Ann M. Hoppel

A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.

Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.

Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.

But are NPs and PAs taking full advantage of them?

Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.

In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”

But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”

It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”

NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”

As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”

Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”

“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.

“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”

Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.

“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”

And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.

For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”

Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”

Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.

NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.

The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”

“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.

“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”

Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”

Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”

Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”

Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.

“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”

At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”

Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”

But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.

“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”

Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.

“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”

A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.

Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.

Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.

But are NPs and PAs taking full advantage of them?

Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.

In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”

But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”

It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”

NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”

As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”

Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”

“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.

“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”

Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.

“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”

And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.

For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”

Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”

Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.

NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.

The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”

“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.

“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”

Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”

Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”

Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”

Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.

“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”

At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”

Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”

But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.

“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”

Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.

“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”

A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.

Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.

Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.

But are NPs and PAs taking full advantage of them?

Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.

In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”

But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”

It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”

NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”

As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”

Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”

“Older adults have physiological changes that cause them to be a completely separate population from adults,” says Bakerjian, who also points out that 65 is a somewhat arbitrary age: It does not reflect the fact that such changes occur earlier or later in some individuals.

“It’s hard to describe unless you actually do it, but older adults are the most heterogeneous group,” Kemle says. “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.”

Clinicians who care for older adults need to know everything from the normal process of aging to how diseases present differently at advanced ages. They need to understand the geriatric syndromes, which include dementia, incontinence, and falls.

“It’s also about understanding the health care world of aging,” Resnick adds. “Medicare and Medicaid, the dually eligible, nursing home care, assisted living care—all of those are really quite different than [in] the acute care setting or a primary care practice.”

And clinicians who care for older adults must be prepared to address multiple conditions and think outside the box. For example, if a 55-year-old presents to the emergency department with chest pain, a heart attack is a logical diagnosis.

For a 75-year-old with chest pain, however, “Maybe they had a heart attack, but maybe the chest pain is because they have pneumonia, and maybe they have pneumonia because they fell and were on the floor for an hour,” Segal-Gidan says. “It’s much more complicated, and that’s what scares people away from wanting to care for older people.”

Clinicians also need to recognize the burdens that caring for the elderly places on informal caregivers. “We need to be aware that oftentimes the middle-aged and ‘young’ old people that we’re seeing are suffering from illnesses because of the increased stress of their caregiving role,” Kemle points out. “I think sometimes people forget that it’s not just the patient—it’s the entire family and those interwoven relationships.”

Roles for NPs, PAs in Team
There are indications that PAs and NPs could make a big difference in geriatrics. Significantly, team care is considered essential for older adults and is associated with better outcomes, such as lower rates of hospital readmissions, shorter lengths of stay in hospitals, better quality of life, and higher function. “A single provider really can’t do everything older patients need,” Kemle says.

NPs and PAs already play an important role in geriatric health care. About one-third of visits to PAs are made by older adults, and 78% of PAs report treating at least some patients older than 85. Among NPs, 23% of office visits and 47% of hospital outpatient visits are made by people 65 and older.

The IOM report indicates that “health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some responsibilities that they already have—to help ensure that all members of the health care workforce are used at their highest level of competence.”

“We have so few geriatricians that we need to preserve them for the most highly complex care,” Bakerjian says. She envisions a system in which NPs provide routine primary care in nursing homes or private offices, while the geriatrician acts as a consultant—not just to the NP but also to physicians in other specialties.

“Physician time and knowledge shouldn’t be spent on managing chronic medical problems that NPs can do,” Resnick adds. “That time should go to diagnosing and managing more complicated illnesses—diagnoses that an NP may not know anything about. That’s the beauty of the team, and it’s the only way we’re going to have sufficient resources.”

Among PAs, there are mixed reviews as to how fully their role in geriatric care is being recognized. “NPs have advanced themselves as part of the solution,” Segal-Gidan observes. “PAs aren’t seen so readily as pieces of those teams. The PA profession, in my opinion, has not stepped forward and taken on a leadership role that it could—and I think should—in this area.”

Kemle, however, has had positive experiences in her role as the American Academy of Physician Assistants Liaison to the AGS. “The physician community is very anxious to embrace us, and I’m not sure you would find that in every specialty,” she says. Among the AGS’s working group on workforce issues, “there has been a lot of discussion about ‘Now, this is not physician-only. We need to be inclusive of everyone and work together to develop interdisciplinary curricula.’”

Collaborating in a team is one of the things Bakerjian finds most rewarding in her work. “We work closely with the physical therapist, the dietitian, the psychologist or psychiatrist, the pharmacist, the physicians, the nursing staff, the activities director [in a nursing home],” she says. “It’s a very interdisciplinary or multidisciplinary environment to which all of those people contribute.”

Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.

“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”

At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”

Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”

But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.

“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”

Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.

“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”

Broken. Grossly underfunded. In crisis. That’s how psychiatric and behavioral health specialists describe the current state of mental health care in the United States. The problems that plague the health care system in general—workforce shortages, barriers to access, and inadequate reimbursement—are only exacerbated in mental health.

“Mental illness isn’t glamorous,” says Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa Behavioral Health in Iowa City. Taking an example from the academic medical center setting, he adds, “It’s nice to have the cardiac surgery wing dedicated to or named after your family—but nobody wants a mental health wing named after them.”

Stigma is perhaps the greatest challenge with this patient population. “Until this country really embraces the notion that mental health is inherent in every aspect of a person’s general health,” says Gail W. Stuart, PhD, APRN, FAAN, Professor and Dean of the College of Nursing at Medical University of South Carolina, Charleston, “I think the stigma issue is going to continue to make it difficult to overcome these problems.”

From Hospitals to Jails
The current state of mental health care in the US is perhaps a direct result of the deinstitutionalization that occurred in the 1980s. By that time, most mental health hospitals were overcrowded, and in the worst cases, patients were subject to neglect and even abuse. (Recall, if you can, Geraldo Rivera skulking through the dark at Willowbrook State School in Staten Island, NY; his 1972 exposé brought the issue to the forefront.)

Following the public outcry over the treatment of these patients who—mental illness or not—were people, there was a movement to reduce the number of long-term hospitalizations for mental illness. Along the way, the number of hospital beds available for mentally ill patients also declined, as freestanding hospitals and private facilities closed. What have these patients been left with?

“The thought was that people would be maintained in the community—there would be community support services, halfway houses, boarding homes, community-based programs,” says Catherine R. Judd, MS, PA-C, President of the Association of Psychiatric PAs, who works in the Department of Psychiatry at the University of Texas Southwestern Medical Center, Dallas. “The idea is good, but unfortunately, most of those programs have really not materialized to the extent or with the capacity to take care of the people who are out there.”

Without these services—and with an overtaxed health care system in general—many patients with mental illness find themselves adrift. And, eventually, incarcerated. An estimate from the US Department of Justice indicates that 24% of state and 21% of local prisoners have a recent history of mental illness. The largest psychiatric hospital in the country is the Los Angeles County Jail.

The problem is so widespread and so serious that both Judd and Jeanne Clement, EdD, APRN, BC, FAAN, President of the American Psychiatric Nurses Association (APNA), describe it in identical terms: “The jails and prisons have become the de facto mental health system.”

“More and more mentally ill people are in the streets, not receiving services, not taking medication as prescribed, with less-than-optimal case management in the community,” says Judd, who also works with the chronic mentally ill at the Dallas County Jail. “So, they are picked up on substance abuse–related charges or criminal trespassing or burglary. Consequently, they’re brought to jail.”

In Dallas, a divert court has been established, with the aim of getting chronic, persistent mentally ill patients “back to clinics and back on medication as quickly as possible without incarcerating them,” Judd notes. For such a program to succeed, of course, you need clinics—and providers—to divert these patients to.

Problems of Access
Talk with clinicians who work in psychiatry, mental health, or behavioral health settings, and you’ll hear a familiar litany of problems. For one thing, there is the shortage of providers. “Here in Iowa, we’ve got areas where we have one psychiatrist covering five counties,” St. John says. “It’s almost impossible to get in with someone, and then when you do, it’s a five- or 10-minute appointment, because they’re just so busy.”

The number of clinicians choosing psychiatry—particularly psychiatric nursing—has declined significantly, perhaps due to insufficient funding for educational programs. “The highest number we had going into psychiatric nursing was when the National Institute of Mental Health, which was then separate from the NIH, had training grants,” explains Clement, who is the Director of the Graduate Specialty Program in Psychiatric–Mental Health Nursing at Ohio State University, Columbus. “And many of us who had those training grants are getting way past retirement age!”

The allure of other specialties also keeps people from mental health fields. “There are a lot of jobs and openings for PAs in psychiatry,” St. John says, “but there are a lot of jobs in orthopedics or surgery, too—and that’s what tends to draw them.”

The shortage of mental health care providers and subsequent lack of access to services means a larger role for primary care providers. High-profile expert panels have highlighted the need for integration of mental health into primary care settings—which St. John says is already largely the case.

“Most mental illness is treated in primary care, not in mental health settings,” he points out. “Mental health settings should really be reserved for the more challenging patients, the more difficult diagnoses and problems, and co-occurring illnesses.”

“Most primary care clinicians have some education in relationship to diagnosing and treating mild to moderate mental health issues, and then they refer on when needed,” Clement says. “The problem is, referring on is more and more difficult if there aren’t any people to refer to, or if waiting lists are as long as they currently are.”

Time is just as much of a problem in primary care as it is in specialty care, and when it comes to psychiatric and behavioral disorders, you can’t just order a lab test or an x-ray. “In psychiatry, you have to talk with the person and try to figure out what’s going on in their head and how that’s affecting their function,” St. John says. “It takes more time, and in primary care, that’s the problem they have. They’ve got appointments that may only have 10 minutes scheduled, and that’s not adequate to obtain a decent psychiatric history.”

The importance of both primary care providers and mental health specialists cannot be downplayed, because mental illnesses are among the most disabling and deadly. “If you look at disabling conditions, depression is right up there at the top,” St. John says. “Actually, it’s predicted that in the next three or four years, worldwide, depression will be the number one disabling illness.”

Anorexia is associated with a 15% death rate, and the completed suicide rate for persons with severe depression is also 15%. “If you were to look at one issue alone that we’re missing the boat on, it’s suicide,” Stuart says. “There are more suicides globally than there are deaths from war and violence combined—and the incidence of suicide is rising. So if, for example, a primary care provider sees someone who’s depressed, they have to go the next step and also ask about potential suicidal thought.”

Clement says it is equally important to integrate primary care services into mental health settings, since many patients with mental illnesses “are not going to show up in a private office in a primary care setting. And people with mental illness die 25 years earlier than the general population, from treatable medical illnesses.”

This is why, for example, the APNA is partnering with the Smoking Cessation Leadership Center. “Persons with mental illness are purchasing approximately half of the cigarettes that are being bought in the US,” Clement says. “And many of the treatable medical illnesses that people are dying from are related to smoking. It’s a whole person you’re working with, not just a brain or a body.”

Reimbursement Issue
Reimbursement is one of the major deterrents to the pursuit of a career in mental health care. “The whole reimbursement issue makes it difficult to attract people to work in mental health, particularly in community-based clinics, state hospitals, prisons, and jails,” which Judd says results in a lack of services for the seriously mentally ill and decreased access for people of low income.

The biggest problem is parity—or rather, the lack of it. What services are covered and at what rate tends to vary by state, and mental health is often not covered at the same rate as physical health. “There are a number of states that now have parity in mental health,” Clement observes. “If insurance is offered for physical health and [includes] mental health coverage, it has to be at exactly the same level as physical health, in terms of copays and lifetime limits.” But even so, there is not always parity in parity.

