Unpublished data from a study of OEF/OIF veterans referred for behavioral health assessment (as cited in a -report by the Iraq and Afghanistan Veterans of America) indicated that more than half of those who were currently or recently separated from their partner reported “conflicts involving shouting, pushing, or shoving.” Another 22% of those surveyed reported concerns that their children “did not act warmly” toward them or “were afraid” of them.

Even more distressing is the possibility of suicide; the rate among active-duty veterans is on track to surpass the demographically adjusted civilian rate, but statistics on veterans who have completed their service are more difficult to obtain. These issues negatively impact not only the soldier but also his or her family. 

“Soldiers aren’t getting the help they need, so the families are suffering,” says McNulty, who is conducting research on the effects of reunification. Her data, which she is preparing for publication, indicate that spouses were most likely to take steps toward divorce within three months of their soldier’s return home. Other high-risk factors, such as contemplation of suicide or use of prescription medications for stress, remained high throughout the study, which ended 12 months after the soldier’s return.

“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”

Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.

“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”

Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended. 

“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”

Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.

Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”

Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”

The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.

“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”

“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?

“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”

The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.

To most Americans, the sight of a soldier returning from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and being reunited with his or her family epitomizes a happy ending. After all, parents, spouses, and children, having sent their loved ones to serve in Afghanistan or Iraq, now have their heroes returned safely to them. Not every family has been so fortunate, and each reunion is a small victory, a moment to reflect on what has been lost since 2001—and to be grateful for what has not.

But sometimes the battle continues when the troops come home. It may be a very different battle—but then again, the conflicts in Iraq and Afghanistan represent a very different kind of war. What our soldiers have experienced in theatre, through extended and multiple deployments, often leaves them with lingering, not-so-obvious injuries. The effects of these psychological and emotional wounds, if they are not properly healed, impact not only the soldiers but also their families.

The Department of Veterans Affairs (VA) has been developing programs and services to meet soldiers’ physical and mental health needs, but not every OEF/OIF veteran is going to have ready access to a top-notch VA facility. Health care providers in non-VA settings may represent the only contact some soldiers and their families will have with the health care system.

“I think providers have the burden here, because they’re the ones that are going to be on the front lines, seeing these families,” says Peggy Anne Fisher McNulty, DrPH, CPNP, CFNP, RN, an Assistant Professor in the University of Hawaii at Manoa School of Nursing and Dental Hygiene, who served with the US Navy Nurse Corps for more than 30 years. “I think it’s going to be their mission to open that door and get families the help they need.”

Invisible Wounds
Last year, the RAND Corporation’s Center for Military Health Policy Research issued a report outlining the effects the current conflicts have had on soldiers. A confidential survey of almost 2,000 returned veterans indicated that nearly 19% met criteria for either posttraumatic stress disorder (PTSD) or depression, and nearly 20% reported experiencing a probable traumatic brain injury during deployment. An earlier report from the VA’s Special Committee on PTSD suggested that up to 20% of OEF/OIF veterans are “at risk for significant symptoms short of full diagnosis but severe enough to cause significant functional impairment.”

Beyond potential clinical diagnoses, soldiers’ lives in theatre are just much different from civilian life. Deployment has been described as a year-long adrenaline rush, filled with stressors, and soldiers are trained to have a battle mindset and focus on the mission.

“That frame of mind is hard to transition back from,” says Master Sergeant Christopher Pugh of the Community-Based Warrior Transition Unit of Massachusetts, an Iraq veteran who was preparing to redeploy when Clinician Reviews spoke with him. “For most soldiers who come off the plane, they’re not focused on battle mind or potential problems. They just want to get through the process and go home to their loved ones if possible. And that’s usually when the problems start arising.”

Readjustment issues can include difficulty dealing with crowds, loss of patience with certain individuals, and a lingering sense of urgency that others don’t feel. “You feel like if you need to get something done, it has to be done right away,” Pugh explains, “whereas it’s not as important to anyone else.”

But if left unaddressed, any of these underlying stressors could eventually manifest in the form of domestic, substance abuse, or gambling problems. According to a study published in JAMA last year, nearly 12% of soldiers report problems with alcohol on their postdeployment health assessment forms. Unpublished data from a study of OEF/OIF veterans referred for behavioral health assessment (as cited in a -report by the Iraq and Afghanistan Veterans of America) indicated that more than half of those who were currently or recently separated from their partner reported “conflicts involving shouting, pushing, or shoving.” Another 22% of those surveyed reported concerns that their children “did not act warmly” toward them or “were afraid” of them.

Even more distressing is the possibility of suicide; the rate among active-duty veterans is on track to surpass the demographically adjusted civilian rate, but statistics on veterans who have completed their service are more difficult to obtain. These issues negatively impact not only the soldier but also his or her family. 

“Soldiers aren’t getting the help they need, so the families are suffering,” says McNulty, who is conducting research on the effects of reunification. Her data, which she is preparing for publication, indicate that spouses were most likely to take steps toward divorce within three months of their soldier’s return home. Other high-risk factors, such as contemplation of suicide or use of prescription medications for stress, remained high throughout the study, which ended 12 months after the soldier’s return.

“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”

Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.

“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”

Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended. 

“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”

Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.

Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”

Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”

The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.

“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”

“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?

“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”

The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.

To most Americans, the sight of a soldier returning from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and being reunited with his or her family epitomizes a happy ending. After all, parents, spouses, and children, having sent their loved ones to serve in Afghanistan or Iraq, now have their heroes returned safely to them. Not every family has been so fortunate, and each reunion is a small victory, a moment to reflect on what has been lost since 2001—and to be grateful for what has not.

But sometimes the battle continues when the troops come home. It may be a very different battle—but then again, the conflicts in Iraq and Afghanistan represent a very different kind of war. What our soldiers have experienced in theatre, through extended and multiple deployments, often leaves them with lingering, not-so-obvious injuries. The effects of these psychological and emotional wounds, if they are not properly healed, impact not only the soldiers but also their families.

The Department of Veterans Affairs (VA) has been developing programs and services to meet soldiers’ physical and mental health needs, but not every OEF/OIF veteran is going to have ready access to a top-notch VA facility. Health care providers in non-VA settings may represent the only contact some soldiers and their families will have with the health care system.

“I think providers have the burden here, because they’re the ones that are going to be on the front lines, seeing these families,” says Peggy Anne Fisher McNulty, DrPH, CPNP, CFNP, RN, an Assistant Professor in the University of Hawaii at Manoa School of Nursing and Dental Hygiene, who served with the US Navy Nurse Corps for more than 30 years. “I think it’s going to be their mission to open that door and get families the help they need.”

Invisible Wounds
Last year, the RAND Corporation’s Center for Military Health Policy Research issued a report outlining the effects the current conflicts have had on soldiers. A confidential survey of almost 2,000 returned veterans indicated that nearly 19% met criteria for either posttraumatic stress disorder (PTSD) or depression, and nearly 20% reported experiencing a probable traumatic brain injury during deployment. An earlier report from the VA’s Special Committee on PTSD suggested that up to 20% of OEF/OIF veterans are “at risk for significant symptoms short of full diagnosis but severe enough to cause significant functional impairment.”

Beyond potential clinical diagnoses, soldiers’ lives in theatre are just much different from civilian life. Deployment has been described as a year-long adrenaline rush, filled with stressors, and soldiers are trained to have a battle mindset and focus on the mission.

“That frame of mind is hard to transition back from,” says Master Sergeant Christopher Pugh of the Community-Based Warrior Transition Unit of Massachusetts, an Iraq veteran who was preparing to redeploy when Clinician Reviews spoke with him. “For most soldiers who come off the plane, they’re not focused on battle mind or potential problems. They just want to get through the process and go home to their loved ones if possible. And that’s usually when the problems start arising.”

Readjustment issues can include difficulty dealing with crowds, loss of patience with certain individuals, and a lingering sense of urgency that others don’t feel. “You feel like if you need to get something done, it has to be done right away,” Pugh explains, “whereas it’s not as important to anyone else.”

But if left unaddressed, any of these underlying stressors could eventually manifest in the form of domestic, substance abuse, or gambling problems. According to a study published in JAMA last year, nearly 12% of soldiers report problems with alcohol on their postdeployment health assessment forms. Unpublished data from a study of OEF/OIF veterans referred for behavioral health assessment (as cited in a -report by the Iraq and Afghanistan Veterans of America) indicated that more than half of those who were currently or recently separated from their partner reported “conflicts involving shouting, pushing, or shoving.” Another 22% of those surveyed reported concerns that their children “did not act warmly” toward them or “were afraid” of them.

Even more distressing is the possibility of suicide; the rate among active-duty veterans is on track to surpass the demographically adjusted civilian rate, but statistics on veterans who have completed their service are more difficult to obtain. These issues negatively impact not only the soldier but also his or her family. 

“Soldiers aren’t getting the help they need, so the families are suffering,” says McNulty, who is conducting research on the effects of reunification. Her data, which she is preparing for publication, indicate that spouses were most likely to take steps toward divorce within three months of their soldier’s return home. Other high-risk factors, such as contemplation of suicide or use of prescription medications for stress, remained high throughout the study, which ended 12 months after the soldier’s return.

“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”

Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.

“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”

Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended. 

“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”

Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.

Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”

Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”

The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.

“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”

“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?

“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”

The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.

By now, the story of Nadya Suleman is well known. The 33-year-old California woman gave birth to octuplets—only the second set born in the United States—on January 26. Within a few weeks, what was initially reported as a heartwarming story of medicine’s finest hour had ignited a nationwide backlash as details of Suleman’s situation became known. The divorced single mom already had six children younger than 8 when she underwent the fertility treatments that led to an eight-baby bonanza.

Should Suleman have been allowed to undergo the additional treatments? Did her medical team violate guidelines by implanting more than the generally accepted number of embryos? Is it fair to burden taxpayers with the costs of raising her large family—particularly in the current economic climate?

Clinician Reviews does not profess to have the answers to these questions. But we did ask a panel of editorial board members and other experts for their take on the thorny ethical questions Suleman’s case has raised.

How do you feel about a woman with six children younger than 8 receiving fertility treatments and delivering another eight babies?

Stephen Nunn, MPAS, PA-C, a founding member of the Association of PAs in Ob-Gyn, who worked with the first successful in vitro fertilization program in Arizona for 18 years: The issue for me isn’t so much that she already has six children, but the real and serious risks to both the mother and fetuses with multiple gestation. The American Society of Reproductive Medicine has established guidelines for the number of embryos to be transferred, which for this patient would be three. It appears these guidelines were not used in this case. This would not have generated the same response had Ms. Suleman received fertility treatment in an effort to achieve a singleton or, at most, twin gestation.

Obviously, we do not know all the details; however, I wonder why so many embryos were placed. If there were a total of seven, as the press has stated, then there would have been more than one opportunity to achieve a single pregnancy. Even if the mother did not want the other embryos destroyed, she could have donated them to another woman.

Rebecca Scott, PhD, PA-C, Clinical Coordinator in the Physician Assistant Program at Northeastern University, Boston, and an elected member of the Board of Health in Sandwich, Massachusetts: I have been thinking about how this really illustrates a tension that we’ve had in our history of the rights of the individual versus the rights of the whole community. We have this long tradition of saying, “Everybody ought to be able to have children.” This seems to fit into that continuum of the individual’s right being very strongly upheld in this country over, perhaps, what is best for the good of society.

This is so interesting because other societies are quite up-front about their goals for their population. I remember traveling in Hungary at one point, where the people were not reproducing enough to replace the population. So the government said, “It’s in our best interests to have enough people to support the society,” and they actually subsidized moms with the equivalent of a factory worker’s wage to stay home with children for three years, up to three children’s worth.

The big thing that troubles me about this is where do the rights of the group get accounted for? Should we be paying tax dollars to subsidize people who want to have children?

Austin D. Potenza II, JD, a Phoenix-based attorney and Adjunct Professor at the Arizona School of Health Sciences, where he has taught a course on medical ethics for 10 years: I think in our society everything has to be open for discussion, but we have to realize that at some point it’s just discussion. Under current ethical thinking, the most important perspective is that of a competent patient. We as a society don’t make these kinds of decisions—whether it is getting fertility treatment or having multiple births—for people.

A close second is the perspective of the infants, but it is problematic to base a societal response on what is right for children when it comes to fertility and multiple birth. Is being born into a family of 14 somehow worse than not being born at all? If we’re trying to save children, what exactly are we saving them from? And why look at just these children? If we try to have a responsible answer to these questions, it is myopic to look only at this family.

Think about the thousands of children who are born into horrible poverty, hunger, abuse, and neglect. We don’t regulate their parents’ reproductive decisions. And that’s just considering our own country; if we really want to be concerned about children, think about places like Sierra Leone, where the infant mortality rate is about 25%. Although the consideration of the children is compelling, it is much more important to consider how to help them once they are born, rather than thinking of the solution in terms of fertility and multiple births.     

The next important ethical perspective is that of the caregiver [discussed in depth later]. 

Finally, society is a stakeholder, and this seems to be the perspective from which most people are approaching the issue. The typical questions you’re going to hear are, “Is the cost of care for this mother and these children going to fall on the rest of us as taxpayers? Is this part of what’s straining the health care and social support systems?” These are all valid questions, but they beg an awful lot of other questions that we have to answer first. For example, what should we spend our collective money on? Who decides?  

While it is understandable why the public is upset by this story, at the same time, does anyone have the right to impose restrictions on someone’s procreation? Where, if at all, do we draw a line in the sand? 

Marie-Eileen Onieal, PhD, CPNP, FAANP, Director of Medical Services for the Massachusetts Department of Youth Services and Clinician Reviews NP Editor-in-Chief: I think the line between moral soundness and legal rights was crossed when the woman put her desires to have more children above the needs of the children she already bore. Before the octup-let pregnancy, she needed more than minimal assistance to care for the six children she already had; at least two have special needs requiring more attention and care.  

I think, especially in the face of the fact that she is almost totally dependent on others to help her provide for her family, we as a society have a moral and legal obligation to impose restrictions on procreation (especially when one’s procreating consumes as many resources as this woman consumed).

Rebecca Scott: I don’t think sending hate mail and death threats is any way to respond in a civil society. But I think we do need to say, “No, it is not all right for somebody to be using taxpayer dollars to subsidize,” you know, whatever it is that the individual wants to do that is way above and beyond what most of us would consider reasonable. 

If we look at the welfare-to-work initiatives that took place under the Clinton administration, that’s a start on an answer. We made the decision at that point that it was OK to say to people, “You have to get off welfare. You must go to work.” But we also enabled people to do that by saying, “We will subsidize Medicaid so that you can continue to get coverage at these low-paying jobs where you don’t earn enough money to be able to pay for health care.”

Stephen Nunn: To me, the principle here is Primum non nocere or “First, do no harm.” A twin pregnancy is considered high risk just because it’s a twin pregnancy. Those risks skyrocket with each additional fetus. The main risk here is to the fetuses, their individual and collective survival, and the potential for future problems after birth, such as cerebral palsy, blindness, and learning disabilities. So, the risks and benefits have to be weighed on an individual basis.

Personally, I can see no circumstance to justify transferring more than four embryos—ever! Holding to this guideline is not restricting a woman’s right to procreation. It’s not saying “No,” it’s saying, “Not this many.”

Although the obstetrician’s patient is the mother, not the fetus, I believe the fertility specialist can’t take such a narrow view of his or her responsibilities. Ordinarily, an obstetrician becomes involved after pregnancy has occurred, while the fertility specialist is involved prior and thus has a greater duty in regard to the potential eventual outcome. Too much success can lead ultimately to failure.

Moving forward, where do we go from here? How might these issues be addressed?

Rebecca Scott: What I’m afraid is going to happen is that we’re going to react in a heavy-handed way and set up all kinds of oversight and come at it with a legislative approach—you know, somebody in the state legislature’s going to say, “Well, we’re going to make a rule about this.”

What I hope will happen is that we’ll have a good deal of dialogue about what’s appropriate and that that dialogue will include fertility specialists, public health experts, citizens in general, and government/public health departments and that the dialogue will try to come out with some policies and procedures to guide thinking in this kind of situation.

Austin Potenza: It’s very difficult for me to imagine any legislature taking on this issue. It would be politically impossible to attempt to regulate who can have children, and how many. Think back to the Terri Schiavo case, which was such a travesty in Congress. Everybody was trying to get involved, and it was obviously completely beyond the scope of their expertise and their ability. It was just a political nightmare. This is similar because it is government involvement in an intensely personal decision, in a country dedicated to personal freedoms. If we get involved in birth regulation, we’re repeating China’s mistakes and going against the fundamentally individual-rights focus of our society.

The next most likely—but still unlikely—step would be federal or state Medicare/Medicaid programs trying to regulate what kind of services they’ll pay for, in an effort to prevent these multiple births. In most cases, I don’t believe public or private money is available for fertility treatment, but I’m not expert in that area. Certainly, private insurers can decide, by contract, what they will and won’t cover, but when the government gets involved, it becomes more problematic. That could be seen as the state mandating forced embryo reductions. 

The only place that this could be regulated with any type of efficiency would be in the professional responsibility codes and the licensing boards of the various health care specialties.

What role can and should health care providers play in situations such as this? Where do their responsibilities end?

Randy D. Danielsen, PhD, PA-C, DFAAPA, Dean of the Arizona School of Health Sciences at A. T. Still University and Clinician Reviews PA Editor-in-Chief: We as clinicians must first require patients to be competent in their decision making, indicating the ability to make choices based on an understanding of the relevant consequences of their action. For the most part, this is subjective and relies on the skills of the clinician in recognizing the ability of the patient to understand and give consent.   

All clinicians have an obligation to be patient advocates in their area of expertise, but this does not give them the authority to overrule patients (except in certain situations).

Marie-Eileen Onieal: Given that this patient already had six young children, at least two with special needs, I think the role of the provider is to counsel the woman against trying to have more children. Providing for a large family takes energy, patience, and finances. I do not doubt that she loves the children; I just doubt that she is able to provide for their developmental needs—even the most basic physiological and safety needs. Clearer heads must prevail in situations where the person may not have sound judgment or may not have fully considered the consequences of his or her decision. 