Furthermore, many people who need mental health services fall under the Medicaid program, which is state-based and just as variable. “Definitions of ‘medical necessity’ differ, and providers don’t get paid unless they can document according to medical necessity,” Clement says. “Even though what people—particularly those in the Medicaid and public mental health systems—need, along with their treatment, is a community-based program that helps people find jobs and housing. But that’s not ‘medical necessity.’”

Another problem is the sheer expense of some of the medications for mental disorders. “A lot of the drugs that we use to treat serious mental illnesses are horrendously expensive,” St. John notes. “They’ll almost bankrupt some states.… We just don’t have those budgets.”

Achieving parity and improving reimbursement is a slow process. Clement has been involved at the federal level with a parity bill, but as she notes, “that has not been resolved in terms of the differences between the House and the Senate.” Since so many of the programs are administered at a state level anyway, some suggest that might be a good place to begin working on reform.

In October 2007, the Annapolis Coalition, of which Stuart is President of the Board of Directors, released an action plan for reforming the mental health system—particularly for addressing workforce needs. The report (available at www.annapoliscoalition.org) includes the most specific recommendations possible in an overarching “framework” document, and Stuart says the coalition is currently working with some states—including North Carolina, Connecticut, New Mexico, and California—to identify and prioritize their needs and determine how best to tailor the plan to them.

“We’re really approaching it not at a federal level but seeing that the true change would come about at a state level,” Stuart says. “The need is derived differently by each state. If I can use the analogy, it’s a little bit like having a general way of approaching hypertension, but then you tailor it to the individual.”

Whether at the state or federal level, St. John thinks major changes to reimbursement for mental health care will require a cultural shift. “We reimburse for activity, we reimburse for procedures; we don’t reimburse for time spent or for decision making or thinking,” he points out. When a clinician is being reimbursed 50% (compared to 90% for other medical care), or $12 to $15 per visit for providing medication management, “You have to see large volumes of people in order to get reimbursed enough to pay for yourself and your staff.”

In the current economic climate, finding the money is going to take some shuffling. “It would be unrealistic to say that there are new dollars out there, because clearly there are not,” Stuart says. “So I think the issue is to reallocate the current resources that are out there and evaluate, Are we getting the best return on our investment of these dollars?”

The irony is that the people with the greatest needs for treatment, monitoring, and support services are the ones who face the biggest barriers to accessing care. “Services are more readily available to people who have jobs, have insurance—which would tell you in and of itself they’re probably higher functioning to start with,” Judd says. “I mean, if you’re having stress holding down a job, you’re probably higher functioning at your baseline than the homeless person who is living in the streets and under bridges and doesn’t go to shelters because they’re too paranoid to be around other people.”

Taking the Shame Out of Mental Illness
No discussion of mental health care can be complete without addressing the stigma associated with mental illness. Americans may have responded with outrage when they saw the deplorable conditions at mental hospitals, but many are still leery of being associated with a mental illness, whether in themselves or in a family member. And the cases that garner the most media attention are not necessarily the ones that reduce stigma.

What Americans see on the nightly news is the schizophrenic man who stops taking his medication and then stabs another man to death while he’s waiting for a train. Or the mother with chronic depression who can’t get out of bed until someone notices her kids look dirty and underfed, and Social Services steps in to remove them from the home. Do we, as a society, recognize the double tragedy of those situations? Or do we shake our heads in disgust, slap on a “crazy guy” or “bad mom” label, and change the channel?

Public service campaigns are trying to reduce the stigma associated with mental illness, to point out that it can affect anyone. The faces of the mentally ill are diverse: There’s the grandfather with Alzheimer’s disease who mistakes his granddaughter for his daughter. The 2-year-old autistic girl who has difficulty connecting with family and friends. The soldiers returning from the war zones in Iraq and Afghanistan, struggling with posttraumatic stress disorder (PTSD).

“The message that is being sent that needs to be broadcast more and heard with a different ear is that there is no health without mental health,” Clement says. St. John adds that it will take “a lot of time and education” to get that message out to the public, to let people know that it’s OK—in fact, it’s better—to acknowledge mental illness and seek help for it.

Stuart thinks the troops’ return from overseas, which is generating more stories about traumatic brain injury, PTSD, depression, and suicide, may start to turn the tide. “Perhaps because these are our veterans and our heroes, they’ve served the country, it’s opening up a public discussion in a way that’s different from seeing the aberrant, violent patient who does something very disruptive,” she says. “So, in a sense—and this sounds odd—we’re normalizing mental health problems, saying that all kinds of people from all walks of life can develop mental health problems, just as they can develop physical health problems.”

The key will be ensuring that the pendulum doesn’t swing too far the other way and cause the “stigma reduction” movement to generate its own problems. “On the one hand, we’re trying to destigmatize mental illness, but on the other hand, it [sometimes] seems like we’re calling any aberrant behavior or problems in life, stress or problems of adjustment, a mental illness,” Judd observes.

There are certain niches in which mental illness seems almost “trendy,” and industry advertising may encourage that. “Pharmaceutical companies are putting advertisements out there that would imply, ‘Gee, you’re getting divorced because you had conflict in your marriage—maybe you have bipolar disorder’ or ‘Your child isn’t doing well in school, so surely he has ADHD and needs to be on medication,’” Judd says. “There’s this promoting of drugs for anything and everything. And so that’s kind of the other extreme, where any problems in life in functioning must be because of a mental illness, and therefore you need a drug.”

Restored to Life
With such a grim picture of mental health care in the US, it hardly seems surprising that clinicians don’t flock to the specialty. Yet, Clement, Judd, St. John, and Stuart did. Why?

For Judd, “the science of it is extremely interesting.” She thinks that as psychiatry becomes more biological and clinicians delve more deeply into what is affecting a patient’s function (Is it trauma, prenatal influences, infection, genetics?) and how that impacts treatment choices, more practitioners might choose mental health care. But the biggest reward, she says, is seeing people “return to a higher level of functioning.”

“I have never, ever sat down with a client that I have not felt privileged to be allowed into their lives,” says Clement, who has been a nurse for 49 years and a psychiatric nurse for 47 of them. “People allow clinicians into their lives in a very different way than they do anybody else.”

That can be especially true in mental health, when clinicians must interact on a very intimate level with their patients. It can be challenging, frustrating, even devastating (such as when a patient takes his or her own life). But it can also be infinitely rewarding. That is why St. John moved from family practice and emergency settings to psychiatry, where he has spent the past 15 years.

“When you see people who kind of get back into life and start working more toward their life goals, and you start seeing them get back into their family and their work and their social function, perking up and engaging in the world,” he says, his voice conveying a deep sense of fulfillment, “there’s just nothing more rewarding than that.”

Broken. Grossly underfunded. In crisis. That’s how psychiatric and behavioral health specialists describe the current state of mental health care in the United States. The problems that plague the health care system in general—workforce shortages, barriers to access, and inadequate reimbursement—are only exacerbated in mental health.

“Mental illness isn’t glamorous,” says Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa Behavioral Health in Iowa City. Taking an example from the academic medical center setting, he adds, “It’s nice to have the cardiac surgery wing dedicated to or named after your family—but nobody wants a mental health wing named after them.”

Stigma is perhaps the greatest challenge with this patient population. “Until this country really embraces the notion that mental health is inherent in every aspect of a person’s general health,” says Gail W. Stuart, PhD, APRN, FAAN, Professor and Dean of the College of Nursing at Medical University of South Carolina, Charleston, “I think the stigma issue is going to continue to make it difficult to overcome these problems.”

From Hospitals to Jails
The current state of mental health care in the US is perhaps a direct result of the deinstitutionalization that occurred in the 1980s. By that time, most mental health hospitals were overcrowded, and in the worst cases, patients were subject to neglect and even abuse. (Recall, if you can, Geraldo Rivera skulking through the dark at Willowbrook State School in Staten Island, NY; his 1972 exposé brought the issue to the forefront.)

Following the public outcry over the treatment of these patients who—mental illness or not—were people, there was a movement to reduce the number of long-term hospitalizations for mental illness. Along the way, the number of hospital beds available for mentally ill patients also declined, as freestanding hospitals and private facilities closed. What have these patients been left with?

“The thought was that people would be maintained in the community—there would be community support services, halfway houses, boarding homes, community-based programs,” says Catherine R. Judd, MS, PA-C, President of the Association of Psychiatric PAs, who works in the Department of Psychiatry at the University of Texas Southwestern Medical Center, Dallas. “The idea is good, but unfortunately, most of those programs have really not materialized to the extent or with the capacity to take care of the people who are out there.”

Without these services—and with an overtaxed health care system in general—many patients with mental illness find themselves adrift. And, eventually, incarcerated. An estimate from the US Department of Justice indicates that 24% of state and 21% of local prisoners have a recent history of mental illness. The largest psychiatric hospital in the country is the Los Angeles County Jail.

The problem is so widespread and so serious that both Judd and Jeanne Clement, EdD, APRN, BC, FAAN, President of the American Psychiatric Nurses Association (APNA), describe it in identical terms: “The jails and prisons have become the de facto mental health system.”

“More and more mentally ill people are in the streets, not receiving services, not taking medication as prescribed, with less-than-optimal case management in the community,” says Judd, who also works with the chronic mentally ill at the Dallas County Jail. “So, they are picked up on substance abuse–related charges or criminal trespassing or burglary. Consequently, they’re brought to jail.”

In Dallas, a divert court has been established, with the aim of getting chronic, persistent mentally ill patients “back to clinics and back on medication as quickly as possible without incarcerating them,” Judd notes. For such a program to succeed, of course, you need clinics—and providers—to divert these patients to.

Problems of Access
Talk with clinicians who work in psychiatry, mental health, or behavioral health settings, and you’ll hear a familiar litany of problems. For one thing, there is the shortage of providers. “Here in Iowa, we’ve got areas where we have one psychiatrist covering five counties,” St. John says. “It’s almost impossible to get in with someone, and then when you do, it’s a five- or 10-minute appointment, because they’re just so busy.”

The number of clinicians choosing psychiatry—particularly psychiatric nursing—has declined significantly, perhaps due to insufficient funding for educational programs. “The highest number we had going into psychiatric nursing was when the National Institute of Mental Health, which was then separate from the NIH, had training grants,” explains Clement, who is the Director of the Graduate Specialty Program in Psychiatric–Mental Health Nursing at Ohio State University, Columbus. “And many of us who had those training grants are getting way past retirement age!”

The allure of other specialties also keeps people from mental health fields. “There are a lot of jobs and openings for PAs in psychiatry,” St. John says, “but there are a lot of jobs in orthopedics or surgery, too—and that’s what tends to draw them.”

The shortage of mental health care providers and subsequent lack of access to services means a larger role for primary care providers. High-profile expert panels have highlighted the need for integration of mental health into primary care settings—which St. John says is already largely the case.

“Most mental illness is treated in primary care, not in mental health settings,” he points out. “Mental health settings should really be reserved for the more challenging patients, the more difficult diagnoses and problems, and co-occurring illnesses.”

“Most primary care clinicians have some education in relationship to diagnosing and treating mild to moderate mental health issues, and then they refer on when needed,” Clement says. “The problem is, referring on is more and more difficult if there aren’t any people to refer to, or if waiting lists are as long as they currently are.”