I think that those professionals whose specialty is infertility and assisting women in getting pregnant must have a moral code, a gauge if you will, that not only puts a stop to repeated failed attempts but also repeated successful births, especially if a pregnancy has resulted in multiple births. I think the responsibility is to have the ability to say “no,” and that responsibility doesn’t end.

Stephen Nunn: The role of the provider is an active and interactive one. The mother should undergo a psychologic or psychiatric evaluation. Risks and benefits need to be clearly explained and explored in an unbiased atmosphere. The provider has, in my opinion, the right to put limits on their involvement, such as adhering to established guidelines, protecting the potential fetuses’ health, insisting on a mental health evaluation, and refusing to be a party, if necessary.

Austin Potenza: Our medical system has gone, in the past 50 years, from one of paternalistic physicians and caregivers who really controlled all of the major decision-making in health care to one where it’s the patient who now is the king, makes all the major decisions, and is involved in his or her care. The health care provider is there to facilitate, maybe guide, those decisions, but not to interfere in them, unless they involve illegality (ie, assisted suicide) or overriding personal ethical beliefs (ie, abortion). But the decisions are ultimately the responsibility of the patient, if the patient is competent.

The point at which the caregiver’s responsibility becomes heightened is the point at which damage is being done to the patient—or, in cases such as this, to the fetuses, and that damage is foreseeable and preventable. Short of that, the caregiver’s role is generally secondary to the patient’s when it comes to medical decision-making.

What, if any, impact do you think the scientific/medical achievement in this case—which culminated in the successful delivery of octuplets —had on the clinicians’ judgment?

Marie-Eileen Onieal: I think that this event has placed the fertility specialty in jeopardy of being regulated for the wrong reasons. I think the physician took advantage of the science available.

Randy Danielsen: The technology in this case seems to have overridden the social implications. I am sure this case will be added to many others where the rights of the individual counter the ethical obligations of the provider in an absence of legal intervention.

Rebecca Scott: The way it comes across to me is that there’s a certain kind of arrogance in doing that kind of thing. And it’s the same kind of arrogance that we had a century ago, saying, “You’re mentally retarded; you should not be having children, therefore I am sterilizing you whether you want to be sterilized or not.” It’s kind of the flip side of that attitude.

At the same time, I really have a horror of setting up a situation where individual health care providers refuse to provide appropriate care because of individual beliefs. I think if we start going down that road, we’re really asking for trouble…. Medical decision-making is rarely clear-cut. The interaction between patient and provider is so much of a negotiation, tinged with so many “shades of gray,” that I believe we really have to think very carefully about whether making decisions for patients is appropriate.

Stephen Nunn: I doubt the notoriety of an octuplet birth held any sway over the decision. In fact, it probably was a negative factor. I am aware of a professed fertility specialist who became famous—or rather infamous—for being responsible for the largest number of quad births in the nation. For various reasons, the state medical board investigated, and the doctor agreed to stop the practices that led to this.

The remarkable thing seems to be that multiple gestations survive, not that they happen. I suspect that in the coming years, we will start hearing more about various learning and other disabilities as these children enter the school system.

Austin Potenza: It’s a very relevant question, and it really goes to the heart of ethical thinking. Whose interests is the caregiver really serving? The caregiver’s, by making a medical breakthrough, or the patient’s? I certainly can’t define whether such considerations had an influence in this case, but they clearly shouldn’t….

The truth is our medical abilities are advancing at just an amazing rate, and I think it’s sometimes hard to tell the difference between doing something because we can do it and doing something because it’s the right thing to do for a particular patient in a particular circumstance. Medical ethics is fighting to catch up with the medical advances that are being made, and we always have to be thinking about these things.

By now, the story of Nadya Suleman is well known. The 33-year-old California woman gave birth to octuplets—only the second set born in the United States—on January 26. Within a few weeks, what was initially reported as a heartwarming story of medicine’s finest hour had ignited a nationwide backlash as details of Suleman’s situation became known. The divorced single mom already had six children younger than 8 when she underwent the fertility treatments that led to an eight-baby bonanza.

Should Suleman have been allowed to undergo the additional treatments? Did her medical team violate guidelines by implanting more than the generally accepted number of embryos? Is it fair to burden taxpayers with the costs of raising her large family—particularly in the current economic climate?

Clinician Reviews does not profess to have the answers to these questions. But we did ask a panel of editorial board members and other experts for their take on the thorny ethical questions Suleman’s case has raised.

How do you feel about a woman with six children younger than 8 receiving fertility treatments and delivering another eight babies?

Stephen Nunn, MPAS, PA-C, a founding member of the Association of PAs in Ob-Gyn, who worked with the first successful in vitro fertilization program in Arizona for 18 years: The issue for me isn’t so much that she already has six children, but the real and serious risks to both the mother and fetuses with multiple gestation. The American Society of Reproductive Medicine has established guidelines for the number of embryos to be transferred, which for this patient would be three. It appears these guidelines were not used in this case. This would not have generated the same response had Ms. Suleman received fertility treatment in an effort to achieve a singleton or, at most, twin gestation.

Obviously, we do not know all the details; however, I wonder why so many embryos were placed. If there were a total of seven, as the press has stated, then there would have been more than one opportunity to achieve a single pregnancy. Even if the mother did not want the other embryos destroyed, she could have donated them to another woman.

Rebecca Scott, PhD, PA-C, Clinical Coordinator in the Physician Assistant Program at Northeastern University, Boston, and an elected member of the Board of Health in Sandwich, Massachusetts: I have been thinking about how this really illustrates a tension that we’ve had in our history of the rights of the individual versus the rights of the whole community. We have this long tradition of saying, “Everybody ought to be able to have children.” This seems to fit into that continuum of the individual’s right being very strongly upheld in this country over, perhaps, what is best for the good of society.

This is so interesting because other societies are quite up-front about their goals for their population. I remember traveling in Hungary at one point, where the people were not reproducing enough to replace the population. So the government said, “It’s in our best interests to have enough people to support the society,” and they actually subsidized moms with the equivalent of a factory worker’s wage to stay home with children for three years, up to three children’s worth.

The big thing that troubles me about this is where do the rights of the group get accounted for? Should we be paying tax dollars to subsidize people who want to have children?

Austin D. Potenza II, JD, a Phoenix-based attorney and Adjunct Professor at the Arizona School of Health Sciences, where he has taught a course on medical ethics for 10 years: I think in our society everything has to be open for discussion, but we have to realize that at some point it’s just discussion. Under current ethical thinking, the most important perspective is that of a competent patient. We as a society don’t make these kinds of decisions—whether it is getting fertility treatment or having multiple births—for people.

A close second is the perspective of the infants, but it is problematic to base a societal response on what is right for children when it comes to fertility and multiple birth. Is being born into a family of 14 somehow worse than not being born at all? If we’re trying to save children, what exactly are we saving them from? And why look at just these children? If we try to have a responsible answer to these questions, it is myopic to look only at this family.

Think about the thousands of children who are born into horrible poverty, hunger, abuse, and neglect. We don’t regulate their parents’ reproductive decisions. And that’s just considering our own country; if we really want to be concerned about children, think about places like Sierra Leone, where the infant mortality rate is about 25%. Although the consideration of the children is compelling, it is much more important to consider how to help them once they are born, rather than thinking of the solution in terms of fertility and multiple births.     

The next important ethical perspective is that of the caregiver [discussed in depth later]. 

Finally, society is a stakeholder, and this seems to be the perspective from which most people are approaching the issue. The typical questions you’re going to hear are, “Is the cost of care for this mother and these children going to fall on the rest of us as taxpayers? Is this part of what’s straining the health care and social support systems?” These are all valid questions, but they beg an awful lot of other questions that we have to answer first. For example, what should we spend our collective money on? Who decides?  

While it is understandable why the public is upset by this story, at the same time, does anyone have the right to impose restrictions on someone’s procreation? Where, if at all, do we draw a line in the sand? 

Marie-Eileen Onieal, PhD, CPNP, FAANP, Director of Medical Services for the Massachusetts Department of Youth Services and Clinician Reviews NP Editor-in-Chief: I think the line between moral soundness and legal rights was crossed when the woman put her desires to have more children above the needs of the children she already bore. Before the octup-let pregnancy, she needed more than minimal assistance to care for the six children she already had; at least two have special needs requiring more attention and care.  

I think, especially in the face of the fact that she is almost totally dependent on others to help her provide for her family, we as a society have a moral and legal obligation to impose restrictions on procreation (especially when one’s procreating consumes as many resources as this woman consumed).

Rebecca Scott: I don’t think sending hate mail and death threats is any way to respond in a civil society. But I think we do need to say, “No, it is not all right for somebody to be using taxpayer dollars to subsidize,” you know, whatever it is that the individual wants to do that is way above and beyond what most of us would consider reasonable. 

If we look at the welfare-to-work initiatives that took place under the Clinton administration, that’s a start on an answer. We made the decision at that point that it was OK to say to people, “You have to get off welfare. You must go to work.” But we also enabled people to do that by saying, “We will subsidize Medicaid so that you can continue to get coverage at these low-paying jobs where you don’t earn enough money to be able to pay for health care.”

Stephen Nunn: To me, the principle here is Primum non nocere or “First, do no harm.” A twin pregnancy is considered high risk just because it’s a twin pregnancy. Those risks skyrocket with each additional fetus. The main risk here is to the fetuses, their individual and collective survival, and the potential for future problems after birth, such as cerebral palsy, blindness, and learning disabilities. So, the risks and benefits have to be weighed on an individual basis.

Personally, I can see no circumstance to justify transferring more than four embryos—ever! Holding to this guideline is not restricting a woman’s right to procreation. It’s not saying “No,” it’s saying, “Not this many.”

Although the obstetrician’s patient is the mother, not the fetus, I believe the fertility specialist can’t take such a narrow view of his or her responsibilities. Ordinarily, an obstetrician becomes involved after pregnancy has occurred, while the fertility specialist is involved prior and thus has a greater duty in regard to the potential eventual outcome. Too much success can lead ultimately to failure.

Moving forward, where do we go from here? How might these issues be addressed?

Rebecca Scott: What I’m afraid is going to happen is that we’re going to react in a heavy-handed way and set up all kinds of oversight and come at it with a legislative approach—you know, somebody in the state legislature’s going to say, “Well, we’re going to make a rule about this.”

What I hope will happen is that we’ll have a good deal of dialogue about what’s appropriate and that that dialogue will include fertility specialists, public health experts, citizens in general, and government/public health departments and that the dialogue will try to come out with some policies and procedures to guide thinking in this kind of situation.

Austin Potenza: It’s very difficult for me to imagine any legislature taking on this issue. It would be politically impossible to attempt to regulate who can have children, and how many. Think back to the Terri Schiavo case, which was such a travesty in Congress. Everybody was trying to get involved, and it was obviously completely beyond the scope of their expertise and their ability. It was just a political nightmare. This is similar because it is government involvement in an intensely personal decision, in a country dedicated to personal freedoms. If we get involved in birth regulation, we’re repeating China’s mistakes and going against the fundamentally individual-rights focus of our society.

The next most likely—but still unlikely—step would be federal or state Medicare/Medicaid programs trying to regulate what kind of services they’ll pay for, in an effort to prevent these multiple births. In most cases, I don’t believe public or private money is available for fertility treatment, but I’m not expert in that area. Certainly, private insurers can decide, by contract, what they will and won’t cover, but when the government gets involved, it becomes more problematic. That could be seen as the state mandating forced embryo reductions. 

The only place that this could be regulated with any type of efficiency would be in the professional responsibility codes and the licensing boards of the various health care specialties.

What role can and should health care providers play in situations such as this? Where do their responsibilities end?

Randy D. Danielsen, PhD, PA-C, DFAAPA, Dean of the Arizona School of Health Sciences at A. T. Still University and Clinician Reviews PA Editor-in-Chief: We as clinicians must first require patients to be competent in their decision making, indicating the ability to make choices based on an understanding of the relevant consequences of their action. For the most part, this is subjective and relies on the skills of the clinician in recognizing the ability of the patient to understand and give consent.   

All clinicians have an obligation to be patient advocates in their area of expertise, but this does not give them the authority to overrule patients (except in certain situations).

Marie-Eileen Onieal: Given that this patient already had six young children, at least two with special needs, I think the role of the provider is to counsel the woman against trying to have more children. Providing for a large family takes energy, patience, and finances. I do not doubt that she loves the children; I just doubt that she is able to provide for their developmental needs—even the most basic physiological and safety needs. Clearer heads must prevail in situations where the person may not have sound judgment or may not have fully considered the consequences of his or her decision. 

I think that those professionals whose specialty is infertility and assisting women in getting pregnant must have a moral code, a gauge if you will, that not only puts a stop to repeated failed attempts but also repeated successful births, especially if a pregnancy has resulted in multiple births. I think the responsibility is to have the ability to say “no,” and that responsibility doesn’t end.

Stephen Nunn: The role of the provider is an active and interactive one. The mother should undergo a psychologic or psychiatric evaluation. Risks and benefits need to be clearly explained and explored in an unbiased atmosphere. The provider has, in my opinion, the right to put limits on their involvement, such as adhering to established guidelines, protecting the potential fetuses’ health, insisting on a mental health evaluation, and refusing to be a party, if necessary.

Austin Potenza: Our medical system has gone, in the past 50 years, from one of paternalistic physicians and caregivers who really controlled all of the major decision-making in health care to one where it’s the patient who now is the king, makes all the major decisions, and is involved in his or her care. The health care provider is there to facilitate, maybe guide, those decisions, but not to interfere in them, unless they involve illegality (ie, assisted suicide) or overriding personal ethical beliefs (ie, abortion). But the decisions are ultimately the responsibility of the patient, if the patient is competent.

The point at which the caregiver’s responsibility becomes heightened is the point at which damage is being done to the patient—or, in cases such as this, to the fetuses, and that damage is foreseeable and preventable. Short of that, the caregiver’s role is generally secondary to the patient’s when it comes to medical decision-making.

What, if any, impact do you think the scientific/medical achievement in this case—which culminated in the successful delivery of octuplets —had on the clinicians’ judgment?

Marie-Eileen Onieal: I think that this event has placed the fertility specialty in jeopardy of being regulated for the wrong reasons. I think the physician took advantage of the science available.

Randy Danielsen: The technology in this case seems to have overridden the social implications. I am sure this case will be added to many others where the rights of the individual counter the ethical obligations of the provider in an absence of legal intervention.

Rebecca Scott: The way it comes across to me is that there’s a certain kind of arrogance in doing that kind of thing. And it’s the same kind of arrogance that we had a century ago, saying, “You’re mentally retarded; you should not be having children, therefore I am sterilizing you whether you want to be sterilized or not.” It’s kind of the flip side of that attitude.

At the same time, I really have a horror of setting up a situation where individual health care providers refuse to provide appropriate care because of individual beliefs. I think if we start going down that road, we’re really asking for trouble…. Medical decision-making is rarely clear-cut. The interaction between patient and provider is so much of a negotiation, tinged with so many “shades of gray,” that I believe we really have to think very carefully about whether making decisions for patients is appropriate.

Stephen Nunn: I doubt the notoriety of an octuplet birth held any sway over the decision. In fact, it probably was a negative factor. I am aware of a professed fertility specialist who became famous—or rather infamous—for being responsible for the largest number of quad births in the nation. For various reasons, the state medical board investigated, and the doctor agreed to stop the practices that led to this.

The remarkable thing seems to be that multiple gestations survive, not that they happen. I suspect that in the coming years, we will start hearing more about various learning and other disabilities as these children enter the school system.

Austin Potenza: It’s a very relevant question, and it really goes to the heart of ethical thinking. Whose interests is the caregiver really serving? The caregiver’s, by making a medical breakthrough, or the patient’s? I certainly can’t define whether such considerations had an influence in this case, but they clearly shouldn’t….

The truth is our medical abilities are advancing at just an amazing rate, and I think it’s sometimes hard to tell the difference between doing something because we can do it and doing something because it’s the right thing to do for a particular patient in a particular circumstance. Medical ethics is fighting to catch up with the medical advances that are being made, and we always have to be thinking about these things.

By now, the story of Nadya Suleman is well known. The 33-year-old California woman gave birth to octuplets—only the second set born in the United States—on January 26. Within a few weeks, what was initially reported as a heartwarming story of medicine’s finest hour had ignited a nationwide backlash as details of Suleman’s situation became known. The divorced single mom already had six children younger than 8 when she underwent the fertility treatments that led to an eight-baby bonanza.

Should Suleman have been allowed to undergo the additional treatments? Did her medical team violate guidelines by implanting more than the generally accepted number of embryos? Is it fair to burden taxpayers with the costs of raising her large family—particularly in the current economic climate?

Clinician Reviews does not profess to have the answers to these questions. But we did ask a panel of editorial board members and other experts for their take on the thorny ethical questions Suleman’s case has raised.

How do you feel about a woman with six children younger than 8 receiving fertility treatments and delivering another eight babies?

Stephen Nunn, MPAS, PA-C, a founding member of the Association of PAs in Ob-Gyn, who worked with the first successful in vitro fertilization program in Arizona for 18 years: The issue for me isn’t so much that she already has six children, but the real and serious risks to both the mother and fetuses with multiple gestation. The American Society of Reproductive Medicine has established guidelines for the number of embryos to be transferred, which for this patient would be three. It appears these guidelines were not used in this case. This would not have generated the same response had Ms. Suleman received fertility treatment in an effort to achieve a singleton or, at most, twin gestation.

Obviously, we do not know all the details; however, I wonder why so many embryos were placed. If there were a total of seven, as the press has stated, then there would have been more than one opportunity to achieve a single pregnancy. Even if the mother did not want the other embryos destroyed, she could have donated them to another woman.