Time is just as much of a problem in primary care as it is in specialty care, and when it comes to psychiatric and behavioral disorders, you can’t just order a lab test or an x-ray. “In psychiatry, you have to talk with the person and try to figure out what’s going on in their head and how that’s affecting their function,” St. John says. “It takes more time, and in primary care, that’s the problem they have. They’ve got appointments that may only have 10 minutes scheduled, and that’s not adequate to obtain a decent psychiatric history.”

The importance of both primary care providers and mental health specialists cannot be downplayed, because mental illnesses are among the most disabling and deadly. “If you look at disabling conditions, depression is right up there at the top,” St. John says. “Actually, it’s predicted that in the next three or four years, worldwide, depression will be the number one disabling illness.”

Anorexia is associated with a 15% death rate, and the completed suicide rate for persons with severe depression is also 15%. “If you were to look at one issue alone that we’re missing the boat on, it’s suicide,” Stuart says. “There are more suicides globally than there are deaths from war and violence combined—and the incidence of suicide is rising. So if, for example, a primary care provider sees someone who’s depressed, they have to go the next step and also ask about potential suicidal thought.”

Clement says it is equally important to integrate primary care services into mental health settings, since many patients with mental illnesses “are not going to show up in a private office in a primary care setting. And people with mental illness die 25 years earlier than the general population, from treatable medical illnesses.”

This is why, for example, the APNA is partnering with the Smoking Cessation Leadership Center. “Persons with mental illness are purchasing approximately half of the cigarettes that are being bought in the US,” Clement says. “And many of the treatable medical illnesses that people are dying from are related to smoking. It’s a whole person you’re working with, not just a brain or a body.”

Reimbursement Issue
Reimbursement is one of the major deterrents to the pursuit of a career in mental health care. “The whole reimbursement issue makes it difficult to attract people to work in mental health, particularly in community-based clinics, state hospitals, prisons, and jails,” which Judd says results in a lack of services for the seriously mentally ill and decreased access for people of low income.

The biggest problem is parity—or rather, the lack of it. What services are covered and at what rate tends to vary by state, and mental health is often not covered at the same rate as physical health. “There are a number of states that now have parity in mental health,” Clement observes. “If insurance is offered for physical health and [includes] mental health coverage, it has to be at exactly the same level as physical health, in terms of copays and lifetime limits.” But even so, there is not always parity in parity.

Furthermore, many people who need mental health services fall under the Medicaid program, which is state-based and just as variable. “Definitions of ‘medical necessity’ differ, and providers don’t get paid unless they can document according to medical necessity,” Clement says. “Even though what people—particularly those in the Medicaid and public mental health systems—need, along with their treatment, is a community-based program that helps people find jobs and housing. But that’s not ‘medical necessity.’”

Another problem is the sheer expense of some of the medications for mental disorders. “A lot of the drugs that we use to treat serious mental illnesses are horrendously expensive,” St. John notes. “They’ll almost bankrupt some states.… We just don’t have those budgets.”

Achieving parity and improving reimbursement is a slow process. Clement has been involved at the federal level with a parity bill, but as she notes, “that has not been resolved in terms of the differences between the House and the Senate.” Since so many of the programs are administered at a state level anyway, some suggest that might be a good place to begin working on reform.

In October 2007, the Annapolis Coalition, of which Stuart is President of the Board of Directors, released an action plan for reforming the mental health system—particularly for addressing workforce needs. The report (available at www.annapoliscoalition.org) includes the most specific recommendations possible in an overarching “framework” document, and Stuart says the coalition is currently working with some states—including North Carolina, Connecticut, New Mexico, and California—to identify and prioritize their needs and determine how best to tailor the plan to them.

“We’re really approaching it not at a federal level but seeing that the true change would come about at a state level,” Stuart says. “The need is derived differently by each state. If I can use the analogy, it’s a little bit like having a general way of approaching hypertension, but then you tailor it to the individual.”

Whether at the state or federal level, St. John thinks major changes to reimbursement for mental health care will require a cultural shift. “We reimburse for activity, we reimburse for procedures; we don’t reimburse for time spent or for decision making or thinking,” he points out. When a clinician is being reimbursed 50% (compared to 90% for other medical care), or $12 to $15 per visit for providing medication management, “You have to see large volumes of people in order to get reimbursed enough to pay for yourself and your staff.”

In the current economic climate, finding the money is going to take some shuffling. “It would be unrealistic to say that there are new dollars out there, because clearly there are not,” Stuart says. “So I think the issue is to reallocate the current resources that are out there and evaluate, Are we getting the best return on our investment of these dollars?”

The irony is that the people with the greatest needs for treatment, monitoring, and support services are the ones who face the biggest barriers to accessing care. “Services are more readily available to people who have jobs, have insurance—which would tell you in and of itself they’re probably higher functioning to start with,” Judd says. “I mean, if you’re having stress holding down a job, you’re probably higher functioning at your baseline than the homeless person who is living in the streets and under bridges and doesn’t go to shelters because they’re too paranoid to be around other people.”

Taking the Shame Out of Mental Illness
No discussion of mental health care can be complete without addressing the stigma associated with mental illness. Americans may have responded with outrage when they saw the deplorable conditions at mental hospitals, but many are still leery of being associated with a mental illness, whether in themselves or in a family member. And the cases that garner the most media attention are not necessarily the ones that reduce stigma.

What Americans see on the nightly news is the schizophrenic man who stops taking his medication and then stabs another man to death while he’s waiting for a train. Or the mother with chronic depression who can’t get out of bed until someone notices her kids look dirty and underfed, and Social Services steps in to remove them from the home. Do we, as a society, recognize the double tragedy of those situations? Or do we shake our heads in disgust, slap on a “crazy guy” or “bad mom” label, and change the channel?

Public service campaigns are trying to reduce the stigma associated with mental illness, to point out that it can affect anyone. The faces of the mentally ill are diverse: There’s the grandfather with Alzheimer’s disease who mistakes his granddaughter for his daughter. The 2-year-old autistic girl who has difficulty connecting with family and friends. The soldiers returning from the war zones in Iraq and Afghanistan, struggling with posttraumatic stress disorder (PTSD).

“The message that is being sent that needs to be broadcast more and heard with a different ear is that there is no health without mental health,” Clement says. St. John adds that it will take “a lot of time and education” to get that message out to the public, to let people know that it’s OK—in fact, it’s better—to acknowledge mental illness and seek help for it.

Stuart thinks the troops’ return from overseas, which is generating more stories about traumatic brain injury, PTSD, depression, and suicide, may start to turn the tide. “Perhaps because these are our veterans and our heroes, they’ve served the country, it’s opening up a public discussion in a way that’s different from seeing the aberrant, violent patient who does something very disruptive,” she says. “So, in a sense—and this sounds odd—we’re normalizing mental health problems, saying that all kinds of people from all walks of life can develop mental health problems, just as they can develop physical health problems.”

The key will be ensuring that the pendulum doesn’t swing too far the other way and cause the “stigma reduction” movement to generate its own problems. “On the one hand, we’re trying to destigmatize mental illness, but on the other hand, it [sometimes] seems like we’re calling any aberrant behavior or problems in life, stress or problems of adjustment, a mental illness,” Judd observes.

There are certain niches in which mental illness seems almost “trendy,” and industry advertising may encourage that. “Pharmaceutical companies are putting advertisements out there that would imply, ‘Gee, you’re getting divorced because you had conflict in your marriage—maybe you have bipolar disorder’ or ‘Your child isn’t doing well in school, so surely he has ADHD and needs to be on medication,’” Judd says. “There’s this promoting of drugs for anything and everything. And so that’s kind of the other extreme, where any problems in life in functioning must be because of a mental illness, and therefore you need a drug.”

Restored to Life
With such a grim picture of mental health care in the US, it hardly seems surprising that clinicians don’t flock to the specialty. Yet, Clement, Judd, St. John, and Stuart did. Why?

For Judd, “the science of it is extremely interesting.” She thinks that as psychiatry becomes more biological and clinicians delve more deeply into what is affecting a patient’s function (Is it trauma, prenatal influences, infection, genetics?) and how that impacts treatment choices, more practitioners might choose mental health care. But the biggest reward, she says, is seeing people “return to a higher level of functioning.”

“I have never, ever sat down with a client that I have not felt privileged to be allowed into their lives,” says Clement, who has been a nurse for 49 years and a psychiatric nurse for 47 of them. “People allow clinicians into their lives in a very different way than they do anybody else.”

That can be especially true in mental health, when clinicians must interact on a very intimate level with their patients. It can be challenging, frustrating, even devastating (such as when a patient takes his or her own life). But it can also be infinitely rewarding. That is why St. John moved from family practice and emergency settings to psychiatry, where he has spent the past 15 years.

“When you see people who kind of get back into life and start working more toward their life goals, and you start seeing them get back into their family and their work and their social function, perking up and engaging in the world,” he says, his voice conveying a deep sense of fulfillment, “there’s just nothing more rewarding than that.”

Broken. Grossly underfunded. In crisis. That’s how psychiatric and behavioral health specialists describe the current state of mental health care in the United States. The problems that plague the health care system in general—workforce shortages, barriers to access, and inadequate reimbursement—are only exacerbated in mental health.

“Mental illness isn’t glamorous,” says Don St. John, MA, PA-C, who practices in adult outpatient psychiatry at the University of Iowa Behavioral Health in Iowa City. Taking an example from the academic medical center setting, he adds, “It’s nice to have the cardiac surgery wing dedicated to or named after your family—but nobody wants a mental health wing named after them.”

Stigma is perhaps the greatest challenge with this patient population. “Until this country really embraces the notion that mental health is inherent in every aspect of a person’s general health,” says Gail W. Stuart, PhD, APRN, FAAN, Professor and Dean of the College of Nursing at Medical University of South Carolina, Charleston, “I think the stigma issue is going to continue to make it difficult to overcome these problems.”

From Hospitals to Jails
The current state of mental health care in the US is perhaps a direct result of the deinstitutionalization that occurred in the 1980s. By that time, most mental health hospitals were overcrowded, and in the worst cases, patients were subject to neglect and even abuse. (Recall, if you can, Geraldo Rivera skulking through the dark at Willowbrook State School in Staten Island, NY; his 1972 exposé brought the issue to the forefront.)

Following the public outcry over the treatment of these patients who—mental illness or not—were people, there was a movement to reduce the number of long-term hospitalizations for mental illness. Along the way, the number of hospital beds available for mentally ill patients also declined, as freestanding hospitals and private facilities closed. What have these patients been left with?

“The thought was that people would be maintained in the community—there would be community support services, halfway houses, boarding homes, community-based programs,” says Catherine R. Judd, MS, PA-C, President of the Association of Psychiatric PAs, who works in the Department of Psychiatry at the University of Texas Southwestern Medical Center, Dallas. “The idea is good, but unfortunately, most of those programs have really not materialized to the extent or with the capacity to take care of the people who are out there.”

Without these services—and with an overtaxed health care system in general—many patients with mental illness find themselves adrift. And, eventually, incarcerated. An estimate from the US Department of Justice indicates that 24% of state and 21% of local prisoners have a recent history of mental illness. The largest psychiatric hospital in the country is the Los Angeles County Jail.

The problem is so widespread and so serious that both Judd and Jeanne Clement, EdD, APRN, BC, FAAN, President of the American Psychiatric Nurses Association (APNA), describe it in identical terms: “The jails and prisons have become the de facto mental health system.”

“More and more mentally ill people are in the streets, not receiving services, not taking medication as prescribed, with less-than-optimal case management in the community,” says Judd, who also works with the chronic mentally ill at the Dallas County Jail. “So, they are picked up on substance abuse–related charges or criminal trespassing or burglary. Consequently, they’re brought to jail.”

In Dallas, a divert court has been established, with the aim of getting chronic, persistent mentally ill patients “back to clinics and back on medication as quickly as possible without incarcerating them,” Judd notes. For such a program to succeed, of course, you need clinics—and providers—to divert these patients to.

Problems of Access
Talk with clinicians who work in psychiatry, mental health, or behavioral health settings, and you’ll hear a familiar litany of problems. For one thing, there is the shortage of providers. “Here in Iowa, we’ve got areas where we have one psychiatrist covering five counties,” St. John says. “It’s almost impossible to get in with someone, and then when you do, it’s a five- or 10-minute appointment, because they’re just so busy.”

The number of clinicians choosing psychiatry—particularly psychiatric nursing—has declined significantly, perhaps due to insufficient funding for educational programs. “The highest number we had going into psychiatric nursing was when the National Institute of Mental Health, which was then separate from the NIH, had training grants,” explains Clement, who is the Director of the Graduate Specialty Program in Psychiatric–Mental Health Nursing at Ohio State University, Columbus. “And many of us who had those training grants are getting way past retirement age!”

The allure of other specialties also keeps people from mental health fields. “There are a lot of jobs and openings for PAs in psychiatry,” St. John says, “but there are a lot of jobs in orthopedics or surgery, too—and that’s what tends to draw them.”

The shortage of mental health care providers and subsequent lack of access to services means a larger role for primary care providers. High-profile expert panels have highlighted the need for integration of mental health into primary care settings—which St. John says is already largely the case.

“Most mental illness is treated in primary care, not in mental health settings,” he points out. “Mental health settings should really be reserved for the more challenging patients, the more difficult diagnoses and problems, and co-occurring illnesses.”

“Most primary care clinicians have some education in relationship to diagnosing and treating mild to moderate mental health issues, and then they refer on when needed,” Clement says. “The problem is, referring on is more and more difficult if there aren’t any people to refer to, or if waiting lists are as long as they currently are.”

Time is just as much of a problem in primary care as it is in specialty care, and when it comes to psychiatric and behavioral disorders, you can’t just order a lab test or an x-ray. “In psychiatry, you have to talk with the person and try to figure out what’s going on in their head and how that’s affecting their function,” St. John says. “It takes more time, and in primary care, that’s the problem they have. They’ve got appointments that may only have 10 minutes scheduled, and that’s not adequate to obtain a decent psychiatric history.”

The importance of both primary care providers and mental health specialists cannot be downplayed, because mental illnesses are among the most disabling and deadly. “If you look at disabling conditions, depression is right up there at the top,” St. John says. “Actually, it’s predicted that in the next three or four years, worldwide, depression will be the number one disabling illness.”

Anorexia is associated with a 15% death rate, and the completed suicide rate for persons with severe depression is also 15%. “If you were to look at one issue alone that we’re missing the boat on, it’s suicide,” Stuart says. “There are more suicides globally than there are deaths from war and violence combined—and the incidence of suicide is rising. So if, for example, a primary care provider sees someone who’s depressed, they have to go the next step and also ask about potential suicidal thought.”

Clement says it is equally important to integrate primary care services into mental health settings, since many patients with mental illnesses “are not going to show up in a private office in a primary care setting. And people with mental illness die 25 years earlier than the general population, from treatable medical illnesses.”

This is why, for example, the APNA is partnering with the Smoking Cessation Leadership Center. “Persons with mental illness are purchasing approximately half of the cigarettes that are being bought in the US,” Clement says. “And many of the treatable medical illnesses that people are dying from are related to smoking. It’s a whole person you’re working with, not just a brain or a body.”

Reimbursement Issue
Reimbursement is one of the major deterrents to the pursuit of a career in mental health care. “The whole reimbursement issue makes it difficult to attract people to work in mental health, particularly in community-based clinics, state hospitals, prisons, and jails,” which Judd says results in a lack of services for the seriously mentally ill and decreased access for people of low income.

The biggest problem is parity—or rather, the lack of it. What services are covered and at what rate tends to vary by state, and mental health is often not covered at the same rate as physical health. “There are a number of states that now have parity in mental health,” Clement observes. “If insurance is offered for physical health and [includes] mental health coverage, it has to be at exactly the same level as physical health, in terms of copays and lifetime limits.” But even so, there is not always parity in parity.

Furthermore, many people who need mental health services fall under the Medicaid program, which is state-based and just as variable. “Definitions of ‘medical necessity’ differ, and providers don’t get paid unless they can document according to medical necessity,” Clement says. “Even though what people—particularly those in the Medicaid and public mental health systems—need, along with their treatment, is a community-based program that helps people find jobs and housing. But that’s not ‘medical necessity.’”

Another problem is the sheer expense of some of the medications for mental disorders. “A lot of the drugs that we use to treat serious mental illnesses are horrendously expensive,” St. John notes. “They’ll almost bankrupt some states.… We just don’t have those budgets.”

Achieving parity and improving reimbursement is a slow process. Clement has been involved at the federal level with a parity bill, but as she notes, “that has not been resolved in terms of the differences between the House and the Senate.” Since so many of the programs are administered at a state level anyway, some suggest that might be a good place to begin working on reform.

In October 2007, the Annapolis Coalition, of which Stuart is President of the Board of Directors, released an action plan for reforming the mental health system—particularly for addressing workforce needs. The report (available at www.annapoliscoalition.org) includes the most specific recommendations possible in an overarching “framework” document, and Stuart says the coalition is currently working with some states—including North Carolina, Connecticut, New Mexico, and California—to identify and prioritize their needs and determine how best to tailor the plan to them.

“We’re really approaching it not at a federal level but seeing that the true change would come about at a state level,” Stuart says. “The need is derived differently by each state. If I can use the analogy, it’s a little bit like having a general way of approaching hypertension, but then you tailor it to the individual.”

Whether at the state or federal level, St. John thinks major changes to reimbursement for mental health care will require a cultural shift. “We reimburse for activity, we reimburse for procedures; we don’t reimburse for time spent or for decision making or thinking,” he points out. When a clinician is being reimbursed 50% (compared to 90% for other medical care), or $12 to $15 per visit for providing medication management, “You have to see large volumes of people in order to get reimbursed enough to pay for yourself and your staff.”

In the current economic climate, finding the money is going to take some shuffling. “It would be unrealistic to say that there are new dollars out there, because clearly there are not,” Stuart says. “So I think the issue is to reallocate the current resources that are out there and evaluate, Are we getting the best return on our investment of these dollars?”

The irony is that the people with the greatest needs for treatment, monitoring, and support services are the ones who face the biggest barriers to accessing care. “Services are more readily available to people who have jobs, have insurance—which would tell you in and of itself they’re probably higher functioning to start with,” Judd says. “I mean, if you’re having stress holding down a job, you’re probably higher functioning at your baseline than the homeless person who is living in the streets and under bridges and doesn’t go to shelters because they’re too paranoid to be around other people.”

Taking the Shame Out of Mental Illness
No discussion of mental health care can be complete without addressing the stigma associated with mental illness. Americans may have responded with outrage when they saw the deplorable conditions at mental hospitals, but many are still leery of being associated with a mental illness, whether in themselves or in a family member. And the cases that garner the most media attention are not necessarily the ones that reduce stigma.

What Americans see on the nightly news is the schizophrenic man who stops taking his medication and then stabs another man to death while he’s waiting for a train. Or the mother with chronic depression who can’t get out of bed until someone notices her kids look dirty and underfed, and Social Services steps in to remove them from the home. Do we, as a society, recognize the double tragedy of those situations? Or do we shake our heads in disgust, slap on a “crazy guy” or “bad mom” label, and change the channel?

Public service campaigns are trying to reduce the stigma associated with mental illness, to point out that it can affect anyone. The faces of the mentally ill are diverse: There’s the grandfather with Alzheimer’s disease who mistakes his granddaughter for his daughter. The 2-year-old autistic girl who has difficulty connecting with family and friends. The soldiers returning from the war zones in Iraq and Afghanistan, struggling with posttraumatic stress disorder (PTSD).

“The message that is being sent that needs to be broadcast more and heard with a different ear is that there is no health without mental health,” Clement says. St. John adds that it will take “a lot of time and education” to get that message out to the public, to let people know that it’s OK—in fact, it’s better—to acknowledge mental illness and seek help for it.

Stuart thinks the troops’ return from overseas, which is generating more stories about traumatic brain injury, PTSD, depression, and suicide, may start to turn the tide. “Perhaps because these are our veterans and our heroes, they’ve served the country, it’s opening up a public discussion in a way that’s different from seeing the aberrant, violent patient who does something very disruptive,” she says. “So, in a sense—and this sounds odd—we’re normalizing mental health problems, saying that all kinds of people from all walks of life can develop mental health problems, just as they can develop physical health problems.”

The key will be ensuring that the pendulum doesn’t swing too far the other way and cause the “stigma reduction” movement to generate its own problems. “On the one hand, we’re trying to destigmatize mental illness, but on the other hand, it [sometimes] seems like we’re calling any aberrant behavior or problems in life, stress or problems of adjustment, a mental illness,” Judd observes.

There are certain niches in which mental illness seems almost “trendy,” and industry advertising may encourage that. “Pharmaceutical companies are putting advertisements out there that would imply, ‘Gee, you’re getting divorced because you had conflict in your marriage—maybe you have bipolar disorder’ or ‘Your child isn’t doing well in school, so surely he has ADHD and needs to be on medication,’” Judd says. “There’s this promoting of drugs for anything and everything. And so that’s kind of the other extreme, where any problems in life in functioning must be because of a mental illness, and therefore you need a drug.”

Restored to Life
With such a grim picture of mental health care in the US, it hardly seems surprising that clinicians don’t flock to the specialty. Yet, Clement, Judd, St. John, and Stuart did. Why?

For Judd, “the science of it is extremely interesting.” She thinks that as psychiatry becomes more biological and clinicians delve more deeply into what is affecting a patient’s function (Is it trauma, prenatal influences, infection, genetics?) and how that impacts treatment choices, more practitioners might choose mental health care. But the biggest reward, she says, is seeing people “return to a higher level of functioning.”

“I have never, ever sat down with a client that I have not felt privileged to be allowed into their lives,” says Clement, who has been a nurse for 49 years and a psychiatric nurse for 47 of them. “People allow clinicians into their lives in a very different way than they do anybody else.”

That can be especially true in mental health, when clinicians must interact on a very intimate level with their patients. It can be challenging, frustrating, even devastating (such as when a patient takes his or her own life). But it can also be infinitely rewarding. That is why St. John moved from family practice and emergency settings to psychiatry, where he has spent the past 15 years.

“When you see people who kind of get back into life and start working more toward their life goals, and you start seeing them get back into their family and their work and their social function, perking up and engaging in the world,” he says, his voice conveying a deep sense of fulfillment, “there’s just nothing more rewarding than that.”

Expansion of health insurance coverage has been the central focus of the debate about curing what ails the health care system in the United States. But not everyone agrees that the problem is strictly a matter of insurance.