Rebecca Scott, PhD, PA-C, Clinical Coordinator in the Physician Assistant Program at Northeastern University, Boston, and an elected member of the Board of Health in Sandwich, Massachusetts: I have been thinking about how this really illustrates a tension that we’ve had in our history of the rights of the individual versus the rights of the whole community. We have this long tradition of saying, “Everybody ought to be able to have children.” This seems to fit into that continuum of the individual’s right being very strongly upheld in this country over, perhaps, what is best for the good of society.

This is so interesting because other societies are quite up-front about their goals for their population. I remember traveling in Hungary at one point, where the people were not reproducing enough to replace the population. So the government said, “It’s in our best interests to have enough people to support the society,” and they actually subsidized moms with the equivalent of a factory worker’s wage to stay home with children for three years, up to three children’s worth.

The big thing that troubles me about this is where do the rights of the group get accounted for? Should we be paying tax dollars to subsidize people who want to have children?

Austin D. Potenza II, JD, a Phoenix-based attorney and Adjunct Professor at the Arizona School of Health Sciences, where he has taught a course on medical ethics for 10 years: I think in our society everything has to be open for discussion, but we have to realize that at some point it’s just discussion. Under current ethical thinking, the most important perspective is that of a competent patient. We as a society don’t make these kinds of decisions—whether it is getting fertility treatment or having multiple births—for people.

A close second is the perspective of the infants, but it is problematic to base a societal response on what is right for children when it comes to fertility and multiple birth. Is being born into a family of 14 somehow worse than not being born at all? If we’re trying to save children, what exactly are we saving them from? And why look at just these children? If we try to have a responsible answer to these questions, it is myopic to look only at this family.

Think about the thousands of children who are born into horrible poverty, hunger, abuse, and neglect. We don’t regulate their parents’ reproductive decisions. And that’s just considering our own country; if we really want to be concerned about children, think about places like Sierra Leone, where the infant mortality rate is about 25%. Although the consideration of the children is compelling, it is much more important to consider how to help them once they are born, rather than thinking of the solution in terms of fertility and multiple births.     

The next important ethical perspective is that of the caregiver [discussed in depth later]. 

Finally, society is a stakeholder, and this seems to be the perspective from which most people are approaching the issue. The typical questions you’re going to hear are, “Is the cost of care for this mother and these children going to fall on the rest of us as taxpayers? Is this part of what’s straining the health care and social support systems?” These are all valid questions, but they beg an awful lot of other questions that we have to answer first. For example, what should we spend our collective money on? Who decides?  

While it is understandable why the public is upset by this story, at the same time, does anyone have the right to impose restrictions on someone’s procreation? Where, if at all, do we draw a line in the sand? 

Marie-Eileen Onieal, PhD, CPNP, FAANP, Director of Medical Services for the Massachusetts Department of Youth Services and Clinician Reviews NP Editor-in-Chief: I think the line between moral soundness and legal rights was crossed when the woman put her desires to have more children above the needs of the children she already bore. Before the octup-let pregnancy, she needed more than minimal assistance to care for the six children she already had; at least two have special needs requiring more attention and care.  

I think, especially in the face of the fact that she is almost totally dependent on others to help her provide for her family, we as a society have a moral and legal obligation to impose restrictions on procreation (especially when one’s procreating consumes as many resources as this woman consumed).

Rebecca Scott: I don’t think sending hate mail and death threats is any way to respond in a civil society. But I think we do need to say, “No, it is not all right for somebody to be using taxpayer dollars to subsidize,” you know, whatever it is that the individual wants to do that is way above and beyond what most of us would consider reasonable. 

If we look at the welfare-to-work initiatives that took place under the Clinton administration, that’s a start on an answer. We made the decision at that point that it was OK to say to people, “You have to get off welfare. You must go to work.” But we also enabled people to do that by saying, “We will subsidize Medicaid so that you can continue to get coverage at these low-paying jobs where you don’t earn enough money to be able to pay for health care.”

Stephen Nunn: To me, the principle here is Primum non nocere or “First, do no harm.” A twin pregnancy is considered high risk just because it’s a twin pregnancy. Those risks skyrocket with each additional fetus. The main risk here is to the fetuses, their individual and collective survival, and the potential for future problems after birth, such as cerebral palsy, blindness, and learning disabilities. So, the risks and benefits have to be weighed on an individual basis.

Personally, I can see no circumstance to justify transferring more than four embryos—ever! Holding to this guideline is not restricting a woman’s right to procreation. It’s not saying “No,” it’s saying, “Not this many.”

Although the obstetrician’s patient is the mother, not the fetus, I believe the fertility specialist can’t take such a narrow view of his or her responsibilities. Ordinarily, an obstetrician becomes involved after pregnancy has occurred, while the fertility specialist is involved prior and thus has a greater duty in regard to the potential eventual outcome. Too much success can lead ultimately to failure.

Moving forward, where do we go from here? How might these issues be addressed?

Rebecca Scott: What I’m afraid is going to happen is that we’re going to react in a heavy-handed way and set up all kinds of oversight and come at it with a legislative approach—you know, somebody in the state legislature’s going to say, “Well, we’re going to make a rule about this.”

What I hope will happen is that we’ll have a good deal of dialogue about what’s appropriate and that that dialogue will include fertility specialists, public health experts, citizens in general, and government/public health departments and that the dialogue will try to come out with some policies and procedures to guide thinking in this kind of situation.

Austin Potenza: It’s very difficult for me to imagine any legislature taking on this issue. It would be politically impossible to attempt to regulate who can have children, and how many. Think back to the Terri Schiavo case, which was such a travesty in Congress. Everybody was trying to get involved, and it was obviously completely beyond the scope of their expertise and their ability. It was just a political nightmare. This is similar because it is government involvement in an intensely personal decision, in a country dedicated to personal freedoms. If we get involved in birth regulation, we’re repeating China’s mistakes and going against the fundamentally individual-rights focus of our society.

The next most likely—but still unlikely—step would be federal or state Medicare/Medicaid programs trying to regulate what kind of services they’ll pay for, in an effort to prevent these multiple births. In most cases, I don’t believe public or private money is available for fertility treatment, but I’m not expert in that area. Certainly, private insurers can decide, by contract, what they will and won’t cover, but when the government gets involved, it becomes more problematic. That could be seen as the state mandating forced embryo reductions. 

The only place that this could be regulated with any type of efficiency would be in the professional responsibility codes and the licensing boards of the various health care specialties.

What role can and should health care providers play in situations such as this? Where do their responsibilities end?

Randy D. Danielsen, PhD, PA-C, DFAAPA, Dean of the Arizona School of Health Sciences at A. T. Still University and Clinician Reviews PA Editor-in-Chief: We as clinicians must first require patients to be competent in their decision making, indicating the ability to make choices based on an understanding of the relevant consequences of their action. For the most part, this is subjective and relies on the skills of the clinician in recognizing the ability of the patient to understand and give consent.   

All clinicians have an obligation to be patient advocates in their area of expertise, but this does not give them the authority to overrule patients (except in certain situations).

Marie-Eileen Onieal: Given that this patient already had six young children, at least two with special needs, I think the role of the provider is to counsel the woman against trying to have more children. Providing for a large family takes energy, patience, and finances. I do not doubt that she loves the children; I just doubt that she is able to provide for their developmental needs—even the most basic physiological and safety needs. Clearer heads must prevail in situations where the person may not have sound judgment or may not have fully considered the consequences of his or her decision. 

I think that those professionals whose specialty is infertility and assisting women in getting pregnant must have a moral code, a gauge if you will, that not only puts a stop to repeated failed attempts but also repeated successful births, especially if a pregnancy has resulted in multiple births. I think the responsibility is to have the ability to say “no,” and that responsibility doesn’t end.

Stephen Nunn: The role of the provider is an active and interactive one. The mother should undergo a psychologic or psychiatric evaluation. Risks and benefits need to be clearly explained and explored in an unbiased atmosphere. The provider has, in my opinion, the right to put limits on their involvement, such as adhering to established guidelines, protecting the potential fetuses’ health, insisting on a mental health evaluation, and refusing to be a party, if necessary.

Austin Potenza: Our medical system has gone, in the past 50 years, from one of paternalistic physicians and caregivers who really controlled all of the major decision-making in health care to one where it’s the patient who now is the king, makes all the major decisions, and is involved in his or her care. The health care provider is there to facilitate, maybe guide, those decisions, but not to interfere in them, unless they involve illegality (ie, assisted suicide) or overriding personal ethical beliefs (ie, abortion). But the decisions are ultimately the responsibility of the patient, if the patient is competent.

The point at which the caregiver’s responsibility becomes heightened is the point at which damage is being done to the patient—or, in cases such as this, to the fetuses, and that damage is foreseeable and preventable. Short of that, the caregiver’s role is generally secondary to the patient’s when it comes to medical decision-making.

What, if any, impact do you think the scientific/medical achievement in this case—which culminated in the successful delivery of octuplets —had on the clinicians’ judgment?

Marie-Eileen Onieal: I think that this event has placed the fertility specialty in jeopardy of being regulated for the wrong reasons. I think the physician took advantage of the science available.

Randy Danielsen: The technology in this case seems to have overridden the social implications. I am sure this case will be added to many others where the rights of the individual counter the ethical obligations of the provider in an absence of legal intervention.

Rebecca Scott: The way it comes across to me is that there’s a certain kind of arrogance in doing that kind of thing. And it’s the same kind of arrogance that we had a century ago, saying, “You’re mentally retarded; you should not be having children, therefore I am sterilizing you whether you want to be sterilized or not.” It’s kind of the flip side of that attitude.

At the same time, I really have a horror of setting up a situation where individual health care providers refuse to provide appropriate care because of individual beliefs. I think if we start going down that road, we’re really asking for trouble…. Medical decision-making is rarely clear-cut. The interaction between patient and provider is so much of a negotiation, tinged with so many “shades of gray,” that I believe we really have to think very carefully about whether making decisions for patients is appropriate.

Stephen Nunn: I doubt the notoriety of an octuplet birth held any sway over the decision. In fact, it probably was a negative factor. I am aware of a professed fertility specialist who became famous—or rather infamous—for being responsible for the largest number of quad births in the nation. For various reasons, the state medical board investigated, and the doctor agreed to stop the practices that led to this.

The remarkable thing seems to be that multiple gestations survive, not that they happen. I suspect that in the coming years, we will start hearing more about various learning and other disabilities as these children enter the school system.

Austin Potenza: It’s a very relevant question, and it really goes to the heart of ethical thinking. Whose interests is the caregiver really serving? The caregiver’s, by making a medical breakthrough, or the patient’s? I certainly can’t define whether such considerations had an influence in this case, but they clearly shouldn’t….

The truth is our medical abilities are advancing at just an amazing rate, and I think it’s sometimes hard to tell the difference between doing something because we can do it and doing something because it’s the right thing to do for a particular patient in a particular circumstance. Medical ethics is fighting to catch up with the medical advances that are being made, and we always have to be thinking about these things.

If you want to talk about NPs and PAs around the world, check your generalizations at the door. Quite simply, there are few statements that would apply to every PA or every advanced practice nurse (APN, perhaps a more all-encompassing term in this context) from Boston to Botswana.

In a very broad sense, the health care issues affecting the larger world are similar to those faced in the United States: shortages of providers, spiraling costs, and a growing need for health care services due to an increase in chronic and infectious diseases. At the same time, economic, cultural, and political differences have a major impact on how countries approach these problems and how they can attempt to solve them. Poverty and lack of access mean something remarkably different in Africa than they do in the US.

This is why, even as PAs and NPs enthusiastically promote their professions as a viable solution to the world’s health care problems, it is essential to remember that one size does not fit all. “We need to encourage countries to adapt what we’re doing,” says Ruth Ballweg, MPA, PA-C, Director of the MEDEX Northwest Division of PA Studies at the University of Washington in Seattle and Director of International Affairs for the National Commission on Certification of Physician Assistants (NCCPA), “not adopt what we’re doing.”

Globe Trotting
Clinicians meeting their counterparts from another country may not immediately recognize the roles. Even the names are not always the same: In South Africa, the PA-equivalent role is the clinical associate, while in Mozambique, persons trained to do basic surgery are known as tecnicos de medicina. And among APNs, a survey of 34 countries conducted by the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) turned up 17 different titles.

These professions are often designed to address a specific need. Whereas a majority of APNs in the US are family nurse practitioners in out-of-hospital settings, in Asian countries, such as Japan, Taiwan, and Singapore, “it is more common to see roles develop in hospital settings, such as critical care or mental health or emergency departments,” according to Madrean Schober, MSN, NP-C, FAANP, an international health care consultant who is currently Senior Visiting Fellow at the Alice Lee Centre for Nursing Studies at the National University of Singapore. This is because primary care services may not be available or as developed as they are in the US.

Needs can also vary within regions. Queensland, Australia, has a need for clinicians in rural and remote areas; by contrast, South Australia has shortages in surgery and specialties.

In terms of adopting the US model, Ballweg sees the PA international scene divided into two groups. “There are the developed countries, where the model looks a lot like the US model … and then there are the developing countries, where it is really a model that looks a bit different,” she says. “And the main reason these other countries look a bit different is that there is such a shortage of physicians that there aren’t any physicians to assist!”

At the same time, in the less developed countries of the world, advanced practice roles may already exist—just in an informal or unofficial capacity. “If you look at poor countries in Africa, nurses have always had, I think, what we would call expanded roles,” says Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP, Co-Chair of the Education and Practice Subgroup for the INP/APNN. “They’re very highly thought of, and they work fairly independently because there’s a huge shortage of health care providers. I think a lot of nurses in these countries might be practicing more closely to the role, and then you would educate them to validate the practice.”

A good illustration of this is Botswana—in fact, Schober, who is also the International Liaison for the American Academy of Nurse Practitioners, says it is her favorite example. Due to a physician shortage, nurses in Botswana found themselves required to provide primary care services in communities—often as the sole provider.

“Eventually, recognizing that they lacked education and skills to continue providing quality services, nurses lobbied the Ministry of Health [MOH] for more education,” Schober explained in an e-mail to Clinician Reviews. The MOH instituted a one-year FNP program, developed in consultation with an American nurse in 1986; the program, which has evolved to 18 months, is now integrating with a Master’s-level program at the University of Botswana.

The International Council of Nurses recommends a Master’s degree for APNs; practical reasons prevent it from being a requirement. “In a very highly developed country, where there are lots of standardized educational programs, it’s pretty easy to say, ‘This should be a Master’s level,’” points out Pulcini, an Associate Professor and Department Chair at the William F. Connell School of Nursing, Boston College. “But if you don’t have a lot of Master’s programs, it’s not quite as easy.”

Respecting Differences
American clinicians who want to share their experience and accumulated wisdom with countries seeking guidance need to bear in mind that while the NP or PA model is a great idea, it may not work exactly the same way in another part of the world. The most well-intentioned efforts can be undermined if proper attention is not given to the cultural contexts of the country in question.

“You don’t just import something and say, ‘This model is going to work here,’” Ballweg says. “You actually go through a fairly detailed process to say, ‘What are our needs?’ Otherwise, you could end up with PAs and NPs in any of these countries working in the specialty hospitals, for the people who are fee-for-service and make a lot of money, and you wouldn’t have accomplished anything.”

Schober, who has worked with more than 20 different countries that are exploring the APN roles, notes, “All too often, countries are seduced by the concept but are unaware of the complexities and difficulties associated with developing and implementing the roles. ”

Issues of reciprocity between nations are already creeping up (however premature in most cases), bringing to the forefront a number of practical and ethical concerns. “There is this whole issue of whether there should be an international certifying exam for PAs,” Ballweg observes. “What needs more discussion is the ‘should we.’ Everybody is still working all this through, but I think I can safely say that we [the NCCPA] do not want to create an infrastructure that encourages brain drain. At the same time, we want to provide assistance to countries and regions that want to develop credentialing mechanisms.”

It would be unethical to prevent a clinician from taking advantage of better opportunities in another country. But at the same time, the goal of developing APN or PA roles in these nations is to better meet the needs of the people within that country. This is a complicated issue, Schober says, “with no easy nonpolitical answer.” One positive step that countries can take to offset the risk of a “brain drain” is to create incentives that will attract and retain homeland clinicians.

Differences in language and cultural norms, and even in the practice of medicine, may make a universal exam impractical, anyway. “That doesn’t mean that a credentialing process isn’t a good thing,” Ballweg says. “It just might look very different in Africa than it would in the United Kingdom or the European community, compared to the US and Canada.”

American clinicians who interact with their international counterparts must be prepared to be diplomats, in a way. In addition to being sensitive to cultural differences, it is essential to understand how the US fits into the world stage. “Become knowledgeable about the world in general” is Schober’s advice. “In working internationally, you are often expected not only to comment on the value of APNs to health care systems but also to provide your opinion on the US approach to foreign policy or to the economic downturn.”

Sharing information encourages learning on both sides and promotes mutual respect. It also provides an opportunity to prevent missteps that may have been made previously. “In many places, in the early days, PAs and NPs were pitted against each other,” Ballweg points out about the US, “and some people still view us as competitors.”

Ballweg shares the Clinician Reviews philosophy of NPs and PAs working together. Whenever people in other countries ask about the NP/PA relationship—and yes, the question does come up—she provides examples of how the professions can support each other.

“I try to make the point that if you just have individual training programs, then you just have training programs,” Ballweg says. “But if you have PAs and NPs working together and moving ahead on a policy front, then you have a movement.

“That’s really what we want—to create this movement that has to do with access to care and improving global health everywhere.”

If you want to talk about NPs and PAs around the world, check your generalizations at the door. Quite simply, there are few statements that would apply to every PA or every advanced practice nurse (APN, perhaps a more all-encompassing term in this context) from Boston to Botswana.

In a very broad sense, the health care issues affecting the larger world are similar to those faced in the United States: shortages of providers, spiraling costs, and a growing need for health care services due to an increase in chronic and infectious diseases. At the same time, economic, cultural, and political differences have a major impact on how countries approach these problems and how they can attempt to solve them. Poverty and lack of access mean something remarkably different in Africa than they do in the US.