“If every American alive today had health insurance, millions still wouldn’t be able to access the primary care that ensures better overall health and reduces health care costs,” according to Daniel Hawkins, Senior Vice President for Policy and Programs of the National Association of Community Health Centers (NACHC). “That’s because provider locations and career choices don’t match up to the need. If we want to fix our health care system, we need to be having the right conversation.”

Number Needed to Serve
Hawkins recently participated in a conference call to discuss the findings from a study conducted by NACHC in partnership with the Robert Graham Center and the George Washington University School of Public Health and Health Services. The report, Access Transformed: Building a Primary Care Workforce for the 21st Century, offered projections on the number of primary care providers—physicians, NPs, PAs, and certified nurse-midwives (CNMs)—that will be required to meet the needs of the approximately 56 million Americans that NACHC classify as “medically disenfranchised” (ie, those who lack access to health care due to shortages of primary care providers in their communities).

Community health centers alone—which serve 18 million patients across the country—currently face a workforce shortage of more than 1,800 primary care providers and almost 1,400 nurses. In order to expand the reach of health centers to 30 million patients by 2015, NACHC projects that an additional 15,585 primary care providers—a little more than one-third of whom would be PAs, NPs, and CNMs—and between 11,553 and 14,397 nurses would be required.

Reaching all medically disenfranchised Americans is an even more daunting goal. In order to adequately serve 69 million patients—including all of those who are disenfranchised—health centers would need at least 51,300 more primary care providers and as many as 44,500 additional nurses.

Currently, centers employ about 7,500 physicians and 4,300 NPs, PAs, and CNMs. “Those numbers represent a 70% increase over the past seven years,” Hawkins said. “But the need is greater still.”

When questioned as to whether the US is dealing with a shortage of primary care providers or a maldistribution of them, Hawkins acknowledged that gauging strictly by volume, the US would need about 3,000 additional primary care providers to meet current needs. However, close to 90 million people live in designated shortage areas, and from their perspective, location is everything.

“Speaking for people who live in underserved areas, it doesn’t matter to me that there may be more physicians than necessary at the community or county down the road—where I live, there’s a shortage,” Hawkins said. “Unless public policy is going to engage in a forced march of those individuals from overserved to underserved areas, the only way that we can really address this problem is to grow primary care.”

Funding Is Essential
So how can the US expand primary care, particularly into areas with the biggest needs? The answer, according to the report, largely involves funding. Many programs that focus on attracting clinicians to underserved areas have experienced budget cuts in recent years—a trend that would have to be reversed if the primary care workforce is going to expand sufficiently, according to NACHC.

“Perhaps most importantly, programs like the National Health Service Corps [NHSC] need substantial additional funding,” Hawkins said. His organization estimates that the NHSC would need an increase from its current funding level of less than $125 million to $770 million by 2015 in order to produce the provider workforce needed by health centers alone.

Hawkins was joined in the tele-conference by Gary Wiltz, MD, Executive Director and Clinical Director of Teche Action Board in Franklin, Louisiana. As a medical student, Wiltz benefited from an NHSC scholarship. His three-year commitment to work in an underserved area in exchange for the financial assistance has turned into 26 years (and counting) at the Teche Action Clinic in Louisiana’s Bayou country.

“The [NHSC] program has proven to be effective,” Wiltz said. “It’s so popular right now that, from the [most recent] stats we were able to gather, they’re funding only one scholarship recipient per seven applicants.”

According to the NHSC Job Opportunities List for fiscal year (FY) 2008, almost 4,900 positions went unfilled because of the lack of funding to support them. The administration’s request for FY2009 funding for NHSC, at $121 million, continues the trend of declining federal appropriations for the program.

“Also needing expansion are programs that train nurse practitioners, nurse-midwives, and physician assistants,” Hawkins said.

The NACHC report noted a decline in support for federal Health Professions and Nurse Training Programs (Titles VII and VIII of the Public Health Service Act). For FY2009, no appropriations have been requested for Title VII, while the administration’s request for Title VIII, at $156 million, is almost one-third less than the previous year’s funding. In addition, it was proposed that the $62 million Advanced Education Nursing program be eliminated.

Beyond funding for training programs, the report mentions some of the obstacles to full utilization of PAs and NPs as another area in need of improvement if workforce needs are going to be met. “State scope-of-practice standards set boundaries by which key primary care providers, namely NPs and PAs, can deliver care,” according to the report. “State policymakers must consider how these standards encourage or discourage primary care professionals to locate in and form teams in underserved areas.”

Eternal Conundrum of Reimbursement
During the teleconference, Hawkins, Wiltz, and Lil Anderson, Chair of the NACHC Board and President and CEO of RiverStone Health in Billings, Montana, also discussed reforming the reimbursement structure to recognize the importance of primary care. Reimbursement is a perennial issue, but in a troubled economy, can change be achieved?

 “This is not going to be something that’s easily done,” Hawkins admitted.

“As we are in the process of having another national debate on health care reform, part of that debate needs to be about changing our health system from paying for illness care … to paying for prevention and primary care,” Anderson added. “That’s going to take a lot of time, [and] that is an investment that is going to be difficult to convince Congress and the American public to pay for. But it truly is the only way to change the system that we’re in right now, which really reinforces people to get care in the most expensive arena.”

Hawkins outlined a variety of reimbursement components in which reforms could be made, from reducing the use of services that are “questionable at best” to providing bonuses for the delivery of high-quality care. He also talked about the medical home concept and the proposal by its leading proponents to provide compensation for the types of follow-up and patient communication that are not usually reimbursed.

“Putting together those couple of innovations with a fee-for-service payment for the care actually provided to patients during a visit … could significantly boost revenues and payments to primary care providers,” Hawkins said. “And yet, we are convinced that in so doing it would reduce overall spending.”

NACHC estimates that a reduction in emergency department use by persons who do not have a true emergency and whose needs could be addressed in a primary care setting could produce a savings of $18 billion per year. In the case of staffing health centers to meet the needs of 30 million patients, NACHC says the return on investment could be as high as $80 billion dollars annually—“not to mention over 450,000 new jobs,” according to Hawkins.

The full report—which includes projections of how many primary care providers are needed in each state—is available at the NACHC Web site (www.nachc.com).         

Expansion of health insurance coverage has been the central focus of the debate about curing what ails the health care system in the United States. But not everyone agrees that the problem is strictly a matter of insurance.

“If every American alive today had health insurance, millions still wouldn’t be able to access the primary care that ensures better overall health and reduces health care costs,” according to Daniel Hawkins, Senior Vice President for Policy and Programs of the National Association of Community Health Centers (NACHC). “That’s because provider locations and career choices don’t match up to the need. If we want to fix our health care system, we need to be having the right conversation.”

Number Needed to Serve
Hawkins recently participated in a conference call to discuss the findings from a study conducted by NACHC in partnership with the Robert Graham Center and the George Washington University School of Public Health and Health Services. The report, Access Transformed: Building a Primary Care Workforce for the 21st Century, offered projections on the number of primary care providers—physicians, NPs, PAs, and certified nurse-midwives (CNMs)—that will be required to meet the needs of the approximately 56 million Americans that NACHC classify as “medically disenfranchised” (ie, those who lack access to health care due to shortages of primary care providers in their communities).

Community health centers alone—which serve 18 million patients across the country—currently face a workforce shortage of more than 1,800 primary care providers and almost 1,400 nurses. In order to expand the reach of health centers to 30 million patients by 2015, NACHC projects that an additional 15,585 primary care providers—a little more than one-third of whom would be PAs, NPs, and CNMs—and between 11,553 and 14,397 nurses would be required.

Reaching all medically disenfranchised Americans is an even more daunting goal. In order to adequately serve 69 million patients—including all of those who are disenfranchised—health centers would need at least 51,300 more primary care providers and as many as 44,500 additional nurses.

Currently, centers employ about 7,500 physicians and 4,300 NPs, PAs, and CNMs. “Those numbers represent a 70% increase over the past seven years,” Hawkins said. “But the need is greater still.”

When questioned as to whether the US is dealing with a shortage of primary care providers or a maldistribution of them, Hawkins acknowledged that gauging strictly by volume, the US would need about 3,000 additional primary care providers to meet current needs. However, close to 90 million people live in designated shortage areas, and from their perspective, location is everything.

“Speaking for people who live in underserved areas, it doesn’t matter to me that there may be more physicians than necessary at the community or county down the road—where I live, there’s a shortage,” Hawkins said. “Unless public policy is going to engage in a forced march of those individuals from overserved to underserved areas, the only way that we can really address this problem is to grow primary care.”

Funding Is Essential
So how can the US expand primary care, particularly into areas with the biggest needs? The answer, according to the report, largely involves funding. Many programs that focus on attracting clinicians to underserved areas have experienced budget cuts in recent years—a trend that would have to be reversed if the primary care workforce is going to expand sufficiently, according to NACHC.

“Perhaps most importantly, programs like the National Health Service Corps [NHSC] need substantial additional funding,” Hawkins said. His organization estimates that the NHSC would need an increase from its current funding level of less than $125 million to $770 million by 2015 in order to produce the provider workforce needed by health centers alone.

Hawkins was joined in the tele-conference by Gary Wiltz, MD, Executive Director and Clinical Director of Teche Action Board in Franklin, Louisiana. As a medical student, Wiltz benefited from an NHSC scholarship. His three-year commitment to work in an underserved area in exchange for the financial assistance has turned into 26 years (and counting) at the Teche Action Clinic in Louisiana’s Bayou country.

“The [NHSC] program has proven to be effective,” Wiltz said. “It’s so popular right now that, from the [most recent] stats we were able to gather, they’re funding only one scholarship recipient per seven applicants.”

According to the NHSC Job Opportunities List for fiscal year (FY) 2008, almost 4,900 positions went unfilled because of the lack of funding to support them. The administration’s request for FY2009 funding for NHSC, at $121 million, continues the trend of declining federal appropriations for the program.

“Also needing expansion are programs that train nurse practitioners, nurse-midwives, and physician assistants,” Hawkins said.

The NACHC report noted a decline in support for federal Health Professions and Nurse Training Programs (Titles VII and VIII of the Public Health Service Act). For FY2009, no appropriations have been requested for Title VII, while the administration’s request for Title VIII, at $156 million, is almost one-third less than the previous year’s funding. In addition, it was proposed that the $62 million Advanced Education Nursing program be eliminated.

Beyond funding for training programs, the report mentions some of the obstacles to full utilization of PAs and NPs as another area in need of improvement if workforce needs are going to be met. “State scope-of-practice standards set boundaries by which key primary care providers, namely NPs and PAs, can deliver care,” according to the report. “State policymakers must consider how these standards encourage or discourage primary care professionals to locate in and form teams in underserved areas.”

Eternal Conundrum of Reimbursement
During the teleconference, Hawkins, Wiltz, and Lil Anderson, Chair of the NACHC Board and President and CEO of RiverStone Health in Billings, Montana, also discussed reforming the reimbursement structure to recognize the importance of primary care. Reimbursement is a perennial issue, but in a troubled economy, can change be achieved?

 “This is not going to be something that’s easily done,” Hawkins admitted.

“As we are in the process of having another national debate on health care reform, part of that debate needs to be about changing our health system from paying for illness care … to paying for prevention and primary care,” Anderson added. “That’s going to take a lot of time, [and] that is an investment that is going to be difficult to convince Congress and the American public to pay for. But it truly is the only way to change the system that we’re in right now, which really reinforces people to get care in the most expensive arena.”

Hawkins outlined a variety of reimbursement components in which reforms could be made, from reducing the use of services that are “questionable at best” to providing bonuses for the delivery of high-quality care. He also talked about the medical home concept and the proposal by its leading proponents to provide compensation for the types of follow-up and patient communication that are not usually reimbursed.

“Putting together those couple of innovations with a fee-for-service payment for the care actually provided to patients during a visit … could significantly boost revenues and payments to primary care providers,” Hawkins said. “And yet, we are convinced that in so doing it would reduce overall spending.”

NACHC estimates that a reduction in emergency department use by persons who do not have a true emergency and whose needs could be addressed in a primary care setting could produce a savings of $18 billion per year. In the case of staffing health centers to meet the needs of 30 million patients, NACHC says the return on investment could be as high as $80 billion dollars annually—“not to mention over 450,000 new jobs,” according to Hawkins.

The full report—which includes projections of how many primary care providers are needed in each state—is available at the NACHC Web site (www.nachc.com).         

Expansion of health insurance coverage has been the central focus of the debate about curing what ails the health care system in the United States. But not everyone agrees that the problem is strictly a matter of insurance.

“If every American alive today had health insurance, millions still wouldn’t be able to access the primary care that ensures better overall health and reduces health care costs,” according to Daniel Hawkins, Senior Vice President for Policy and Programs of the National Association of Community Health Centers (NACHC). “That’s because provider locations and career choices don’t match up to the need. If we want to fix our health care system, we need to be having the right conversation.”

Number Needed to Serve
Hawkins recently participated in a conference call to discuss the findings from a study conducted by NACHC in partnership with the Robert Graham Center and the George Washington University School of Public Health and Health Services. The report, Access Transformed: Building a Primary Care Workforce for the 21st Century, offered projections on the number of primary care providers—physicians, NPs, PAs, and certified nurse-midwives (CNMs)—that will be required to meet the needs of the approximately 56 million Americans that NACHC classify as “medically disenfranchised” (ie, those who lack access to health care due to shortages of primary care providers in their communities).

Community health centers alone—which serve 18 million patients across the country—currently face a workforce shortage of more than 1,800 primary care providers and almost 1,400 nurses. In order to expand the reach of health centers to 30 million patients by 2015, NACHC projects that an additional 15,585 primary care providers—a little more than one-third of whom would be PAs, NPs, and CNMs—and between 11,553 and 14,397 nurses would be required.

Reaching all medically disenfranchised Americans is an even more daunting goal. In order to adequately serve 69 million patients—including all of those who are disenfranchised—health centers would need at least 51,300 more primary care providers and as many as 44,500 additional nurses.

Currently, centers employ about 7,500 physicians and 4,300 NPs, PAs, and CNMs. “Those numbers represent a 70% increase over the past seven years,” Hawkins said. “But the need is greater still.”

When questioned as to whether the US is dealing with a shortage of primary care providers or a maldistribution of them, Hawkins acknowledged that gauging strictly by volume, the US would need about 3,000 additional primary care providers to meet current needs. However, close to 90 million people live in designated shortage areas, and from their perspective, location is everything.

“Speaking for people who live in underserved areas, it doesn’t matter to me that there may be more physicians than necessary at the community or county down the road—where I live, there’s a shortage,” Hawkins said. “Unless public policy is going to engage in a forced march of those individuals from overserved to underserved areas, the only way that we can really address this problem is to grow primary care.”

Funding Is Essential
So how can the US expand primary care, particularly into areas with the biggest needs? The answer, according to the report, largely involves funding. Many programs that focus on attracting clinicians to underserved areas have experienced budget cuts in recent years—a trend that would have to be reversed if the primary care workforce is going to expand sufficiently, according to NACHC.

“Perhaps most importantly, programs like the National Health Service Corps [NHSC] need substantial additional funding,” Hawkins said. His organization estimates that the NHSC would need an increase from its current funding level of less than $125 million to $770 million by 2015 in order to produce the provider workforce needed by health centers alone.

Hawkins was joined in the tele-conference by Gary Wiltz, MD, Executive Director and Clinical Director of Teche Action Board in Franklin, Louisiana. As a medical student, Wiltz benefited from an NHSC scholarship. His three-year commitment to work in an underserved area in exchange for the financial assistance has turned into 26 years (and counting) at the Teche Action Clinic in Louisiana’s Bayou country.

“The [NHSC] program has proven to be effective,” Wiltz said. “It’s so popular right now that, from the [most recent] stats we were able to gather, they’re funding only one scholarship recipient per seven applicants.”

According to the NHSC Job Opportunities List for fiscal year (FY) 2008, almost 4,900 positions went unfilled because of the lack of funding to support them. The administration’s request for FY2009 funding for NHSC, at $121 million, continues the trend of declining federal appropriations for the program.

“Also needing expansion are programs that train nurse practitioners, nurse-midwives, and physician assistants,” Hawkins said.

The NACHC report noted a decline in support for federal Health Professions and Nurse Training Programs (Titles VII and VIII of the Public Health Service Act). For FY2009, no appropriations have been requested for Title VII, while the administration’s request for Title VIII, at $156 million, is almost one-third less than the previous year’s funding. In addition, it was proposed that the $62 million Advanced Education Nursing program be eliminated.

Beyond funding for training programs, the report mentions some of the obstacles to full utilization of PAs and NPs as another area in need of improvement if workforce needs are going to be met. “State scope-of-practice standards set boundaries by which key primary care providers, namely NPs and PAs, can deliver care,” according to the report. “State policymakers must consider how these standards encourage or discourage primary care professionals to locate in and form teams in underserved areas.”

Eternal Conundrum of Reimbursement
During the teleconference, Hawkins, Wiltz, and Lil Anderson, Chair of the NACHC Board and President and CEO of RiverStone Health in Billings, Montana, also discussed reforming the reimbursement structure to recognize the importance of primary care. Reimbursement is a perennial issue, but in a troubled economy, can change be achieved?

 “This is not going to be something that’s easily done,” Hawkins admitted.

“As we are in the process of having another national debate on health care reform, part of that debate needs to be about changing our health system from paying for illness care … to paying for prevention and primary care,” Anderson added. “That’s going to take a lot of time, [and] that is an investment that is going to be difficult to convince Congress and the American public to pay for. But it truly is the only way to change the system that we’re in right now, which really reinforces people to get care in the most expensive arena.”

Hawkins outlined a variety of reimbursement components in which reforms could be made, from reducing the use of services that are “questionable at best” to providing bonuses for the delivery of high-quality care. He also talked about the medical home concept and the proposal by its leading proponents to provide compensation for the types of follow-up and patient communication that are not usually reimbursed.

“Putting together those couple of innovations with a fee-for-service payment for the care actually provided to patients during a visit … could significantly boost revenues and payments to primary care providers,” Hawkins said. “And yet, we are convinced that in so doing it would reduce overall spending.”

NACHC estimates that a reduction in emergency department use by persons who do not have a true emergency and whose needs could be addressed in a primary care setting could produce a savings of $18 billion per year. In the case of staffing health centers to meet the needs of 30 million patients, NACHC says the return on investment could be as high as $80 billion dollars annually—“not to mention over 450,000 new jobs,” according to Hawkins.

The full report—which includes projections of how many primary care providers are needed in each state—is available at the NACHC Web site (www.nachc.com).         

Health care is always one of the top issues on the national agenda, and as the United States prepares to elect its first new president in eight years, all eyes are on the presumptive Democratic and Republican nominees, Sen Barack Obama (D, Illinois) and Sen John McCain (R, Arizona).

Yet, “presidential elections seem a little remote, I think, in terms of actual impact on one’s life,” says Nicole Gara, Vice President of Government and Professional Affairs for the American Academy of Physician Assistants (AAPA). “I think it’s hard for local members of Congress to get attention, and it’s even harder for people running for state office. But those are probably the places that you should start.”

That’s why leaders from both AAPA and the American Academy of Nurse Practitioners (AANP) are encouraging all members of their respective professions to do their duty as American citizens and health care professionals. The message is simple: VOTE!

Focus on Financing
Neither the AANP nor the AAPA endorses presidential candidates. However, leaders from both organizations are keeping an eye on the campaigns. So how much attention are the presumptive nominees paying to nonphysician clinicians?

AAPA President Cynthia B. Lord, MHS, PA-C, may speak for most Americans (or at least the cynical ones) when she says, with a laugh, “If you really look at McCain and Obama—the two big candidates—at their health care policy, first of all, they change every day depending on who they’re speaking to, I think.” Getting serious, she adds, “But they’re basically focused on financing; everything is about financing.”

Her assessment is echoed by Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the AANP. “One of the things I find is that they talk a lot about how to pay the insurance and [give] a lot of attention to doctors and hospitals,” she says. “But there doesn’t seem—yet—to be a good awareness on the part of either candidate of the role that other health care professionals play in the health care system.”

“Are we on the radar? I don’t see any evidence of that,” adds Gara. “They’re really concerned with the financing aspects. They’re not drilling down to workforce issues very much.” (See sidebar.)

Getting those issues adequately addressed may be more difficult than usual in light of the current state of the nation. Polls have indicated that health care has dropped from the No. 2 to the No. 3 spot, behind the war and the economy, in terms of issues considered most important by voters. “It gets harder when the economy gets tough,” Towers says. “People have to be able to eat, work, hang onto their houses.”

“The war and the price of gas and everything else could easily consume everybody’s attention,” adds Gara. “But the [health care] system is probably failing badly, and really, procrastination isn’t going to help.”

The “Other” 468
Every four years, an increasingly large chunk of the national attention is focused on the US presidential elections. “I think you can’t help it, it’s like a four-year primary,” Gara says with a laugh. “The election season gets longer and longer, and for pretty much everybody who turns on the TV, that’s what they’re going to see in the news.”

But this election year, one-third of the seats in the US Senate and the entire House of Representatives are up for grabs—that’s a combined total of 468 legislators. Clinicians “need to be looking not just at what the president is going to be thinking but also what the representatives from their state or district are thinking,” Towers observes.

Health care providers received a reminder of the importance of supporting and working with members of Congress during the recent Medicare reimbursement bill brouhaha. To forestall a 10.6% payment reduction for physicians (scheduled to take effect on July 1), Congress instead voted to reduce reimbursement to private insurance companies that serve Medicare recipients. When President Bush exercised his right to veto the bill, members of both the House of Representatives and the Senate voted by an overwhelming majority (383 to 41 in the House and 70 to 26 in the Senate) to override his veto. (The measure is considered a stopgap, and Congress will have to revisit the issue in 18 months; Towers says, “It depends a lot on how the elections go, as to just what direction that might take.”)

Cindy Lord knows firsthand what effect that reimbursement cut could have had. She works in a primary care practice in eastern Connecticut (“we are in the underserved part of Connecticut—as much as it can be underserved”). “If that 10.6% reduction had gone through, our practice—it’s a family practice, but after many years, it gets very elderly; almost all of my patients are 80- and 90-year-old farmers who are still doing well, but elderly—wouldn’t be able to accept any new Medicare patients,” she says. “We would have had to close our practice to those people. It was stressing the two docs I work with.”

The elderly are just one of a growing number of patient groups whose needs are not being adequately met. “When you look at the elderly and Medicare, the disparities among ethnic minorities, as well as just access—47 million people without insurance, or even worse, the underinsured—and then you look at the chronic disease we can’t care for …,” Lord trails off. “I don’t know. The list goes on and on.”

And that is the primary reason why AANP and AAPA are encouraging all members of the professions they represent to take action.