This is why, even as PAs and NPs enthusiastically promote their professions as a viable solution to the world’s health care problems, it is essential to remember that one size does not fit all. “We need to encourage countries to adapt what we’re doing,” says Ruth Ballweg, MPA, PA-C, Director of the MEDEX Northwest Division of PA Studies at the University of Washington in Seattle and Director of International Affairs for the National Commission on Certification of Physician Assistants (NCCPA), “not adopt what we’re doing.”

Globe Trotting
Clinicians meeting their counterparts from another country may not immediately recognize the roles. Even the names are not always the same: In South Africa, the PA-equivalent role is the clinical associate, while in Mozambique, persons trained to do basic surgery are known as tecnicos de medicina. And among APNs, a survey of 34 countries conducted by the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) turned up 17 different titles.

These professions are often designed to address a specific need. Whereas a majority of APNs in the US are family nurse practitioners in out-of-hospital settings, in Asian countries, such as Japan, Taiwan, and Singapore, “it is more common to see roles develop in hospital settings, such as critical care or mental health or emergency departments,” according to Madrean Schober, MSN, NP-C, FAANP, an international health care consultant who is currently Senior Visiting Fellow at the Alice Lee Centre for Nursing Studies at the National University of Singapore. This is because primary care services may not be available or as developed as they are in the US.

Needs can also vary within regions. Queensland, Australia, has a need for clinicians in rural and remote areas; by contrast, South Australia has shortages in surgery and specialties.

In terms of adopting the US model, Ballweg sees the PA international scene divided into two groups. “There are the developed countries, where the model looks a lot like the US model … and then there are the developing countries, where it is really a model that looks a bit different,” she says. “And the main reason these other countries look a bit different is that there is such a shortage of physicians that there aren’t any physicians to assist!”

At the same time, in the less developed countries of the world, advanced practice roles may already exist—just in an informal or unofficial capacity. “If you look at poor countries in Africa, nurses have always had, I think, what we would call expanded roles,” says Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP, Co-Chair of the Education and Practice Subgroup for the INP/APNN. “They’re very highly thought of, and they work fairly independently because there’s a huge shortage of health care providers. I think a lot of nurses in these countries might be practicing more closely to the role, and then you would educate them to validate the practice.”

A good illustration of this is Botswana—in fact, Schober, who is also the International Liaison for the American Academy of Nurse Practitioners, says it is her favorite example. Due to a physician shortage, nurses in Botswana found themselves required to provide primary care services in communities—often as the sole provider.

“Eventually, recognizing that they lacked education and skills to continue providing quality services, nurses lobbied the Ministry of Health [MOH] for more education,” Schober explained in an e-mail to Clinician Reviews. The MOH instituted a one-year FNP program, developed in consultation with an American nurse in 1986; the program, which has evolved to 18 months, is now integrating with a Master’s-level program at the University of Botswana.

The International Council of Nurses recommends a Master’s degree for APNs; practical reasons prevent it from being a requirement. “In a very highly developed country, where there are lots of standardized educational programs, it’s pretty easy to say, ‘This should be a Master’s level,’” points out Pulcini, an Associate Professor and Department Chair at the William F. Connell School of Nursing, Boston College. “But if you don’t have a lot of Master’s programs, it’s not quite as easy.”

Respecting Differences
American clinicians who want to share their experience and accumulated wisdom with countries seeking guidance need to bear in mind that while the NP or PA model is a great idea, it may not work exactly the same way in another part of the world. The most well-intentioned efforts can be undermined if proper attention is not given to the cultural contexts of the country in question.

“You don’t just import something and say, ‘This model is going to work here,’” Ballweg says. “You actually go through a fairly detailed process to say, ‘What are our needs?’ Otherwise, you could end up with PAs and NPs in any of these countries working in the specialty hospitals, for the people who are fee-for-service and make a lot of money, and you wouldn’t have accomplished anything.”

Schober, who has worked with more than 20 different countries that are exploring the APN roles, notes, “All too often, countries are seduced by the concept but are unaware of the complexities and difficulties associated with developing and implementing the roles. ”

Issues of reciprocity between nations are already creeping up (however premature in most cases), bringing to the forefront a number of practical and ethical concerns. “There is this whole issue of whether there should be an international certifying exam for PAs,” Ballweg observes. “What needs more discussion is the ‘should we.’ Everybody is still working all this through, but I think I can safely say that we [the NCCPA] do not want to create an infrastructure that encourages brain drain. At the same time, we want to provide assistance to countries and regions that want to develop credentialing mechanisms.”

It would be unethical to prevent a clinician from taking advantage of better opportunities in another country. But at the same time, the goal of developing APN or PA roles in these nations is to better meet the needs of the people within that country. This is a complicated issue, Schober says, “with no easy nonpolitical answer.” One positive step that countries can take to offset the risk of a “brain drain” is to create incentives that will attract and retain homeland clinicians.

Differences in language and cultural norms, and even in the practice of medicine, may make a universal exam impractical, anyway. “That doesn’t mean that a credentialing process isn’t a good thing,” Ballweg says. “It just might look very different in Africa than it would in the United Kingdom or the European community, compared to the US and Canada.”

American clinicians who interact with their international counterparts must be prepared to be diplomats, in a way. In addition to being sensitive to cultural differences, it is essential to understand how the US fits into the world stage. “Become knowledgeable about the world in general” is Schober’s advice. “In working internationally, you are often expected not only to comment on the value of APNs to health care systems but also to provide your opinion on the US approach to foreign policy or to the economic downturn.”

Sharing information encourages learning on both sides and promotes mutual respect. It also provides an opportunity to prevent missteps that may have been made previously. “In many places, in the early days, PAs and NPs were pitted against each other,” Ballweg points out about the US, “and some people still view us as competitors.”

Ballweg shares the Clinician Reviews philosophy of NPs and PAs working together. Whenever people in other countries ask about the NP/PA relationship—and yes, the question does come up—she provides examples of how the professions can support each other.

“I try to make the point that if you just have individual training programs, then you just have training programs,” Ballweg says. “But if you have PAs and NPs working together and moving ahead on a policy front, then you have a movement.

“That’s really what we want—to create this movement that has to do with access to care and improving global health everywhere.”

If you want to talk about NPs and PAs around the world, check your generalizations at the door. Quite simply, there are few statements that would apply to every PA or every advanced practice nurse (APN, perhaps a more all-encompassing term in this context) from Boston to Botswana.

In a very broad sense, the health care issues affecting the larger world are similar to those faced in the United States: shortages of providers, spiraling costs, and a growing need for health care services due to an increase in chronic and infectious diseases. At the same time, economic, cultural, and political differences have a major impact on how countries approach these problems and how they can attempt to solve them. Poverty and lack of access mean something remarkably different in Africa than they do in the US.

This is why, even as PAs and NPs enthusiastically promote their professions as a viable solution to the world’s health care problems, it is essential to remember that one size does not fit all. “We need to encourage countries to adapt what we’re doing,” says Ruth Ballweg, MPA, PA-C, Director of the MEDEX Northwest Division of PA Studies at the University of Washington in Seattle and Director of International Affairs for the National Commission on Certification of Physician Assistants (NCCPA), “not adopt what we’re doing.”

Globe Trotting
Clinicians meeting their counterparts from another country may not immediately recognize the roles. Even the names are not always the same: In South Africa, the PA-equivalent role is the clinical associate, while in Mozambique, persons trained to do basic surgery are known as tecnicos de medicina. And among APNs, a survey of 34 countries conducted by the International Nurse Practitioner/Advanced Practice Nursing Network (INP/APNN) turned up 17 different titles.

These professions are often designed to address a specific need. Whereas a majority of APNs in the US are family nurse practitioners in out-of-hospital settings, in Asian countries, such as Japan, Taiwan, and Singapore, “it is more common to see roles develop in hospital settings, such as critical care or mental health or emergency departments,” according to Madrean Schober, MSN, NP-C, FAANP, an international health care consultant who is currently Senior Visiting Fellow at the Alice Lee Centre for Nursing Studies at the National University of Singapore. This is because primary care services may not be available or as developed as they are in the US.

Needs can also vary within regions. Queensland, Australia, has a need for clinicians in rural and remote areas; by contrast, South Australia has shortages in surgery and specialties.

In terms of adopting the US model, Ballweg sees the PA international scene divided into two groups. “There are the developed countries, where the model looks a lot like the US model … and then there are the developing countries, where it is really a model that looks a bit different,” she says. “And the main reason these other countries look a bit different is that there is such a shortage of physicians that there aren’t any physicians to assist!”

At the same time, in the less developed countries of the world, advanced practice roles may already exist—just in an informal or unofficial capacity. “If you look at poor countries in Africa, nurses have always had, I think, what we would call expanded roles,” says Joyce Pulcini, PhD, RN, PNP-BC, FAAN, FAANP, Co-Chair of the Education and Practice Subgroup for the INP/APNN. “They’re very highly thought of, and they work fairly independently because there’s a huge shortage of health care providers. I think a lot of nurses in these countries might be practicing more closely to the role, and then you would educate them to validate the practice.”

A good illustration of this is Botswana—in fact, Schober, who is also the International Liaison for the American Academy of Nurse Practitioners, says it is her favorite example. Due to a physician shortage, nurses in Botswana found themselves required to provide primary care services in communities—often as the sole provider.

“Eventually, recognizing that they lacked education and skills to continue providing quality services, nurses lobbied the Ministry of Health [MOH] for more education,” Schober explained in an e-mail to Clinician Reviews. The MOH instituted a one-year FNP program, developed in consultation with an American nurse in 1986; the program, which has evolved to 18 months, is now integrating with a Master’s-level program at the University of Botswana.

The International Council of Nurses recommends a Master’s degree for APNs; practical reasons prevent it from being a requirement. “In a very highly developed country, where there are lots of standardized educational programs, it’s pretty easy to say, ‘This should be a Master’s level,’” points out Pulcini, an Associate Professor and Department Chair at the William F. Connell School of Nursing, Boston College. “But if you don’t have a lot of Master’s programs, it’s not quite as easy.”

Respecting Differences
American clinicians who want to share their experience and accumulated wisdom with countries seeking guidance need to bear in mind that while the NP or PA model is a great idea, it may not work exactly the same way in another part of the world. The most well-intentioned efforts can be undermined if proper attention is not given to the cultural contexts of the country in question.

“You don’t just import something and say, ‘This model is going to work here,’” Ballweg says. “You actually go through a fairly detailed process to say, ‘What are our needs?’ Otherwise, you could end up with PAs and NPs in any of these countries working in the specialty hospitals, for the people who are fee-for-service and make a lot of money, and you wouldn’t have accomplished anything.”

Schober, who has worked with more than 20 different countries that are exploring the APN roles, notes, “All too often, countries are seduced by the concept but are unaware of the complexities and difficulties associated with developing and implementing the roles. ”

Issues of reciprocity between nations are already creeping up (however premature in most cases), bringing to the forefront a number of practical and ethical concerns. “There is this whole issue of whether there should be an international certifying exam for PAs,” Ballweg observes. “What needs more discussion is the ‘should we.’ Everybody is still working all this through, but I think I can safely say that we [the NCCPA] do not want to create an infrastructure that encourages brain drain. At the same time, we want to provide assistance to countries and regions that want to develop credentialing mechanisms.”

It would be unethical to prevent a clinician from taking advantage of better opportunities in another country. But at the same time, the goal of developing APN or PA roles in these nations is to better meet the needs of the people within that country. This is a complicated issue, Schober says, “with no easy nonpolitical answer.” One positive step that countries can take to offset the risk of a “brain drain” is to create incentives that will attract and retain homeland clinicians.

Differences in language and cultural norms, and even in the practice of medicine, may make a universal exam impractical, anyway. “That doesn’t mean that a credentialing process isn’t a good thing,” Ballweg says. “It just might look very different in Africa than it would in the United Kingdom or the European community, compared to the US and Canada.”

American clinicians who interact with their international counterparts must be prepared to be diplomats, in a way. In addition to being sensitive to cultural differences, it is essential to understand how the US fits into the world stage. “Become knowledgeable about the world in general” is Schober’s advice. “In working internationally, you are often expected not only to comment on the value of APNs to health care systems but also to provide your opinion on the US approach to foreign policy or to the economic downturn.”

Sharing information encourages learning on both sides and promotes mutual respect. It also provides an opportunity to prevent missteps that may have been made previously. “In many places, in the early days, PAs and NPs were pitted against each other,” Ballweg points out about the US, “and some people still view us as competitors.”

Ballweg shares the Clinician Reviews philosophy of NPs and PAs working together. Whenever people in other countries ask about the NP/PA relationship—and yes, the question does come up—she provides examples of how the professions can support each other.

“I try to make the point that if you just have individual training programs, then you just have training programs,” Ballweg says. “But if you have PAs and NPs working together and moving ahead on a policy front, then you have a movement.

“That’s really what we want—to create this movement that has to do with access to care and improving global health everywhere.”

In addition to doing countless other things, American Academy of Nurse Practitioners Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, works full-time on Capitol Hill. Towers, whose agenda for 2009 includes “all things related to health care reform,” shared some of her thoughts on the year ahead with Clinician Reviews.

What are some of the challenges of working with a new administration and a new Congress? What can be done to work around those obstacles?

The biggest challenge is that you have newcomers—and we have a lot of them—who often need to be educated about what NPs do, what our preparation is, and how we can have a positive impact in the health care arena. So it’s important for NPs, particularly if they have a new legislator coming to Congress, to try to meet with him or her and talk about what we do and what some of our issues are. [Editor’s note: While Towers speaks for NPs, her response certainly applies to PAs as well.]

What opportunities do you think the Obama administration might create for nonphysician providers?
President-Elect Obama is inviting input from and appointing people who have been known to be supportive of nonphysician providers, such as Mr. Daschle and Dr. Fox [Secretary of Health and Human Services (HHS) nominee Tom Daschle and Claude Earl Fox, MD, MPH, a member of the HHS agency review team for Obama’s transition team]. These are people who have some understanding of what nonphysician providers can do and how they can contribute to the health care scene, both in terms of high-quality care and in terms of cost-effectiveness. We feel that that should make it a little easier for us to have influence.

Based on your knowledge of the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
I think everybody recognizes that you can’t just overturn the apple cart. You can’t do it any way, but with the precariousness of the economy right now, you just can’t do a major revamp in that kind of atmosphere. The changes that are being proposed are based on existing systems. That’s a different kind of challenge for us than if it was a total revamp.

What they have proposed are all things that have been discussed in the past and are logical in terms of trying to find ways to reach more people and make things more cost-effective. But in order to keep people healthy, there is an expenditure that has to be made. Nothing is going to come cheap.

On the other hand, when you say, “A $5 Band-Aid is not going to fix it,” that’s right. But what you want to do is try to make the cost go down to where it’s a logical cost. If you reduce the Band-Aid to a nickel, then you can use the other $4.95 to deal with other issues.

One of the things that’s being talked about more now than it has been in the past—it’s not necessarily coming from the Obama camp—is the fact that there are things we can do in terms of health care that don’t have anything to do with health care providers, hospitals, that sort of thing—such as parks, playgrounds, good nutrition, schools.

With the understanding that the wholesale health care reform we probably need will take time—longer than one year, possibly longer than a single term—what do you think the priorities need to be?
A lot has to do with the economy at this point in time. What’s being tossed around now is that there are going to be short-term things being dealt with initially. So we’re talking about SGR [sustainable growth rate], we’re talking about SCHIP [State Children’s Health Insurance Program], we’re talking about appropriations. We’re not talking about major reform in that first 100 days, which we were talking about many months ago. The priorities are the short-term things, and I think what they’ll try to do is adjust current programs to achieve those things.         

In addition to doing countless other things, American Academy of Nurse Practitioners Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, works full-time on Capitol Hill. Towers, whose agenda for 2009 includes “all things related to health care reform,” shared some of her thoughts on the year ahead with Clinician Reviews.

What are some of the challenges of working with a new administration and a new Congress? What can be done to work around those obstacles?

The biggest challenge is that you have newcomers—and we have a lot of them—who often need to be educated about what NPs do, what our preparation is, and how we can have a positive impact in the health care arena. So it’s important for NPs, particularly if they have a new legislator coming to Congress, to try to meet with him or her and talk about what we do and what some of our issues are. [Editor’s note: While Towers speaks for NPs, her response certainly applies to PAs as well.]

What opportunities do you think the Obama administration might create for nonphysician providers?
President-Elect Obama is inviting input from and appointing people who have been known to be supportive of nonphysician providers, such as Mr. Daschle and Dr. Fox [Secretary of Health and Human Services (HHS) nominee Tom Daschle and Claude Earl Fox, MD, MPH, a member of the HHS agency review team for Obama’s transition team]. These are people who have some understanding of what nonphysician providers can do and how they can contribute to the health care scene, both in terms of high-quality care and in terms of cost-effectiveness. We feel that that should make it a little easier for us to have influence.

Based on your knowledge of the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
I think everybody recognizes that you can’t just overturn the apple cart. You can’t do it any way, but with the precariousness of the economy right now, you just can’t do a major revamp in that kind of atmosphere. The changes that are being proposed are based on existing systems. That’s a different kind of challenge for us than if it was a total revamp.

What they have proposed are all things that have been discussed in the past and are logical in terms of trying to find ways to reach more people and make things more cost-effective. But in order to keep people healthy, there is an expenditure that has to be made. Nothing is going to come cheap.

On the other hand, when you say, “A $5 Band-Aid is not going to fix it,” that’s right. But what you want to do is try to make the cost go down to where it’s a logical cost. If you reduce the Band-Aid to a nickel, then you can use the other $4.95 to deal with other issues.

One of the things that’s being talked about more now than it has been in the past—it’s not necessarily coming from the Obama camp—is the fact that there are things we can do in terms of health care that don’t have anything to do with health care providers, hospitals, that sort of thing—such as parks, playgrounds, good nutrition, schools.