A Right and a Privilege
The right to vote is, of course, a privilege granted to all American adults, but for a health care provider it can hold additional import. Besides being a private citizen with his or her own belief system and priorities, each PA or NP is a professional whose right to practice is legislated and regulated to an extent greater than that for many other careers. And the laws that affect them have an impact, by extension, on the patients they serve.

“As health care providers, when you look at our vision and our mission and the reason that our whole profession was established—to take care of patients—unfortunately, it’s not just about the ‘do good’ and the medicine,” Lord points out. “If we don’t exercise our right to vote, then we truly will have—we’re seeing it now—trouble practicing medicine and caring for our patients. And our patients always come first.”

That dedication to patient care makes NPs and PAs great clinicians—but often, reluctant politicos. “It’s not a natural activity for most people who go into health care,” Gara notes. “They want to take care of patients and make them better. They don’t want to deal with politics and politicians. I think it’s only when they realize how important this is to everyday life that the little light goes on and people start to say, ‘Oh, I can do this and I should do this.’”

“This” begins with exercising the right to vote—although Towers, Gara, and Lord emphasize the importance of being an informed voter. With that in mind, AAPA—which Lord describes as “much more proactive over the last several years”—has launched “PAs for a Healthy America: Vote 2008.” A section of the organization’s Web site, available to both members and nonmembers, provides links to the presumptive Democratic and Republication nominees’ health care platforms (and, hopefully soon, responses to a five-item questionnaire AAPA sent to both candidates), as well as information on who is running for election to Congress.

AAPA “is trying to provide easy resources,” Lord explains. “As an individual, you’ve got to make a decision. And those who say, ‘I don’t have time for this,’ that’s a choice they make. We’re trying to show them this is a choice you need to make, and it’s an easy thing to do.”

Towers encourages NPs to review the information on the candidates’ Web sites, which “tells you a lot about what a candidate does and doesn’t know. Once you look at those things, you get a better grasp of whether or not they’re really tuned in to the issues that affect NPs and their patients.”

Even better, for those who can manage it, is attending town hall meetings or fundraisers that provide an opportunity to ask questions of the candidate directly. Clinicians “need to be asking about what candidates perceive to be the health problems in their state and their district and what they think the resolution should be,” Towers says. From there, you can inquire as to the candidate’s knowledge of NPs or PAs and how he or she would address specific issues that PAs or NPs have.

You Decide
Leaders from AANP and AAPA want you to vote, and they want to make it easy for you to make a decision. But they don’t want to make that decision for you. “I don’t think anybody should be ruled out,” Gara says. “Everybody can be persuaded of the facts, and everybody can be approached. I’m definitely not a one-issue kind of person, so I really hate to see people make decisions based on a single position that somebody has taken.

“[Health care] is really not a partisan issue, you know,” she concludes. “It’s really for everybody.” 

Health care is always one of the top issues on the national agenda, and as the United States prepares to elect its first new president in eight years, all eyes are on the presumptive Democratic and Republican nominees, Sen Barack Obama (D, Illinois) and Sen John McCain (R, Arizona).

Yet, “presidential elections seem a little remote, I think, in terms of actual impact on one’s life,” says Nicole Gara, Vice President of Government and Professional Affairs for the American Academy of Physician Assistants (AAPA). “I think it’s hard for local members of Congress to get attention, and it’s even harder for people running for state office. But those are probably the places that you should start.”

That’s why leaders from both AAPA and the American Academy of Nurse Practitioners (AANP) are encouraging all members of their respective professions to do their duty as American citizens and health care professionals. The message is simple: VOTE!

Focus on Financing
Neither the AANP nor the AAPA endorses presidential candidates. However, leaders from both organizations are keeping an eye on the campaigns. So how much attention are the presumptive nominees paying to nonphysician clinicians?

AAPA President Cynthia B. Lord, MHS, PA-C, may speak for most Americans (or at least the cynical ones) when she says, with a laugh, “If you really look at McCain and Obama—the two big candidates—at their health care policy, first of all, they change every day depending on who they’re speaking to, I think.” Getting serious, she adds, “But they’re basically focused on financing; everything is about financing.”

Her assessment is echoed by Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the AANP. “One of the things I find is that they talk a lot about how to pay the insurance and [give] a lot of attention to doctors and hospitals,” she says. “But there doesn’t seem—yet—to be a good awareness on the part of either candidate of the role that other health care professionals play in the health care system.”

“Are we on the radar? I don’t see any evidence of that,” adds Gara. “They’re really concerned with the financing aspects. They’re not drilling down to workforce issues very much.” (See sidebar.)

Getting those issues adequately addressed may be more difficult than usual in light of the current state of the nation. Polls have indicated that health care has dropped from the No. 2 to the No. 3 spot, behind the war and the economy, in terms of issues considered most important by voters. “It gets harder when the economy gets tough,” Towers says. “People have to be able to eat, work, hang onto their houses.”

“The war and the price of gas and everything else could easily consume everybody’s attention,” adds Gara. “But the [health care] system is probably failing badly, and really, procrastination isn’t going to help.”

The “Other” 468
Every four years, an increasingly large chunk of the national attention is focused on the US presidential elections. “I think you can’t help it, it’s like a four-year primary,” Gara says with a laugh. “The election season gets longer and longer, and for pretty much everybody who turns on the TV, that’s what they’re going to see in the news.”

But this election year, one-third of the seats in the US Senate and the entire House of Representatives are up for grabs—that’s a combined total of 468 legislators. Clinicians “need to be looking not just at what the president is going to be thinking but also what the representatives from their state or district are thinking,” Towers observes.

Health care providers received a reminder of the importance of supporting and working with members of Congress during the recent Medicare reimbursement bill brouhaha. To forestall a 10.6% payment reduction for physicians (scheduled to take effect on July 1), Congress instead voted to reduce reimbursement to private insurance companies that serve Medicare recipients. When President Bush exercised his right to veto the bill, members of both the House of Representatives and the Senate voted by an overwhelming majority (383 to 41 in the House and 70 to 26 in the Senate) to override his veto. (The measure is considered a stopgap, and Congress will have to revisit the issue in 18 months; Towers says, “It depends a lot on how the elections go, as to just what direction that might take.”)

Cindy Lord knows firsthand what effect that reimbursement cut could have had. She works in a primary care practice in eastern Connecticut (“we are in the underserved part of Connecticut—as much as it can be underserved”). “If that 10.6% reduction had gone through, our practice—it’s a family practice, but after many years, it gets very elderly; almost all of my patients are 80- and 90-year-old farmers who are still doing well, but elderly—wouldn’t be able to accept any new Medicare patients,” she says. “We would have had to close our practice to those people. It was stressing the two docs I work with.”

The elderly are just one of a growing number of patient groups whose needs are not being adequately met. “When you look at the elderly and Medicare, the disparities among ethnic minorities, as well as just access—47 million people without insurance, or even worse, the underinsured—and then you look at the chronic disease we can’t care for …,” Lord trails off. “I don’t know. The list goes on and on.”

And that is the primary reason why AANP and AAPA are encouraging all members of the professions they represent to take action.

A Right and a Privilege
The right to vote is, of course, a privilege granted to all American adults, but for a health care provider it can hold additional import. Besides being a private citizen with his or her own belief system and priorities, each PA or NP is a professional whose right to practice is legislated and regulated to an extent greater than that for many other careers. And the laws that affect them have an impact, by extension, on the patients they serve.

“As health care providers, when you look at our vision and our mission and the reason that our whole profession was established—to take care of patients—unfortunately, it’s not just about the ‘do good’ and the medicine,” Lord points out. “If we don’t exercise our right to vote, then we truly will have—we’re seeing it now—trouble practicing medicine and caring for our patients. And our patients always come first.”

That dedication to patient care makes NPs and PAs great clinicians—but often, reluctant politicos. “It’s not a natural activity for most people who go into health care,” Gara notes. “They want to take care of patients and make them better. They don’t want to deal with politics and politicians. I think it’s only when they realize how important this is to everyday life that the little light goes on and people start to say, ‘Oh, I can do this and I should do this.’”

“This” begins with exercising the right to vote—although Towers, Gara, and Lord emphasize the importance of being an informed voter. With that in mind, AAPA—which Lord describes as “much more proactive over the last several years”—has launched “PAs for a Healthy America: Vote 2008.” A section of the organization’s Web site, available to both members and nonmembers, provides links to the presumptive Democratic and Republication nominees’ health care platforms (and, hopefully soon, responses to a five-item questionnaire AAPA sent to both candidates), as well as information on who is running for election to Congress.

AAPA “is trying to provide easy resources,” Lord explains. “As an individual, you’ve got to make a decision. And those who say, ‘I don’t have time for this,’ that’s a choice they make. We’re trying to show them this is a choice you need to make, and it’s an easy thing to do.”

Towers encourages NPs to review the information on the candidates’ Web sites, which “tells you a lot about what a candidate does and doesn’t know. Once you look at those things, you get a better grasp of whether or not they’re really tuned in to the issues that affect NPs and their patients.”

Even better, for those who can manage it, is attending town hall meetings or fundraisers that provide an opportunity to ask questions of the candidate directly. Clinicians “need to be asking about what candidates perceive to be the health problems in their state and their district and what they think the resolution should be,” Towers says. From there, you can inquire as to the candidate’s knowledge of NPs or PAs and how he or she would address specific issues that PAs or NPs have.

You Decide
Leaders from AANP and AAPA want you to vote, and they want to make it easy for you to make a decision. But they don’t want to make that decision for you. “I don’t think anybody should be ruled out,” Gara says. “Everybody can be persuaded of the facts, and everybody can be approached. I’m definitely not a one-issue kind of person, so I really hate to see people make decisions based on a single position that somebody has taken.

“[Health care] is really not a partisan issue, you know,” she concludes. “It’s really for everybody.” 

Health care is always one of the top issues on the national agenda, and as the United States prepares to elect its first new president in eight years, all eyes are on the presumptive Democratic and Republican nominees, Sen Barack Obama (D, Illinois) and Sen John McCain (R, Arizona).

Yet, “presidential elections seem a little remote, I think, in terms of actual impact on one’s life,” says Nicole Gara, Vice President of Government and Professional Affairs for the American Academy of Physician Assistants (AAPA). “I think it’s hard for local members of Congress to get attention, and it’s even harder for people running for state office. But those are probably the places that you should start.”

That’s why leaders from both AAPA and the American Academy of Nurse Practitioners (AANP) are encouraging all members of their respective professions to do their duty as American citizens and health care professionals. The message is simple: VOTE!

Focus on Financing
Neither the AANP nor the AAPA endorses presidential candidates. However, leaders from both organizations are keeping an eye on the campaigns. So how much attention are the presumptive nominees paying to nonphysician clinicians?

AAPA President Cynthia B. Lord, MHS, PA-C, may speak for most Americans (or at least the cynical ones) when she says, with a laugh, “If you really look at McCain and Obama—the two big candidates—at their health care policy, first of all, they change every day depending on who they’re speaking to, I think.” Getting serious, she adds, “But they’re basically focused on financing; everything is about financing.”

Her assessment is echoed by Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the AANP. “One of the things I find is that they talk a lot about how to pay the insurance and [give] a lot of attention to doctors and hospitals,” she says. “But there doesn’t seem—yet—to be a good awareness on the part of either candidate of the role that other health care professionals play in the health care system.”

“Are we on the radar? I don’t see any evidence of that,” adds Gara. “They’re really concerned with the financing aspects. They’re not drilling down to workforce issues very much.” (See sidebar.)