With the understanding that the wholesale health care reform we probably need will take time—longer than one year, possibly longer than a single term—what do you think the priorities need to be?
A lot has to do with the economy at this point in time. What’s being tossed around now is that there are going to be short-term things being dealt with initially. So we’re talking about SGR [sustainable growth rate], we’re talking about SCHIP [State Children’s Health Insurance Program], we’re talking about appropriations. We’re not talking about major reform in that first 100 days, which we were talking about many months ago. The priorities are the short-term things, and I think what they’ll try to do is adjust current programs to achieve those things.         

In addition to doing countless other things, American Academy of Nurse Practitioners Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, works full-time on Capitol Hill. Towers, whose agenda for 2009 includes “all things related to health care reform,” shared some of her thoughts on the year ahead with Clinician Reviews.

What are some of the challenges of working with a new administration and a new Congress? What can be done to work around those obstacles?

The biggest challenge is that you have newcomers—and we have a lot of them—who often need to be educated about what NPs do, what our preparation is, and how we can have a positive impact in the health care arena. So it’s important for NPs, particularly if they have a new legislator coming to Congress, to try to meet with him or her and talk about what we do and what some of our issues are. [Editor’s note: While Towers speaks for NPs, her response certainly applies to PAs as well.]

What opportunities do you think the Obama administration might create for nonphysician providers?
President-Elect Obama is inviting input from and appointing people who have been known to be supportive of nonphysician providers, such as Mr. Daschle and Dr. Fox [Secretary of Health and Human Services (HHS) nominee Tom Daschle and Claude Earl Fox, MD, MPH, a member of the HHS agency review team for Obama’s transition team]. These are people who have some understanding of what nonphysician providers can do and how they can contribute to the health care scene, both in terms of high-quality care and in terms of cost-effectiveness. We feel that that should make it a little easier for us to have influence.

Based on your knowledge of the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
I think everybody recognizes that you can’t just overturn the apple cart. You can’t do it any way, but with the precariousness of the economy right now, you just can’t do a major revamp in that kind of atmosphere. The changes that are being proposed are based on existing systems. That’s a different kind of challenge for us than if it was a total revamp.

What they have proposed are all things that have been discussed in the past and are logical in terms of trying to find ways to reach more people and make things more cost-effective. But in order to keep people healthy, there is an expenditure that has to be made. Nothing is going to come cheap.

On the other hand, when you say, “A $5 Band-Aid is not going to fix it,” that’s right. But what you want to do is try to make the cost go down to where it’s a logical cost. If you reduce the Band-Aid to a nickel, then you can use the other $4.95 to deal with other issues.

One of the things that’s being talked about more now than it has been in the past—it’s not necessarily coming from the Obama camp—is the fact that there are things we can do in terms of health care that don’t have anything to do with health care providers, hospitals, that sort of thing—such as parks, playgrounds, good nutrition, schools.

With the understanding that the wholesale health care reform we probably need will take time—longer than one year, possibly longer than a single term—what do you think the priorities need to be?
A lot has to do with the economy at this point in time. What’s being tossed around now is that there are going to be short-term things being dealt with initially. So we’re talking about SGR [sustainable growth rate], we’re talking about SCHIP [State Children’s Health Insurance Program], we’re talking about appropriations. We’re not talking about major reform in that first 100 days, which we were talking about many months ago. The priorities are the short-term things, and I think what they’ll try to do is adjust current programs to achieve those things.         

For the first time in eight years, a new year brings a new administration to the United States. Most Americans, regardless of their political persuasion, seem ready to embrace what they hope will be a complete change from the status quo.

Patients and health care providers alike will be watching to see whether President-Elect Barack Obama, his Cabinet, and the 111th Congress can initiate the wholesale health care reform the nation needs. Clinician Reviews asked American Academy of Nurse Practitioners President Diana “Dee” Swanson, MSN, NP-C, FAANP, and American Academy of Physician Assistants President Cynthia B. Lord, MHS, PA-C, for their perspectives on what’s ahead—and how NPs and PAs fit in.

What are some of the challenges of working with a new administration and new members of Congress, and how do you work around those obstacles?
Swanson: I would say, probably, having the kind of recognition that we need. There are a lot of loud, moneyed voices out there that dominate the conversation—primarily physician groups and insurance groups. Hopefully with the new administration, they will listen to new, fresh voices—because clearly, the voices that have been heard to date have not offered any solutions to the problems that we face. All they’ve offered is more of the same, with their hand out, asking for more money.

My personal high priority is that we get a seat at the table with the Obama transition team. We have got to get in on the ground floor with a new administration, and it is imperative that we be able to meet with [Secretary of Health and Human Services nominee] Tom Daschle and discuss what we can bring to primary care.

Our health care system is floundering; we all know that. Primary care is floundering. Only 2% of medical school graduates are choosing primary care. There are 125,000-plus NPs out there prepared to provide primary care. We’ve got barriers all over the place to being able to efficiently do that. So my personal priority is to be at the table with the transition team.

Lord: Two things that we’re going to focus on are time and education. We’ve worked with Senator Daschle’s office before, so there are legislative aides and people that we know. But certainly with the new administration and members of Congress to contact, that’s going to take some time. So we’re already well into making those initial contacts, and certainly we’ll call in PAs from various states to help out in key areas.

The other thing that’s going to be required is education, because it is our job to explain why the issues that affect PAs actually affect the ability to provide quality, cost-effective care to patients, and how that impacts patient care. Although we have a number of friends who are still in Congress and in those positions of authority—so we won’t have to start from square one—there’s going to be that whole new regime that comes in.

So I think time and education are going to be our biggest challenges but also opportunities—because we’re not the same profession we were even 10 years ago. We’re not what we were 40 years ago. And we can certainly cite more areas where PAs have made an impact.

Based on what you know about the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
Swanson: From my perspective, it’s a good start. Nobody in the last eight years has seriously addressed health issues at all. I don’t know how it will play out. Clearly, there are a lot of pressing issues—the economy notwithstanding—that will affect the ability of the new administration to implement changes.

I suspect that what we will see will be a collage, I suppose, of existing systems and structures. I think the idea to use the federal employee health model is admirable. Whether President-Elect Obama’s actually going to be able to get that implemented.… Certainly, he has a majority in the House and Senate, [but] not enough to prevent a filibuster, which I’m sure is going to be a challenge when you’re threatening large groups like health insurance companies.

I think his heart is in the right place; I just think there are a lot of factors that won’t come into play until he actually is in office and starts dealing with people. And I think it’s easy to envision what you’d like to see, and it’s another thing to get down to the nuts and bolts of how to make it happen. But I hope they listen to new voices. I hope that they are as open as they seem to be.

Lord: A lot of this is so theoretical when you get down to how it is going to happen. But overall, the concept seems like a reasonable one. It builds on what currently does work, including the employer-sponsored plans, Medicare, Medicaid. I mean, they have to be improved, but there are components that do work. The SCHIP [State Children’s Health Insurance Program]—I talk to PAs across the country, and if it weren’t for SCHIP, some kids would have nothing. So, we do have plans and programs that work. They can work better. We also need to look at insurance reform to make the private market more consumer-friendly.

Another aspect is an improved focus on wellness and health disparities. I’ve always said we chase disease. Health promotion, or disease prevention, means “Let’s truly work on obesity, let’s get you so you don’t have diabetes.” But what do we do? We take care of very sick patients who already have those diseases. At least theoretically, the Obama-Biden model looks at that and says, “This is where we’re going to focus,” on prevention and health care disparities….

Now, of course, when people actually get into office, they always find out what their hurdles are. We seem excited because this group is trying to be more bipartisan and not look at party but rather “Let’s look at the problem and bring in a broad group of players.” So we’re hopeful.

One of the keys is—I hope—that they reach out. Obama has been very smart in using the Internet and mobilizing people, whether it was building his campaign or collecting money, but also now giving people an opportunity to voice their opinions. So I’m hoping they use that information—that they don’t just say, “We want to hear from you,” and then don’t do anything with that.

Allowing for the fact that the level of reform our health care system needs will take time, what do you think should be the priorities? What must be addressed first?
Swanson: What has to be addressed first? The uninsured. From my perspective, I’m a full-time NP in a rural health practice in Indiana, and I see a lot of people who have no health insurance. That has a profound effect on their ability to be healthy, productive, contributing members of their local communities, their state, and the United States. I have people who are insulin-requiring diabetics who can’t afford to test their glucose, who can’t afford testing supplies or insulin—just the basics of managing their care—much less worry about optimal glycemic control. I have people who are young, who have diseases that can cause early demise—hyperlipidemia, hypertension, obesity.

Health care shouldn’t be a privilege. It should be a right. The Declaration of Independence says that we have the right to pursue happiness, and health has to be part of that.

There are innovative plans that are out there. Indiana has the Healthy Indiana Plan, which has been in place for about a year. It’s funded in part by tobacco money. This is for people who are uninsured and can’t afford to purchase employer-offered insurance plans. It covers preventive care, hospital care, acute care. And people are required to get their preventive health care or they lose this health savings account that they accrue over a period of time. They get, I believe, $1,000 in a health savings account, and if they don’t do their preventive care during the year, they lose that. That is a powerful incentive. 

You know, it’s just so interconnected. If your children are unhealthy, they’re not going to do well in school. If you have unhealthy workers, they’re going to cost the system money. A lot of these people wait until they’re in crisis and present to the emergency room, and that’s expensive, as is the hospital. I feel that addressing the needs of the uninsured is critical, and that involves primary care.

Lord: We have to look at universal coverage. But I think philosophically, before you get there, there has to be an understanding amongst all of us in health care—including physicians—that no man is an island. We have to work in coalitions; we have to work together. I can give you a million reasons why PAs are part of the solution, but we’ve always qualified that: We’re part of the solution; we’re not the solution.... Everyone’s role is important. This is about patient care; this isn’t about PAs, or NPs, or physicians. It’s about patients….

And then from there, we need to look at universal coverage: How do we get that access? How do we get people covered? It may very well be addressed by phasing in coverage. It may not just all happen; they may have to do some kind of phase-in.

And on the other end, where’s your workforce? Who’s going to see all these people? You’re between a rock and a hard place. [At the American Medical Association meeting last month] Massachusetts was at the microphone a lot talking about their universal coverage plan, the theory of it and what has developed. Everybody hasn’t even tried to get care yet, but [with] just the increase from everyone knowing that they have access, people are still waiting in line. There just aren’t enough providers. So, my theory is, there are enough sick people to go around. We all have to work together on that and see what the strengths of each group are.

In an ideal world, what would you like to see achieved in terms of health care reform—in general and with regard to NPs/PAs—by the end of 2009?
Swanson: I would like to see that health care is valued and is a right and not a privilege. In an ideal world, everyone would be able to receive health care services. The system would not be physician-centric or system-centric; it would be patient-centric.

We would have electronic health records so that we could communicate among systems. There would be a central repository for an individual’s health records that they themselves could have access to, so that you would never show up in a venue and not have a history for a patient.

There would be no barriers. All qualified providers would be able to provide the services that are needed, without turf issues and false claims of quality—we all know the quality issue is a trumped-up issue. There’s plenty of data out there that people other than physicians probably are better qualified to provide primary care services. So I would like to see no barriers to information, to access, to quality.

Lord: I would certainly like to see a cultural shift—which, in medicine, will certainly be a shift—where we acknowledge that we all are part of this team and that patients come first. There are so many different groups and types of providers, at all different levels; if we could all acknowledge that everyone plays a role, I think we’d get the most out of it. We truly would improve patient care. So there’s my “save the world and create world peace” answer: that we all truly function to the max and don’t worry about who’s stepping on whose toes.

And from a PA’s standpoint, I hope that we see full engagement of the Academy and the PA community in health care reform. I certainly would like to see, instead of us knocking at the door, saying “Please make sure we’re included,” that groups come to us, to the Academy, and say, “We want you at the table. What is your plan? What do you have to offer?”

It can’t just be done legislatively; it can’t just be done by the payers. Everyone has to work together to develop that plan. It’s an exciting time, because everyone wants change. The country wants it; it’s not just one political group. Patients want it, and they’re speaking out. We’re advocating for our patients. I think those things continue to be really important.

For the first time in eight years, a new year brings a new administration to the United States. Most Americans, regardless of their political persuasion, seem ready to embrace what they hope will be a complete change from the status quo.

Patients and health care providers alike will be watching to see whether President-Elect Barack Obama, his Cabinet, and the 111th Congress can initiate the wholesale health care reform the nation needs. Clinician Reviews asked American Academy of Nurse Practitioners President Diana “Dee” Swanson, MSN, NP-C, FAANP, and American Academy of Physician Assistants President Cynthia B. Lord, MHS, PA-C, for their perspectives on what’s ahead—and how NPs and PAs fit in.

What are some of the challenges of working with a new administration and new members of Congress, and how do you work around those obstacles?
Swanson: I would say, probably, having the kind of recognition that we need. There are a lot of loud, moneyed voices out there that dominate the conversation—primarily physician groups and insurance groups. Hopefully with the new administration, they will listen to new, fresh voices—because clearly, the voices that have been heard to date have not offered any solutions to the problems that we face. All they’ve offered is more of the same, with their hand out, asking for more money.

My personal high priority is that we get a seat at the table with the Obama transition team. We have got to get in on the ground floor with a new administration, and it is imperative that we be able to meet with [Secretary of Health and Human Services nominee] Tom Daschle and discuss what we can bring to primary care.

Our health care system is floundering; we all know that. Primary care is floundering. Only 2% of medical school graduates are choosing primary care. There are 125,000-plus NPs out there prepared to provide primary care. We’ve got barriers all over the place to being able to efficiently do that. So my personal priority is to be at the table with the transition team.

Lord: Two things that we’re going to focus on are time and education. We’ve worked with Senator Daschle’s office before, so there are legislative aides and people that we know. But certainly with the new administration and members of Congress to contact, that’s going to take some time. So we’re already well into making those initial contacts, and certainly we’ll call in PAs from various states to help out in key areas.

The other thing that’s going to be required is education, because it is our job to explain why the issues that affect PAs actually affect the ability to provide quality, cost-effective care to patients, and how that impacts patient care. Although we have a number of friends who are still in Congress and in those positions of authority—so we won’t have to start from square one—there’s going to be that whole new regime that comes in.

So I think time and education are going to be our biggest challenges but also opportunities—because we’re not the same profession we were even 10 years ago. We’re not what we were 40 years ago. And we can certainly cite more areas where PAs have made an impact.

Based on what you know about the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
Swanson: From my perspective, it’s a good start. Nobody in the last eight years has seriously addressed health issues at all. I don’t know how it will play out. Clearly, there are a lot of pressing issues—the economy notwithstanding—that will affect the ability of the new administration to implement changes.

I suspect that what we will see will be a collage, I suppose, of existing systems and structures. I think the idea to use the federal employee health model is admirable. Whether President-Elect Obama’s actually going to be able to get that implemented.… Certainly, he has a majority in the House and Senate, [but] not enough to prevent a filibuster, which I’m sure is going to be a challenge when you’re threatening large groups like health insurance companies.

I think his heart is in the right place; I just think there are a lot of factors that won’t come into play until he actually is in office and starts dealing with people. And I think it’s easy to envision what you’d like to see, and it’s another thing to get down to the nuts and bolts of how to make it happen. But I hope they listen to new voices. I hope that they are as open as they seem to be.

Lord: A lot of this is so theoretical when you get down to how it is going to happen. But overall, the concept seems like a reasonable one. It builds on what currently does work, including the employer-sponsored plans, Medicare, Medicaid. I mean, they have to be improved, but there are components that do work. The SCHIP [State Children’s Health Insurance Program]—I talk to PAs across the country, and if it weren’t for SCHIP, some kids would have nothing. So, we do have plans and programs that work. They can work better. We also need to look at insurance reform to make the private market more consumer-friendly.

Another aspect is an improved focus on wellness and health disparities. I’ve always said we chase disease. Health promotion, or disease prevention, means “Let’s truly work on obesity, let’s get you so you don’t have diabetes.” But what do we do? We take care of very sick patients who already have those diseases. At least theoretically, the Obama-Biden model looks at that and says, “This is where we’re going to focus,” on prevention and health care disparities….

Now, of course, when people actually get into office, they always find out what their hurdles are. We seem excited because this group is trying to be more bipartisan and not look at party but rather “Let’s look at the problem and bring in a broad group of players.” So we’re hopeful.

One of the keys is—I hope—that they reach out. Obama has been very smart in using the Internet and mobilizing people, whether it was building his campaign or collecting money, but also now giving people an opportunity to voice their opinions. So I’m hoping they use that information—that they don’t just say, “We want to hear from you,” and then don’t do anything with that.

Allowing for the fact that the level of reform our health care system needs will take time, what do you think should be the priorities? What must be addressed first?
Swanson: What has to be addressed first? The uninsured. From my perspective, I’m a full-time NP in a rural health practice in Indiana, and I see a lot of people who have no health insurance. That has a profound effect on their ability to be healthy, productive, contributing members of their local communities, their state, and the United States. I have people who are insulin-requiring diabetics who can’t afford to test their glucose, who can’t afford testing supplies or insulin—just the basics of managing their care—much less worry about optimal glycemic control. I have people who are young, who have diseases that can cause early demise—hyperlipidemia, hypertension, obesity.

Health care shouldn’t be a privilege. It should be a right. The Declaration of Independence says that we have the right to pursue happiness, and health has to be part of that.

There are innovative plans that are out there. Indiana has the Healthy Indiana Plan, which has been in place for about a year. It’s funded in part by tobacco money. This is for people who are uninsured and can’t afford to purchase employer-offered insurance plans. It covers preventive care, hospital care, acute care. And people are required to get their preventive health care or they lose this health savings account that they accrue over a period of time. They get, I believe, $1,000 in a health savings account, and if they don’t do their preventive care during the year, they lose that. That is a powerful incentive. 

You know, it’s just so interconnected. If your children are unhealthy, they’re not going to do well in school. If you have unhealthy workers, they’re going to cost the system money. A lot of these people wait until they’re in crisis and present to the emergency room, and that’s expensive, as is the hospital. I feel that addressing the needs of the uninsured is critical, and that involves primary care.

Lord: We have to look at universal coverage. But I think philosophically, before you get there, there has to be an understanding amongst all of us in health care—including physicians—that no man is an island. We have to work in coalitions; we have to work together. I can give you a million reasons why PAs are part of the solution, but we’ve always qualified that: We’re part of the solution; we’re not the solution.... Everyone’s role is important. This is about patient care; this isn’t about PAs, or NPs, or physicians. It’s about patients….

And then from there, we need to look at universal coverage: How do we get that access? How do we get people covered? It may very well be addressed by phasing in coverage. It may not just all happen; they may have to do some kind of phase-in.

And on the other end, where’s your workforce? Who’s going to see all these people? You’re between a rock and a hard place. [At the American Medical Association meeting last month] Massachusetts was at the microphone a lot talking about their universal coverage plan, the theory of it and what has developed. Everybody hasn’t even tried to get care yet, but [with] just the increase from everyone knowing that they have access, people are still waiting in line. There just aren’t enough providers. So, my theory is, there are enough sick people to go around. We all have to work together on that and see what the strengths of each group are.

In an ideal world, what would you like to see achieved in terms of health care reform—in general and with regard to NPs/PAs—by the end of 2009?
Swanson: I would like to see that health care is valued and is a right and not a privilege. In an ideal world, everyone would be able to receive health care services. The system would not be physician-centric or system-centric; it would be patient-centric.

We would have electronic health records so that we could communicate among systems. There would be a central repository for an individual’s health records that they themselves could have access to, so that you would never show up in a venue and not have a history for a patient.

There would be no barriers. All qualified providers would be able to provide the services that are needed, without turf issues and false claims of quality—we all know the quality issue is a trumped-up issue. There’s plenty of data out there that people other than physicians probably are better qualified to provide primary care services. So I would like to see no barriers to information, to access, to quality.

Lord: I would certainly like to see a cultural shift—which, in medicine, will certainly be a shift—where we acknowledge that we all are part of this team and that patients come first. There are so many different groups and types of providers, at all different levels; if we could all acknowledge that everyone plays a role, I think we’d get the most out of it. We truly would improve patient care. So there’s my “save the world and create world peace” answer: that we all truly function to the max and don’t worry about who’s stepping on whose toes.

And from a PA’s standpoint, I hope that we see full engagement of the Academy and the PA community in health care reform. I certainly would like to see, instead of us knocking at the door, saying “Please make sure we’re included,” that groups come to us, to the Academy, and say, “We want you at the table. What is your plan? What do you have to offer?”

It can’t just be done legislatively; it can’t just be done by the payers. Everyone has to work together to develop that plan. It’s an exciting time, because everyone wants change. The country wants it; it’s not just one political group. Patients want it, and they’re speaking out. We’re advocating for our patients. I think those things continue to be really important.

For the first time in eight years, a new year brings a new administration to the United States. Most Americans, regardless of their political persuasion, seem ready to embrace what they hope will be a complete change from the status quo.

Patients and health care providers alike will be watching to see whether President-Elect Barack Obama, his Cabinet, and the 111th Congress can initiate the wholesale health care reform the nation needs. Clinician Reviews asked American Academy of Nurse Practitioners President Diana “Dee” Swanson, MSN, NP-C, FAANP, and American Academy of Physician Assistants President Cynthia B. Lord, MHS, PA-C, for their perspectives on what’s ahead—and how NPs and PAs fit in.

What are some of the challenges of working with a new administration and new members of Congress, and how do you work around those obstacles?
Swanson: I would say, probably, having the kind of recognition that we need. There are a lot of loud, moneyed voices out there that dominate the conversation—primarily physician groups and insurance groups. Hopefully with the new administration, they will listen to new, fresh voices—because clearly, the voices that have been heard to date have not offered any solutions to the problems that we face. All they’ve offered is more of the same, with their hand out, asking for more money.

My personal high priority is that we get a seat at the table with the Obama transition team. We have got to get in on the ground floor with a new administration, and it is imperative that we be able to meet with [Secretary of Health and Human Services nominee] Tom Daschle and discuss what we can bring to primary care.

Our health care system is floundering; we all know that. Primary care is floundering. Only 2% of medical school graduates are choosing primary care. There are 125,000-plus NPs out there prepared to provide primary care. We’ve got barriers all over the place to being able to efficiently do that. So my personal priority is to be at the table with the transition team.

Lord: Two things that we’re going to focus on are time and education. We’ve worked with Senator Daschle’s office before, so there are legislative aides and people that we know. But certainly with the new administration and members of Congress to contact, that’s going to take some time. So we’re already well into making those initial contacts, and certainly we’ll call in PAs from various states to help out in key areas.

The other thing that’s going to be required is education, because it is our job to explain why the issues that affect PAs actually affect the ability to provide quality, cost-effective care to patients, and how that impacts patient care. Although we have a number of friends who are still in Congress and in those positions of authority—so we won’t have to start from square one—there’s going to be that whole new regime that comes in.

So I think time and education are going to be our biggest challenges but also opportunities—because we’re not the same profession we were even 10 years ago. We’re not what we were 40 years ago. And we can certainly cite more areas where PAs have made an impact.

Based on what you know about the Obama-Biden health care proposal, how effective do you think the plan is in terms of addressing the nation’s health care problems?
Swanson: From my perspective, it’s a good start. Nobody in the last eight years has seriously addressed health issues at all. I don’t know how it will play out. Clearly, there are a lot of pressing issues—the economy notwithstanding—that will affect the ability of the new administration to implement changes.

I suspect that what we will see will be a collage, I suppose, of existing systems and structures. I think the idea to use the federal employee health model is admirable. Whether President-Elect Obama’s actually going to be able to get that implemented.… Certainly, he has a majority in the House and Senate, [but] not enough to prevent a filibuster, which I’m sure is going to be a challenge when you’re threatening large groups like health insurance companies.

I think his heart is in the right place; I just think there are a lot of factors that won’t come into play until he actually is in office and starts dealing with people. And I think it’s easy to envision what you’d like to see, and it’s another thing to get down to the nuts and bolts of how to make it happen. But I hope they listen to new voices. I hope that they are as open as they seem to be.

Lord: A lot of this is so theoretical when you get down to how it is going to happen. But overall, the concept seems like a reasonable one. It builds on what currently does work, including the employer-sponsored plans, Medicare, Medicaid. I mean, they have to be improved, but there are components that do work. The SCHIP [State Children’s Health Insurance Program]—I talk to PAs across the country, and if it weren’t for SCHIP, some kids would have nothing. So, we do have plans and programs that work. They can work better. We also need to look at insurance reform to make the private market more consumer-friendly.

Another aspect is an improved focus on wellness and health disparities. I’ve always said we chase disease. Health promotion, or disease prevention, means “Let’s truly work on obesity, let’s get you so you don’t have diabetes.” But what do we do? We take care of very sick patients who already have those diseases. At least theoretically, the Obama-Biden model looks at that and says, “This is where we’re going to focus,” on prevention and health care disparities….

Now, of course, when people actually get into office, they always find out what their hurdles are. We seem excited because this group is trying to be more bipartisan and not look at party but rather “Let’s look at the problem and bring in a broad group of players.” So we’re hopeful.

One of the keys is—I hope—that they reach out. Obama has been very smart in using the Internet and mobilizing people, whether it was building his campaign or collecting money, but also now giving people an opportunity to voice their opinions. So I’m hoping they use that information—that they don’t just say, “We want to hear from you,” and then don’t do anything with that.

Allowing for the fact that the level of reform our health care system needs will take time, what do you think should be the priorities? What must be addressed first?
Swanson: What has to be addressed first? The uninsured. From my perspective, I’m a full-time NP in a rural health practice in Indiana, and I see a lot of people who have no health insurance. That has a profound effect on their ability to be healthy, productive, contributing members of their local communities, their state, and the United States. I have people who are insulin-requiring diabetics who can’t afford to test their glucose, who can’t afford testing supplies or insulin—just the basics of managing their care—much less worry about optimal glycemic control. I have people who are young, who have diseases that can cause early demise—hyperlipidemia, hypertension, obesity.

Health care shouldn’t be a privilege. It should be a right. The Declaration of Independence says that we have the right to pursue happiness, and health has to be part of that.

There are innovative plans that are out there. Indiana has the Healthy Indiana Plan, which has been in place for about a year. It’s funded in part by tobacco money. This is for people who are uninsured and can’t afford to purchase employer-offered insurance plans. It covers preventive care, hospital care, acute care. And people are required to get their preventive health care or they lose this health savings account that they accrue over a period of time. They get, I believe, $1,000 in a health savings account, and if they don’t do their preventive care during the year, they lose that. That is a powerful incentive. 

You know, it’s just so interconnected. If your children are unhealthy, they’re not going to do well in school. If you have unhealthy workers, they’re going to cost the system money. A lot of these people wait until they’re in crisis and present to the emergency room, and that’s expensive, as is the hospital. I feel that addressing the needs of the uninsured is critical, and that involves primary care.

Lord: We have to look at universal coverage. But I think philosophically, before you get there, there has to be an understanding amongst all of us in health care—including physicians—that no man is an island. We have to work in coalitions; we have to work together. I can give you a million reasons why PAs are part of the solution, but we’ve always qualified that: We’re part of the solution; we’re not the solution.... Everyone’s role is important. This is about patient care; this isn’t about PAs, or NPs, or physicians. It’s about patients….

And then from there, we need to look at universal coverage: How do we get that access? How do we get people covered? It may very well be addressed by phasing in coverage. It may not just all happen; they may have to do some kind of phase-in.

And on the other end, where’s your workforce? Who’s going to see all these people? You’re between a rock and a hard place. [At the American Medical Association meeting last month] Massachusetts was at the microphone a lot talking about their universal coverage plan, the theory of it and what has developed. Everybody hasn’t even tried to get care yet, but [with] just the increase from everyone knowing that they have access, people are still waiting in line. There just aren’t enough providers. So, my theory is, there are enough sick people to go around. We all have to work together on that and see what the strengths of each group are.

In an ideal world, what would you like to see achieved in terms of health care reform—in general and with regard to NPs/PAs—by the end of 2009?
Swanson: I would like to see that health care is valued and is a right and not a privilege. In an ideal world, everyone would be able to receive health care services. The system would not be physician-centric or system-centric; it would be patient-centric.

We would have electronic health records so that we could communicate among systems. There would be a central repository for an individual’s health records that they themselves could have access to, so that you would never show up in a venue and not have a history for a patient.

There would be no barriers. All qualified providers would be able to provide the services that are needed, without turf issues and false claims of quality—we all know the quality issue is a trumped-up issue. There’s plenty of data out there that people other than physicians probably are better qualified to provide primary care services. So I would like to see no barriers to information, to access, to quality.

Lord: I would certainly like to see a cultural shift—which, in medicine, will certainly be a shift—where we acknowledge that we all are part of this team and that patients come first. There are so many different groups and types of providers, at all different levels; if we could all acknowledge that everyone plays a role, I think we’d get the most out of it. We truly would improve patient care. So there’s my “save the world and create world peace” answer: that we all truly function to the max and don’t worry about who’s stepping on whose toes.

And from a PA’s standpoint, I hope that we see full engagement of the Academy and the PA community in health care reform. I certainly would like to see, instead of us knocking at the door, saying “Please make sure we’re included,” that groups come to us, to the Academy, and say, “We want you at the table. What is your plan? What do you have to offer?”

It can’t just be done legislatively; it can’t just be done by the payers. Everyone has to work together to develop that plan. It’s an exciting time, because everyone wants change. The country wants it; it’s not just one political group. Patients want it, and they’re speaking out. We’re advocating for our patients. I think those things continue to be really important.

NPs and PAs may be colleagues, but when it comes to licensure, certification, and regulation, the professions could not be more different. Nonetheless, practice in specialty areas—and recognition of advanced training and knowledge in those fields—has been an agenda item for both professions, particularly in recent years.

Rather than attempt to combine apples and oranges, Clinician Reviews decided to tackle this topic separately for each group. The PA discussion begins immediately below; if you wish to skip to the NP section, scroll down.

PAs: Specialty Certification?
In the PA world, specialty certification has been on the table for discussion for several decades. Yes, decades. When Janet Lathrop, MBA, President and CEO of the National Commission on Certification of Physician Assistants (NCCPA), speaks to her board of directors or makes a presentation to another organization about specialty certification, one of her slides contains the verbiage of a motion related to the topic. “Everyone thinks they’re minutes from a very recent meeting,” she says, “and they’re from 1978.”

That said, the subject has become a particularly hot one in the past few years. In May 2006, NCCPA “passed a motion to develop specialty recognition, including examinations,” Lathrop says. A subsequent motion, passed by the NCCPA board in August of this year, laid out an 18-month time frame to explore how specialty recognition might be handled.

“It could be that in the 18 months that the workgroup talks about a model, they’ll come back and say, ‘There is no model; we don’t want to do this,’” Lathrop says. “Or they potentially could come back and say, ‘We need to do specialty certification.’ All options remain open for discussion.”

Last month, during its final board meeting of the year, NCCPA updated its points of consensus regarding specialty recognition, which state that the board “will develop and administer specialty recognition according to the following principles:

“a. Specialty recognition will be voluntary and will be independent of NCCPA’s certification and recertification process.

“b. Specialty recognition will support and reinforce relationships between PAs and physicians.

“c. NCCPA will seek input and cooperation from appropriate stakeholders.

“d. Specialty recognition will support the credentialing process and not create barriers to licensure and practice.”

Point “c” is particularly salient, because there are divergent views within the profession as to what form specialty recognition should take.

Joint Dialogue
Much has been made, in various channels, of the fact that NCCPA and the American Academy of Physician Assistants (AAPA) have opposing viewpoints when it comes to specialty certification. This is not entirely surprising, given the different missions that the organizations have. But Greg Thomas, PA, MPH, AAPA’s Senior Vice President for Education, Membership, and Resource Development, would like to dispel some myths.

“AAPA does in fact have policy in opposition to specialty certification, per se, that is based on examination,” he says. “But I think it’s very important to add that we are not only currently participating in, but encourage, the ongoing dialogue about this issue.”

Furthermore, Thomas points out that AAPA policy is not like a Supreme Court decision. “Policy is, by definition, a dynamic thing and can certainly, as times change and as circumstances change, be revisited and potentially changed,” he says. “I’m not saying that’s in the process of happening as we’re speaking. But I think that’s a misconception as well—that because something exists in policy, it cannot be changed.”

AAPA supports the concept of recognition of knowledge and skills in a specialty. “The terminology of certification is where there have been some differences of opinion,” Thomas says. “Our opposition is around certification, which could limit the potential mobility from one specialty to another. That may be a theoretical limitation, but that has been the basis of the opposition.”

Despite the differing perspectives, NCCPA and AAPA are keeping the lines of communication open. Thomas serves as an AAPA representative to the NCCPA, “so we’re not operating in a vacuum on this,” as Lathrop says.

“That doesn’t mean AAPA is supporting it—it means they’re being an appropriate, responsive business organization and saying, ‘OK, let us be in on this, let us hear what you have to say and let us have a voice at the table,’” she adds. “By participating, they’re not doing anything other than participating—finding out information, staying abreast. They don’t have to agree.

“But maybe,” she says, with a note of hope in her voice, “maybe we’ll come up with a model that serves the needs of everyone—most importantly, patients.”

Needs and Concerns
The logistics of what level of recognition is appropriate and acceptable for PAs practicing in specialties is the biggest piece of the puzzle. “In terms of what the specific mechanisms may be, I think it’s premature [to say],” Thomas explains. “That’s exactly the conversation that’s ongoing—not only within AAPA, but within PA specialty organizations, within the NCCPA, and frankly, even within some physician specialty organizations.”

Physician specialty and subspecialty groups have had a role to play in the latest go-round on this topic. PAs practicing in some specialty areas have approached NCCPA about specialty recognition, indicating that the physician organizations governing their specialty have requested some means of confirming that PAs have an appropriate level of training to perform relevant tasks or procedures.

“You can’t just walk out of PA school and put a Swan-Ganz catheter in somebody,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C, who is Immediate Past Chair of the NCCPA and current Chair of NCCPA’s Specialty Task Force. “You have to have some additional training, and then the question becomes, ‘How do we assure the public that the PA has the training?’”

The primary concern is that PAs might end up required to certify in order to practice in a specialty. Or, as Danielsen puts it, “The biggest fear is that PAs will not be able to cross between specialties without jumping through some hoops.”

That has been part of AAPA’s concern, since the PA profession was founded on a generalist medicine model. But members of NCCPA understand the potential limitations as well. “That’s the concern of the profession,” Lathrop acknowledges. “If we build it, will they come? Even if you develop this recognition through NCCPA and even if you don’t require it, if it’s voluntary, it could end up required by the states.”

Anything Is Possible, Nothing Is Definite
So what’s the solution? “If you could figure something out, let me know,” Lathrop says. She is reluctant to comment on what NCCPA’s model (if they develop one) might consist of, “because we don’t know.”

Danielsen is more willing to muse aloud, with the clear understanding that he’s tossing ideas out there and not representing NCCPA, or making suggestions, when he does so. If PAs “hang our hat on the star called ‘physician,’” as he puts it, “maybe we should have the initial certification exam be our licensing exam and then anything else we do be a voluntary board certification, where somebody chooses either formally or informally to go through an educational process and then take a specialty exam.”

Moving outside the realm of examinations, some PA specialty organizations that see the greatest need for this type of recognition have already taken matters into their own hands. “A few have established an advanced membership category for PAs within those specialties who meet certain criteria, such as number of years of practice in that specialty or advanced education or CME that is specifically related,” Thomas points out.

A good example is the distance-learning program that the Society of Dermatology PAs launched this summer through the University of Texas Southwestern. Experienced derm PAs are eligible to participate in Web-based educational modules, with diplomate membership status awarded to those who participate. Whether such programs will suffice to assure physicians—and patients—that PAs have adequate knowledge remains to be seen.

Working with specialty groups is an avenue that AAPA is exploring. “One of the things that AAPA is certainly looking at very seriously is trying to partner with other organizations, notably physician specialty organizations,” Thomas says, “to provide what we’re referring to as ‘intensive educational opportunities’ in a whole host of specialty and subspecialty areas.” He notes that some physician specialty groups already offer or are discussing the possibility of offering affiliate or associate membership to PAs who meet certain criteria.

How the matter of specialty recognition will play out is still anyone’s guess. Truly. “There are people who say we know what we’re going to do, that we’ve known it all along, and this is just smoke and mirrors,” Lathrop says. “But it’s really not. I can honestly say, with all sincerity, I have no idea. I just know that we’re going to work through this for the next 18 months, and hopefully come up with something.”

NPs: Nonregulated Specialties
It may have taken five years and the collaborative efforts of more than 50 organizations, but the nursing community has developed a Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (available at the National Council of State Boards of Nursing [NCSBN] Web site, www.ncsbn.org). The model, as its subtitle indicates, outlines the role of an APRN (which includes certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners), as well as the six population foci in which an APRN may choose to be educated.

The NCSBN endorsed the model this summer, providing credibility at the national level, and now, much like the Nurse Licensure Compact, the model will be taken to the states for approval. If a state signs on to the consensus model and subsequently amends any relevant laws or regulations to conform with its principles, NPs and other APRNs would have a level of reciprocity, enabling them to relocate to any other states that have signed on without having to jump through regulatory hoops.

What is relevant to this particular article is that the consensus model expressly states, “Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.” In other words, as explained by Nancy Chornick, PhD, RN, CAE, Director of Practice for NCSBN, specialty recognition will be “out of the purview of legal recognition.”

Chornick goes on to say, “It’s important for NPs to understand that this is not a value issue. Certification is very valuable. It’s just that we’ve taken it out of the purview of licensure. In this way, we will assure that APRNs have a broad scope of practice, and then they’re free to specialize in whatever areas they want.”

Addressing Concerns
While the nursing community has reached a consensus, that doesn’t mean there weren’t questions and concerns along the way. What may be interesting to some is that it was the regulatory bodies—the state boards of nursing—that were most concerned about the potential limitations of specialty certification.

As APRNs—particularly clinical nurse specialists and NPs—started to specialize more, they would go to the boards of nursing and indicate their desire to be licensed in their specialty. “From my point of view, this put those nurses at a disadvantage, because those nurses then must practice within that scope,” Chornick says. “For instance, if they’re specialized—just to carry it to an extreme—in conditions of the right thyroid lobe, then they have a lot of constraints.”

The pitfalls are twofold. Based on her experiences, Mary Smolenski, EdD, FNP, FAANP, CAE, Director of Certification for the American Nurses Credentialing Center (ANCC), says, “NPs aren’t opposed to recognizing the certification in a particular area. But when it gets down to the fact that, gee, now you can’t work in derm unless you go off and get another certification, that’s where the problem arises.”

A narrow scope of practice could mean a decreased number of job opportunities, if an opening in the particular specialty is not readily available. But an even greater concern on the part of the NCSBN is that “individuals who have a very narrow scope of practice then don’t have the education or evaluation for a broader area,” Chornick says. “So it’s really a patient safety issue. You need to be educated and evaluated and work within a certain scope.”

That said, NPs’ primary education, licensure, and certification provide a platform that can be expanded at the practitioner’s choice. “Anything you can add to your basic licensure that ... shows you met a certain standard in a particular area adds to your recognition in that specialty,” Smolenski says. “You don’t want to be mandated to have that level of certification. But the fact that you have it, and you can say, ‘I do have this specialty knowledge,’ to me is a plus, not a minus.”

Looking Beyond Examination
While stating that “preparation in a specialty area of practice is optional,” the consensus model does “strongly recommend” certification in a specialty, if one is chosen. The model also provides a certain amount of leeway in how this additional knowledge and training are acquired and assessed:

“Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (eg, portfolios, examinations, etc).”

Since professional organizations would monitor specialty practice under the model, Chornick explains, “the profession would establish standards and decide what type of marker, so to speak, or designation would be appropriate for that person.”

Obviously, as a representative of ANCC, Smolenski appreciates the value of examination. But there are practical limitations to how many exams can be offered.

“Theoretically, you can develop an exam for anything,” she observes. “But from a business standpoint and a psychometric standpoint, you can’t—because if you’re trying to develop an exam that means anything, that the public can have faith in, you have to have certain numbers of people [to take it].”

Chornick also cites the expense of certification as a rationale for looking at other methods. “Licensure requires examination, so by allowing the specialties to have the profession in charge, they don’t need the examination,” she says. “A lot of specialties were unable to afford the development of a certification exam, so this will allow for alternative methods.”

For example, ANCC has started looking at portfolios for specialty recognition. Smolenski is already working with some nursing specialty groups to create online portfolios. The advantage is the breadth of information that can be made available to review boards or employers: Individuals might include case studies, articles, and presentations they have authored; a list of committees they’ve participated in; a complete history of work experience; and even a list of procedures they’ve learned, as well as how many times they’ve performed them and who supervised them.

“Portfolios give you a different picture of somebody,” Smolenski notes. “You can see the experiences that people have had and what else they bring to the table that is more broad-based than just passing an exam.”

Methods of specialty recognition beyond examination may also level the playing field for those who freeze up at the very idea of being tested. “A lot of people cannot take tests,” Smolenski points out. “They just don’t do well. And then other people are really good test-takers.

“Exams validate that you’ve met a certain standard—but the issue is, just because you passed the test, does that mean you’re competent?” she adds. “You can’t really equate the two. There’s a lot more to competency than a test.”   

NPs and PAs may be colleagues, but when it comes to licensure, certification, and regulation, the professions could not be more different. Nonetheless, practice in specialty areas—and recognition of advanced training and knowledge in those fields—has been an agenda item for both professions, particularly in recent years.

Rather than attempt to combine apples and oranges, Clinician Reviews decided to tackle this topic separately for each group. The PA discussion begins immediately below; if you wish to skip to the NP section, scroll down.

PAs: Specialty Certification?
In the PA world, specialty certification has been on the table for discussion for several decades. Yes, decades. When Janet Lathrop, MBA, President and CEO of the National Commission on Certification of Physician Assistants (NCCPA), speaks to her board of directors or makes a presentation to another organization about specialty certification, one of her slides contains the verbiage of a motion related to the topic. “Everyone thinks they’re minutes from a very recent meeting,” she says, “and they’re from 1978.”

That said, the subject has become a particularly hot one in the past few years. In May 2006, NCCPA “passed a motion to develop specialty recognition, including examinations,” Lathrop says. A subsequent motion, passed by the NCCPA board in August of this year, laid out an 18-month time frame to explore how specialty recognition might be handled.

“It could be that in the 18 months that the workgroup talks about a model, they’ll come back and say, ‘There is no model; we don’t want to do this,’” Lathrop says. “Or they potentially could come back and say, ‘We need to do specialty certification.’ All options remain open for discussion.”

Last month, during its final board meeting of the year, NCCPA updated its points of consensus regarding specialty recognition, which state that the board “will develop and administer specialty recognition according to the following principles:

“a. Specialty recognition will be voluntary and will be independent of NCCPA’s certification and recertification process.

“b. Specialty recognition will support and reinforce relationships between PAs and physicians.

“c. NCCPA will seek input and cooperation from appropriate stakeholders.

“d. Specialty recognition will support the credentialing process and not create barriers to licensure and practice.”

Point “c” is particularly salient, because there are divergent views within the profession as to what form specialty recognition should take.

Joint Dialogue
Much has been made, in various channels, of the fact that NCCPA and the American Academy of Physician Assistants (AAPA) have opposing viewpoints when it comes to specialty certification. This is not entirely surprising, given the different missions that the organizations have. But Greg Thomas, PA, MPH, AAPA’s Senior Vice President for Education, Membership, and Resource Development, would like to dispel some myths.

“AAPA does in fact have policy in opposition to specialty certification, per se, that is based on examination,” he says. “But I think it’s very important to add that we are not only currently participating in, but encourage, the ongoing dialogue about this issue.”

Furthermore, Thomas points out that AAPA policy is not like a Supreme Court decision. “Policy is, by definition, a dynamic thing and can certainly, as times change and as circumstances change, be revisited and potentially changed,” he says. “I’m not saying that’s in the process of happening as we’re speaking. But I think that’s a misconception as well—that because something exists in policy, it cannot be changed.”

AAPA supports the concept of recognition of knowledge and skills in a specialty. “The terminology of certification is where there have been some differences of opinion,” Thomas says. “Our opposition is around certification, which could limit the potential mobility from one specialty to another. That may be a theoretical limitation, but that has been the basis of the opposition.”

Despite the differing perspectives, NCCPA and AAPA are keeping the lines of communication open. Thomas serves as an AAPA representative to the NCCPA, “so we’re not operating in a vacuum on this,” as Lathrop says.

“That doesn’t mean AAPA is supporting it—it means they’re being an appropriate, responsive business organization and saying, ‘OK, let us be in on this, let us hear what you have to say and let us have a voice at the table,’” she adds. “By participating, they’re not doing anything other than participating—finding out information, staying abreast. They don’t have to agree.

“But maybe,” she says, with a note of hope in her voice, “maybe we’ll come up with a model that serves the needs of everyone—most importantly, patients.”

Needs and Concerns
The logistics of what level of recognition is appropriate and acceptable for PAs practicing in specialties is the biggest piece of the puzzle. “In terms of what the specific mechanisms may be, I think it’s premature [to say],” Thomas explains. “That’s exactly the conversation that’s ongoing—not only within AAPA, but within PA specialty organizations, within the NCCPA, and frankly, even within some physician specialty organizations.”

Physician specialty and subspecialty groups have had a role to play in the latest go-round on this topic. PAs practicing in some specialty areas have approached NCCPA about specialty recognition, indicating that the physician organizations governing their specialty have requested some means of confirming that PAs have an appropriate level of training to perform relevant tasks or procedures.

“You can’t just walk out of PA school and put a Swan-Ganz catheter in somebody,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C, who is Immediate Past Chair of the NCCPA and current Chair of NCCPA’s Specialty Task Force. “You have to have some additional training, and then the question becomes, ‘How do we assure the public that the PA has the training?’”

The primary concern is that PAs might end up required to certify in order to practice in a specialty. Or, as Danielsen puts it, “The biggest fear is that PAs will not be able to cross between specialties without jumping through some hoops.”

That has been part of AAPA’s concern, since the PA profession was founded on a generalist medicine model. But members of NCCPA understand the potential limitations as well. “That’s the concern of the profession,” Lathrop acknowledges. “If we build it, will they come? Even if you develop this recognition through NCCPA and even if you don’t require it, if it’s voluntary, it could end up required by the states.”

Anything Is Possible, Nothing Is Definite
So what’s the solution? “If you could figure something out, let me know,” Lathrop says. She is reluctant to comment on what NCCPA’s model (if they develop one) might consist of, “because we don’t know.”

Danielsen is more willing to muse aloud, with the clear understanding that he’s tossing ideas out there and not representing NCCPA, or making suggestions, when he does so. If PAs “hang our hat on the star called ‘physician,’” as he puts it, “maybe we should have the initial certification exam be our licensing exam and then anything else we do be a voluntary board certification, where somebody chooses either formally or informally to go through an educational process and then take a specialty exam.”

Moving outside the realm of examinations, some PA specialty organizations that see the greatest need for this type of recognition have already taken matters into their own hands. “A few have established an advanced membership category for PAs within those specialties who meet certain criteria, such as number of years of practice in that specialty or advanced education or CME that is specifically related,” Thomas points out.

A good example is the distance-learning program that the Society of Dermatology PAs launched this summer through the University of Texas Southwestern. Experienced derm PAs are eligible to participate in Web-based educational modules, with diplomate membership status awarded to those who participate. Whether such programs will suffice to assure physicians—and patients—that PAs have adequate knowledge remains to be seen.

Working with specialty groups is an avenue that AAPA is exploring. “One of the things that AAPA is certainly looking at very seriously is trying to partner with other organizations, notably physician specialty organizations,” Thomas says, “to provide what we’re referring to as ‘intensive educational opportunities’ in a whole host of specialty and subspecialty areas.” He notes that some physician specialty groups already offer or are discussing the possibility of offering affiliate or associate membership to PAs who meet certain criteria.

How the matter of specialty recognition will play out is still anyone’s guess. Truly. “There are people who say we know what we’re going to do, that we’ve known it all along, and this is just smoke and mirrors,” Lathrop says. “But it’s really not. I can honestly say, with all sincerity, I have no idea. I just know that we’re going to work through this for the next 18 months, and hopefully come up with something.”

NPs: Nonregulated Specialties
It may have taken five years and the collaborative efforts of more than 50 organizations, but the nursing community has developed a Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (available at the National Council of State Boards of Nursing [NCSBN] Web site, www.ncsbn.org). The model, as its subtitle indicates, outlines the role of an APRN (which includes certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners), as well as the six population foci in which an APRN may choose to be educated.

The NCSBN endorsed the model this summer, providing credibility at the national level, and now, much like the Nurse Licensure Compact, the model will be taken to the states for approval. If a state signs on to the consensus model and subsequently amends any relevant laws or regulations to conform with its principles, NPs and other APRNs would have a level of reciprocity, enabling them to relocate to any other states that have signed on without having to jump through regulatory hoops.

What is relevant to this particular article is that the consensus model expressly states, “Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.” In other words, as explained by Nancy Chornick, PhD, RN, CAE, Director of Practice for NCSBN, specialty recognition will be “out of the purview of legal recognition.”

Chornick goes on to say, “It’s important for NPs to understand that this is not a value issue. Certification is very valuable. It’s just that we’ve taken it out of the purview of licensure. In this way, we will assure that APRNs have a broad scope of practice, and then they’re free to specialize in whatever areas they want.”

Addressing Concerns
While the nursing community has reached a consensus, that doesn’t mean there weren’t questions and concerns along the way. What may be interesting to some is that it was the regulatory bodies—the state boards of nursing—that were most concerned about the potential limitations of specialty certification.

As APRNs—particularly clinical nurse specialists and NPs—started to specialize more, they would go to the boards of nursing and indicate their desire to be licensed in their specialty. “From my point of view, this put those nurses at a disadvantage, because those nurses then must practice within that scope,” Chornick says. “For instance, if they’re specialized—just to carry it to an extreme—in conditions of the right thyroid lobe, then they have a lot of constraints.”

The pitfalls are twofold. Based on her experiences, Mary Smolenski, EdD, FNP, FAANP, CAE, Director of Certification for the American Nurses Credentialing Center (ANCC), says, “NPs aren’t opposed to recognizing the certification in a particular area. But when it gets down to the fact that, gee, now you can’t work in derm unless you go off and get another certification, that’s where the problem arises.”

A narrow scope of practice could mean a decreased number of job opportunities, if an opening in the particular specialty is not readily available. But an even greater concern on the part of the NCSBN is that “individuals who have a very narrow scope of practice then don’t have the education or evaluation for a broader area,” Chornick says. “So it’s really a patient safety issue. You need to be educated and evaluated and work within a certain scope.”

That said, NPs’ primary education, licensure, and certification provide a platform that can be expanded at the practitioner’s choice. “Anything you can add to your basic licensure that ... shows you met a certain standard in a particular area adds to your recognition in that specialty,” Smolenski says. “You don’t want to be mandated to have that level of certification. But the fact that you have it, and you can say, ‘I do have this specialty knowledge,’ to me is a plus, not a minus.”

Looking Beyond Examination
While stating that “preparation in a specialty area of practice is optional,” the consensus model does “strongly recommend” certification in a specialty, if one is chosen. The model also provides a certain amount of leeway in how this additional knowledge and training are acquired and assessed:

“Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (eg, portfolios, examinations, etc).”

Since professional organizations would monitor specialty practice under the model, Chornick explains, “the profession would establish standards and decide what type of marker, so to speak, or designation would be appropriate for that person.”

Obviously, as a representative of ANCC, Smolenski appreciates the value of examination. But there are practical limitations to how many exams can be offered.

“Theoretically, you can develop an exam for anything,” she observes. “But from a business standpoint and a psychometric standpoint, you can’t—because if you’re trying to develop an exam that means anything, that the public can have faith in, you have to have certain numbers of people [to take it].”

Chornick also cites the expense of certification as a rationale for looking at other methods. “Licensure requires examination, so by allowing the specialties to have the profession in charge, they don’t need the examination,” she says. “A lot of specialties were unable to afford the development of a certification exam, so this will allow for alternative methods.”

For example, ANCC has started looking at portfolios for specialty recognition. Smolenski is already working with some nursing specialty groups to create online portfolios. The advantage is the breadth of information that can be made available to review boards or employers: Individuals might include case studies, articles, and presentations they have authored; a list of committees they’ve participated in; a complete history of work experience; and even a list of procedures they’ve learned, as well as how many times they’ve performed them and who supervised them.

“Portfolios give you a different picture of somebody,” Smolenski notes. “You can see the experiences that people have had and what else they bring to the table that is more broad-based than just passing an exam.”

Methods of specialty recognition beyond examination may also level the playing field for those who freeze up at the very idea of being tested. “A lot of people cannot take tests,” Smolenski points out. “They just don’t do well. And then other people are really good test-takers.

“Exams validate that you’ve met a certain standard—but the issue is, just because you passed the test, does that mean you’re competent?” she adds. “You can’t really equate the two. There’s a lot more to competency than a test.”   

NPs and PAs may be colleagues, but when it comes to licensure, certification, and regulation, the professions could not be more different. Nonetheless, practice in specialty areas—and recognition of advanced training and knowledge in those fields—has been an agenda item for both professions, particularly in recent years.

Rather than attempt to combine apples and oranges, Clinician Reviews decided to tackle this topic separately for each group. The PA discussion begins immediately below; if you wish to skip to the NP section, scroll down.

PAs: Specialty Certification?
In the PA world, specialty certification has been on the table for discussion for several decades. Yes, decades. When Janet Lathrop, MBA, President and CEO of the National Commission on Certification of Physician Assistants (NCCPA), speaks to her board of directors or makes a presentation to another organization about specialty certification, one of her slides contains the verbiage of a motion related to the topic. “Everyone thinks they’re minutes from a very recent meeting,” she says, “and they’re from 1978.”

That said, the subject has become a particularly hot one in the past few years. In May 2006, NCCPA “passed a motion to develop specialty recognition, including examinations,” Lathrop says. A subsequent motion, passed by the NCCPA board in August of this year, laid out an 18-month time frame to explore how specialty recognition might be handled.

“It could be that in the 18 months that the workgroup talks about a model, they’ll come back and say, ‘There is no model; we don’t want to do this,’” Lathrop says. “Or they potentially could come back and say, ‘We need to do specialty certification.’ All options remain open for discussion.”

Last month, during its final board meeting of the year, NCCPA updated its points of consensus regarding specialty recognition, which state that the board “will develop and administer specialty recognition according to the following principles:

“a. Specialty recognition will be voluntary and will be independent of NCCPA’s certification and recertification process.

“b. Specialty recognition will support and reinforce relationships between PAs and physicians.

“c. NCCPA will seek input and cooperation from appropriate stakeholders.

“d. Specialty recognition will support the credentialing process and not create barriers to licensure and practice.”

Point “c” is particularly salient, because there are divergent views within the profession as to what form specialty recognition should take.

Joint Dialogue
Much has been made, in various channels, of the fact that NCCPA and the American Academy of Physician Assistants (AAPA) have opposing viewpoints when it comes to specialty certification. This is not entirely surprising, given the different missions that the organizations have. But Greg Thomas, PA, MPH, AAPA’s Senior Vice President for Education, Membership, and Resource Development, would like to dispel some myths.

“AAPA does in fact have policy in opposition to specialty certification, per se, that is based on examination,” he says. “But I think it’s very important to add that we are not only currently participating in, but encourage, the ongoing dialogue about this issue.”

Furthermore, Thomas points out that AAPA policy is not like a Supreme Court decision. “Policy is, by definition, a dynamic thing and can certainly, as times change and as circumstances change, be revisited and potentially changed,” he says. “I’m not saying that’s in the process of happening as we’re speaking. But I think that’s a misconception as well—that because something exists in policy, it cannot be changed.”

AAPA supports the concept of recognition of knowledge and skills in a specialty. “The terminology of certification is where there have been some differences of opinion,” Thomas says. “Our opposition is around certification, which could limit the potential mobility from one specialty to another. That may be a theoretical limitation, but that has been the basis of the opposition.”

Despite the differing perspectives, NCCPA and AAPA are keeping the lines of communication open. Thomas serves as an AAPA representative to the NCCPA, “so we’re not operating in a vacuum on this,” as Lathrop says.

“That doesn’t mean AAPA is supporting it—it means they’re being an appropriate, responsive business organization and saying, ‘OK, let us be in on this, let us hear what you have to say and let us have a voice at the table,’” she adds. “By participating, they’re not doing anything other than participating—finding out information, staying abreast. They don’t have to agree.

“But maybe,” she says, with a note of hope in her voice, “maybe we’ll come up with a model that serves the needs of everyone—most importantly, patients.”

Needs and Concerns
The logistics of what level of recognition is appropriate and acceptable for PAs practicing in specialties is the biggest piece of the puzzle. “In terms of what the specific mechanisms may be, I think it’s premature [to say],” Thomas explains. “That’s exactly the conversation that’s ongoing—not only within AAPA, but within PA specialty organizations, within the NCCPA, and frankly, even within some physician specialty organizations.”

Physician specialty and subspecialty groups have had a role to play in the latest go-round on this topic. PAs practicing in some specialty areas have approached NCCPA about specialty recognition, indicating that the physician organizations governing their specialty have requested some means of confirming that PAs have an appropriate level of training to perform relevant tasks or procedures.

“You can’t just walk out of PA school and put a Swan-Ganz catheter in somebody,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C, who is Immediate Past Chair of the NCCPA and current Chair of NCCPA’s Specialty Task Force. “You have to have some additional training, and then the question becomes, ‘How do we assure the public that the PA has the training?’”

The primary concern is that PAs might end up required to certify in order to practice in a specialty. Or, as Danielsen puts it, “The biggest fear is that PAs will not be able to cross between specialties without jumping through some hoops.”

That has been part of AAPA’s concern, since the PA profession was founded on a generalist medicine model. But members of NCCPA understand the potential limitations as well. “That’s the concern of the profession,” Lathrop acknowledges. “If we build it, will they come? Even if you develop this recognition through NCCPA and even if you don’t require it, if it’s voluntary, it could end up required by the states.”

Anything Is Possible, Nothing Is Definite
So what’s the solution? “If you could figure something out, let me know,” Lathrop says. She is reluctant to comment on what NCCPA’s model (if they develop one) might consist of, “because we don’t know.”

Danielsen is more willing to muse aloud, with the clear understanding that he’s tossing ideas out there and not representing NCCPA, or making suggestions, when he does so. If PAs “hang our hat on the star called ‘physician,’” as he puts it, “maybe we should have the initial certification exam be our licensing exam and then anything else we do be a voluntary board certification, where somebody chooses either formally or informally to go through an educational process and then take a specialty exam.”

Moving outside the realm of examinations, some PA specialty organizations that see the greatest need for this type of recognition have already taken matters into their own hands. “A few have established an advanced membership category for PAs within those specialties who meet certain criteria, such as number of years of practice in that specialty or advanced education or CME that is specifically related,” Thomas points out.

A good example is the distance-learning program that the Society of Dermatology PAs launched this summer through the University of Texas Southwestern. Experienced derm PAs are eligible to participate in Web-based educational modules, with diplomate membership status awarded to those who participate. Whether such programs will suffice to assure physicians—and patients—that PAs have adequate knowledge remains to be seen.

Working with specialty groups is an avenue that AAPA is exploring. “One of the things that AAPA is certainly looking at very seriously is trying to partner with other organizations, notably physician specialty organizations,” Thomas says, “to provide what we’re referring to as ‘intensive educational opportunities’ in a whole host of specialty and subspecialty areas.” He notes that some physician specialty groups already offer or are discussing the possibility of offering affiliate or associate membership to PAs who meet certain criteria.

How the matter of specialty recognition will play out is still anyone’s guess. Truly. “There are people who say we know what we’re going to do, that we’ve known it all along, and this is just smoke and mirrors,” Lathrop says. “But it’s really not. I can honestly say, with all sincerity, I have no idea. I just know that we’re going to work through this for the next 18 months, and hopefully come up with something.”

NPs: Nonregulated Specialties
It may have taken five years and the collaborative efforts of more than 50 organizations, but the nursing community has developed a Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (available at the National Council of State Boards of Nursing [NCSBN] Web site, www.ncsbn.org). The model, as its subtitle indicates, outlines the role of an APRN (which includes certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners), as well as the six population foci in which an APRN may choose to be educated.

The NCSBN endorsed the model this summer, providing credibility at the national level, and now, much like the Nurse Licensure Compact, the model will be taken to the states for approval. If a state signs on to the consensus model and subsequently amends any relevant laws or regulations to conform with its principles, NPs and other APRNs would have a level of reciprocity, enabling them to relocate to any other states that have signed on without having to jump through regulatory hoops.

What is relevant to this particular article is that the consensus model expressly states, “Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.” In other words, as explained by Nancy Chornick, PhD, RN, CAE, Director of Practice for NCSBN, specialty recognition will be “out of the purview of legal recognition.”

Chornick goes on to say, “It’s important for NPs to understand that this is not a value issue. Certification is very valuable. It’s just that we’ve taken it out of the purview of licensure. In this way, we will assure that APRNs have a broad scope of practice, and then they’re free to specialize in whatever areas they want.”

Addressing Concerns
While the nursing community has reached a consensus, that doesn’t mean there weren’t questions and concerns along the way. What may be interesting to some is that it was the regulatory bodies—the state boards of nursing—that were most concerned about the potential limitations of specialty certification.

As APRNs—particularly clinical nurse specialists and NPs—started to specialize more, they would go to the boards of nursing and indicate their desire to be licensed in their specialty. “From my point of view, this put those nurses at a disadvantage, because those nurses then must practice within that scope,” Chornick says. “For instance, if they’re specialized—just to carry it to an extreme—in conditions of the right thyroid lobe, then they have a lot of constraints.”

The pitfalls are twofold. Based on her experiences, Mary Smolenski, EdD, FNP, FAANP, CAE, Director of Certification for the American Nurses Credentialing Center (ANCC), says, “NPs aren’t opposed to recognizing the certification in a particular area. But when it gets down to the fact that, gee, now you can’t work in derm unless you go off and get another certification, that’s where the problem arises.”

A narrow scope of practice could mean a decreased number of job opportunities, if an opening in the particular specialty is not readily available. But an even greater concern on the part of the NCSBN is that “individuals who have a very narrow scope of practice then don’t have the education or evaluation for a broader area,” Chornick says. “So it’s really a patient safety issue. You need to be educated and evaluated and work within a certain scope.”

That said, NPs’ primary education, licensure, and certification provide a platform that can be expanded at the practitioner’s choice. “Anything you can add to your basic licensure that ... shows you met a certain standard in a particular area adds to your recognition in that specialty,” Smolenski says. “You don’t want to be mandated to have that level of certification. But the fact that you have it, and you can say, ‘I do have this specialty knowledge,’ to me is a plus, not a minus.”

Looking Beyond Examination
While stating that “preparation in a specialty area of practice is optional,” the consensus model does “strongly recommend” certification in a specialty, if one is chosen. The model also provides a certain amount of leeway in how this additional knowledge and training are acquired and assessed:

“Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (eg, portfolios, examinations, etc).”

Since professional organizations would monitor specialty practice under the model, Chornick explains, “the profession would establish standards and decide what type of marker, so to speak, or designation would be appropriate for that person.”

Obviously, as a representative of ANCC, Smolenski appreciates the value of examination. But there are practical limitations to how many exams can be offered.

“Theoretically, you can develop an exam for anything,” she observes. “But from a business standpoint and a psychometric standpoint, you can’t—because if you’re trying to develop an exam that means anything, that the public can have faith in, you have to have certain numbers of people [to take it].”

Chornick also cites the expense of certification as a rationale for looking at other methods. “Licensure requires examination, so by allowing the specialties to have the profession in charge, they don’t need the examination,” she says. “A lot of specialties were unable to afford the development of a certification exam, so this will allow for alternative methods.”

For example, ANCC has started looking at portfolios for specialty recognition. Smolenski is already working with some nursing specialty groups to create online portfolios. The advantage is the breadth of information that can be made available to review boards or employers: Individuals might include case studies, articles, and presentations they have authored; a list of committees they’ve participated in; a complete history of work experience; and even a list of procedures they’ve learned, as well as how many times they’ve performed them and who supervised them.

“Portfolios give you a different picture of somebody,” Smolenski notes. “You can see the experiences that people have had and what else they bring to the table that is more broad-based than just passing an exam.”

Methods of specialty recognition beyond examination may also level the playing field for those who freeze up at the very idea of being tested. “A lot of people cannot take tests,” Smolenski points out. “They just don’t do well. And then other people are really good test-takers.

“Exams validate that you’ve met a certain standard—but the issue is, just because you passed the test, does that mean you’re competent?” she adds. “You can’t really equate the two. There’s a lot more to competency than a test.”   

In a youth-oriented culture obsessed with Botox, plastic surgery, and age-defying cosmetic products, old tends to be synonymous with decrepit, stinky, cranky, and any number of negative stereotypes. Certainly, many older patients are frail and very close to the end of life.

But the clinicians who work with older adults take great joy in the experience—and when they describe some of their patients, you realize that with their spunk and wisdom, these seniors could teach younger generations a thing or two.

In the independent living community where she provides care, Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and the Secretary of the Board of Directors of the American Geriatrics Society, has a 101-year-old patient with acute angina who is a big fan of physical activity. “She’ll say to me, ‘Barbara, you’re not making me go to the hospital today. I really want to go down and exercise,’” Resnick says. “She feels better after she does it.”

For Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association, one memorable patient is the perfectly cognizant 99-year-old woman “who has a little attitude because her CNA is off and she had to have another CNA do her hair, and she can’t do hair as well. And I get to sit and listen to the stories that she tells about when she was in her 20s … and 30s … and 40s, sharing her experiences at a time that was well before I was born. It’s wonderful.”

Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, also speaks warmly of her patients’ willingness to share. “The attraction for me in geriatrics is that I get to time-travel,” she says. “I get to meet people at the end of their lives and get to know all about them. And they lived in a time and a place that I didn’t—but I get to have that experience.”

Kathy Kemle, PA-C, who cofounded the Society of PAs Caring for the Elderly with Segal-Gidan and who is President of the Georgia Geriatrics Society, learned early to appreciate older people. “I had the good fortune to grow up in a community where I was the only person younger than 50—and I was spoiled rotten,” she says. “So I grew to enjoy being around older adults. They’re just fun people, and you can learn fascinating things.”

And for a clinician, some of them can be dream patients. “As a group, they are the most compliant patients you will meet,” Kemle says with a laugh. “That may change, of course. As my generation gets in there, I’m sure I’ll be as noncompliant as the next one. But the current cohort of older adults are very compliant and very appreciative.”

All four geriatric clinicians interviewed also noted that little things can make a big difference. “Just reducing somebody’s medication can make them less confused,” Segal-Gidan says. “Or putting grab bars in their bathroom can help them to be independent in toileting. You don’t have to do major surgery to make a difference.”

In a youth-oriented culture obsessed with Botox, plastic surgery, and age-defying cosmetic products, old tends to be synonymous with decrepit, stinky, cranky, and any number of negative stereotypes. Certainly, many older patients are frail and very close to the end of life.

But the clinicians who work with older adults take great joy in the experience—and when they describe some of their patients, you realize that with their spunk and wisdom, these seniors could teach younger generations a thing or two.

In the independent living community where she provides care, Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and the Secretary of the Board of Directors of the American Geriatrics Society, has a 101-year-old patient with acute angina who is a big fan of physical activity. “She’ll say to me, ‘Barbara, you’re not making me go to the hospital today. I really want to go down and exercise,’” Resnick says. “She feels better after she does it.”

For Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association, one memorable patient is the perfectly cognizant 99-year-old woman “who has a little attitude because her CNA is off and she had to have another CNA do her hair, and she can’t do hair as well. And I get to sit and listen to the stories that she tells about when she was in her 20s … and 30s … and 40s, sharing her experiences at a time that was well before I was born. It’s wonderful.”

Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, also speaks warmly of her patients’ willingness to share. “The attraction for me in geriatrics is that I get to time-travel,” she says. “I get to meet people at the end of their lives and get to know all about them. And they lived in a time and a place that I didn’t—but I get to have that experience.”

Kathy Kemle, PA-C, who cofounded the Society of PAs Caring for the Elderly with Segal-Gidan and who is President of the Georgia Geriatrics Society, learned early to appreciate older people. “I had the good fortune to grow up in a community where I was the only person younger than 50—and I was spoiled rotten,” she says. “So I grew to enjoy being around older adults. They’re just fun people, and you can learn fascinating things.”

And for a clinician, some of them can be dream patients. “As a group, they are the most compliant patients you will meet,” Kemle says with a laugh. “That may change, of course. As my generation gets in there, I’m sure I’ll be as noncompliant as the next one. But the current cohort of older adults are very compliant and very appreciative.”

All four geriatric clinicians interviewed also noted that little things can make a big difference. “Just reducing somebody’s medication can make them less confused,” Segal-Gidan says. “Or putting grab bars in their bathroom can help them to be independent in toileting. You don’t have to do major surgery to make a difference.”

In a youth-oriented culture obsessed with Botox, plastic surgery, and age-defying cosmetic products, old tends to be synonymous with decrepit, stinky, cranky, and any number of negative stereotypes. Certainly, many older patients are frail and very close to the end of life.

But the clinicians who work with older adults take great joy in the experience—and when they describe some of their patients, you realize that with their spunk and wisdom, these seniors could teach younger generations a thing or two.

In the independent living community where she provides care, Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and the Secretary of the Board of Directors of the American Geriatrics Society, has a 101-year-old patient with acute angina who is a big fan of physical activity. “She’ll say to me, ‘Barbara, you’re not making me go to the hospital today. I really want to go down and exercise,’” Resnick says. “She feels better after she does it.”

For Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association, one memorable patient is the perfectly cognizant 99-year-old woman “who has a little attitude because her CNA is off and she had to have another CNA do her hair, and she can’t do hair as well. And I get to sit and listen to the stories that she tells about when she was in her 20s … and 30s … and 40s, sharing her experiences at a time that was well before I was born. It’s wonderful.”

Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, also speaks warmly of her patients’ willingness to share. “The attraction for me in geriatrics is that I get to time-travel,” she says. “I get to meet people at the end of their lives and get to know all about them. And they lived in a time and a place that I didn’t—but I get to have that experience.”

Kathy Kemle, PA-C, who cofounded the Society of PAs Caring for the Elderly with Segal-Gidan and who is President of the Georgia Geriatrics Society, learned early to appreciate older people. “I had the good fortune to grow up in a community where I was the only person younger than 50—and I was spoiled rotten,” she says. “So I grew to enjoy being around older adults. They’re just fun people, and you can learn fascinating things.”

And for a clinician, some of them can be dream patients. “As a group, they are the most compliant patients you will meet,” Kemle says with a laugh. “That may change, of course. As my generation gets in there, I’m sure I’ll be as noncompliant as the next one. But the current cohort of older adults are very compliant and very appreciative.”

All four geriatric clinicians interviewed also noted that little things can make a big difference. “Just reducing somebody’s medication can make them less confused,” Segal-Gidan says. “Or putting grab bars in their bathroom can help them to be independent in toileting. You don’t have to do major surgery to make a difference.”