Getting those issues adequately addressed may be more difficult than usual in light of the current state of the nation. Polls have indicated that health care has dropped from the No. 2 to the No. 3 spot, behind the war and the economy, in terms of issues considered most important by voters. “It gets harder when the economy gets tough,” Towers says. “People have to be able to eat, work, hang onto their houses.”

“The war and the price of gas and everything else could easily consume everybody’s attention,” adds Gara. “But the [health care] system is probably failing badly, and really, procrastination isn’t going to help.”

The “Other” 468
Every four years, an increasingly large chunk of the national attention is focused on the US presidential elections. “I think you can’t help it, it’s like a four-year primary,” Gara says with a laugh. “The election season gets longer and longer, and for pretty much everybody who turns on the TV, that’s what they’re going to see in the news.”

But this election year, one-third of the seats in the US Senate and the entire House of Representatives are up for grabs—that’s a combined total of 468 legislators. Clinicians “need to be looking not just at what the president is going to be thinking but also what the representatives from their state or district are thinking,” Towers observes.

Health care providers received a reminder of the importance of supporting and working with members of Congress during the recent Medicare reimbursement bill brouhaha. To forestall a 10.6% payment reduction for physicians (scheduled to take effect on July 1), Congress instead voted to reduce reimbursement to private insurance companies that serve Medicare recipients. When President Bush exercised his right to veto the bill, members of both the House of Representatives and the Senate voted by an overwhelming majority (383 to 41 in the House and 70 to 26 in the Senate) to override his veto. (The measure is considered a stopgap, and Congress will have to revisit the issue in 18 months; Towers says, “It depends a lot on how the elections go, as to just what direction that might take.”)

Cindy Lord knows firsthand what effect that reimbursement cut could have had. She works in a primary care practice in eastern Connecticut (“we are in the underserved part of Connecticut—as much as it can be underserved”). “If that 10.6% reduction had gone through, our practice—it’s a family practice, but after many years, it gets very elderly; almost all of my patients are 80- and 90-year-old farmers who are still doing well, but elderly—wouldn’t be able to accept any new Medicare patients,” she says. “We would have had to close our practice to those people. It was stressing the two docs I work with.”

The elderly are just one of a growing number of patient groups whose needs are not being adequately met. “When you look at the elderly and Medicare, the disparities among ethnic minorities, as well as just access—47 million people without insurance, or even worse, the underinsured—and then you look at the chronic disease we can’t care for …,” Lord trails off. “I don’t know. The list goes on and on.”

And that is the primary reason why AANP and AAPA are encouraging all members of the professions they represent to take action.

A Right and a Privilege
The right to vote is, of course, a privilege granted to all American adults, but for a health care provider it can hold additional import. Besides being a private citizen with his or her own belief system and priorities, each PA or NP is a professional whose right to practice is legislated and regulated to an extent greater than that for many other careers. And the laws that affect them have an impact, by extension, on the patients they serve.

“As health care providers, when you look at our vision and our mission and the reason that our whole profession was established—to take care of patients—unfortunately, it’s not just about the ‘do good’ and the medicine,” Lord points out. “If we don’t exercise our right to vote, then we truly will have—we’re seeing it now—trouble practicing medicine and caring for our patients. And our patients always come first.”

That dedication to patient care makes NPs and PAs great clinicians—but often, reluctant politicos. “It’s not a natural activity for most people who go into health care,” Gara notes. “They want to take care of patients and make them better. They don’t want to deal with politics and politicians. I think it’s only when they realize how important this is to everyday life that the little light goes on and people start to say, ‘Oh, I can do this and I should do this.’”

“This” begins with exercising the right to vote—although Towers, Gara, and Lord emphasize the importance of being an informed voter. With that in mind, AAPA—which Lord describes as “much more proactive over the last several years”—has launched “PAs for a Healthy America: Vote 2008.” A section of the organization’s Web site, available to both members and nonmembers, provides links to the presumptive Democratic and Republication nominees’ health care platforms (and, hopefully soon, responses to a five-item questionnaire AAPA sent to both candidates), as well as information on who is running for election to Congress.

AAPA “is trying to provide easy resources,” Lord explains. “As an individual, you’ve got to make a decision. And those who say, ‘I don’t have time for this,’ that’s a choice they make. We’re trying to show them this is a choice you need to make, and it’s an easy thing to do.”

Towers encourages NPs to review the information on the candidates’ Web sites, which “tells you a lot about what a candidate does and doesn’t know. Once you look at those things, you get a better grasp of whether or not they’re really tuned in to the issues that affect NPs and their patients.”

Even better, for those who can manage it, is attending town hall meetings or fundraisers that provide an opportunity to ask questions of the candidate directly. Clinicians “need to be asking about what candidates perceive to be the health problems in their state and their district and what they think the resolution should be,” Towers says. From there, you can inquire as to the candidate’s knowledge of NPs or PAs and how he or she would address specific issues that PAs or NPs have.

You Decide
Leaders from AANP and AAPA want you to vote, and they want to make it easy for you to make a decision. But they don’t want to make that decision for you. “I don’t think anybody should be ruled out,” Gara says. “Everybody can be persuaded of the facts, and everybody can be approached. I’m definitely not a one-issue kind of person, so I really hate to see people make decisions based on a single position that somebody has taken.

“[Health care] is really not a partisan issue, you know,” she concludes. “It’s really for everybody.” 

So, have you heard about the physician shortage—how by 2020, it is estimated that the United States will have approximately 200,000 fewer practicing physicians than the nation will require to meet the increasing needs of a growing, aging, chronically ill population? The Association of American Medical Colleges (AAMC) has already called for a 30% increase in medical school enrollment, but “even with that increase, demand is going to be significantly higher than the supply,” says Edward S. Salsberg, MPA, Director of AAMC’s Center for Workforce Studies.

It may please NPs and PAs to know they are not alone in considering their professions an important part of the solution to the problem. Both groups “play a major role in our thinking about the future,” Salsberg says. “The only way we can balance the need for services and assure access [to care] is if we use more PAs and NPs, and use them more effectively.”

And the Numbers Are …
There is no doubt that the NP and PA professions are thriving. Data from the National Commission on the Certification of Physician Assistants indicate that the number of newly certified PAs in the US has increased from about 1,000 in 1990 to nearly 5,000 last year. “That fivefold increase is enormous,” Salsberg says, “and it means the number of PAs will be rising significantly over the next several decades.”

Data on NPs are a little harder to gather, since there are multiple training models and certification programs; if you consider advanced practice nurses as a group, there are nearly 10,000 new APNs each year. Geraldine Bednash, PhD, RN, FAAN, Executive Director of the American Association of Colleges of Nursing (AACN), says, “For the last decade, we’ve seen enormous growth in the number of individuals who have been educated as NPs and who are practicing as NPs.”

Salsberg is uncertain as to what impact the switch to the Doctor of Nursing Practice (DNP) degree will have on the NP supply. “That does have the potential to slow up the pipeline for several years. So I don’t know what [NPs’] growth rate will be,” he says. “I’m sure it will be significant. I just don’t know whether there will be a delay in the growth.”

Bednash considers that “a reasonable question” but says AACN believes the DNP will actually attract more candidates to NP programs. “We’re seeing people choose graduate school earlier in their careers, so it should expand the number of people who are entering the programs,” she observes. “The big issue for us will not be whether it takes longer [to get NPs educated and into the workforce] but whether we can continue to graduate the same or larger numbers of people every year.” So far, she says, the numbers have continued to rise.

Tweaking the Data
But sheer volume may not be enough to offset the physician shortage. Much like clinical trial results, the NP/PA workforce supply is subject to a number of variables. Roderick S. Hooker, PhD, PA, Director of Rheumatology Research at the Dallas Veterans Affairs Medical Center, who has done extensive analysis of health care supply and demand, tries to be conservative in his own estimates.

“When I look at what the outpatient productivity in the US is on an annual basis, it’s about 1.2 billion outpatient visits,” he explains. “And when we look at who’s minding the store—who’s seeing those patients—the provider of record in about 11% to 13% of cases is a PA or NP. So, while the head count is larger for both camps, the productivity number is small.”

Furthermore, Hooker notes, not all PAs or NPs who are certified (the basis on which most estimates are generated) may be seeing patients. They may have chosen an academic or leadership role that keeps them out of the clinic. Hooker estimates that the number of PAs who are in active practice could be as much as 12% lower than the stated figures.

Both Salsberg and Hooker say more research is needed to determine whether there will be enough NPs and PAs available to offset the physician shortage. “What is the optimal number?” Hooker asks. “Only when we have an optimal number, what people think is the right ratio of ‘doctor to population,’ will we be able to answer that question.”

Salsberg says “better information on the numbers and types and locations of practitioners … would help us do a lot more forecasting. Both professions are growing very rapidly, [but] I don’t know whether we need more [PAs and NPs] or whether the growth we’ve seen in the last 15 years is going to be sufficient.”

Faculty, Funding, and Preceptors
Then there are the practical obstacles to NP and PA education programs maintaining, let alone ramping up, “production.” These are the same problems that have plagued the nursing and medical education systems for years: faculty, funding, and preceptors.

AACN’s Bednash says her organization sees the DNP as part of the solution to the nursing faculty shortage: “To some extent, the work that’s being done to prepare people at the doctoral level for advanced practice will both produce a very high-quality clinician and expand the ability to have people who can serve in faculty roles.”

Foundations, individual institutions, and employers are also developing ways to support graduate nursing education; for example, AACN is working with the California Endowment to provide funding for minority nurses in California to pursue higher education. “The funding they receive from us is based on their commitment to us that they will stay in California and serve as a faculty member for several years,” Bednash says.

Meanwhile, “the bottleneck for the PA programs tends to be clinical sites, not the classroom,” Hooker notes. “You can teach a classroom of 200 people the same way you can teach a classroom of 20. It’s getting people dispersed into preceptorship sites that I think is the conundrum.”

Solutions to that problem have been slow in developing. Hooker, who describes himself as “more of an observer than an activist” (ie, he does not advocate for particular solutions but points out different ways of doing things as food for thought), notes that in Canada and Australia, preceptor sites are purchased as part of the tuition for a program. “They give some remuneration to the mentor, and while it’s not much, it is a very important price signal,” he says. “And that price signal says, ‘We value the time that you spend, and we’re willing to compensate you for it.’”

Whatever solutions are proposed or pursued, the bottom line involves funding: more of it. “[Policy makers] need to focus on graduate education,” Bednash says. “They need to fund the programs so that they can hire additional faculty to expand, and they need to understand that doctoral-level education is the only way somebody is going to be able to have a long-term career in a university and serve as a faculty member.”

Generation Next and the Evolution of Team Care
Finally, there is one other factor—a more sociological one—that could have an impact on the health care workforce supply. That is the younger generation’s desire for a better work/life balance than their parents and grandparents had. As Bednash observes, “The expectation [used to be] that you would work morning, noon, and night, weekends, ’round the clock, forget your family.”

That attitude toward work appears to be changing, regardless of profession. “So the question there is, who’s going to work those nights and weekends?” Salsberg asks. “Someone is going to need to be available, and it remains to be seen [who it will be].”

Bednash says practices will have to consider how to balance work schedules and patient care needs “so no one profession ends up having the right to preferential expectations about how that work life should play out. It probably means there will need to be more physicians and more nurses so that all the care needs can be met.”

Besides a greater interest in a 9-to-5 job (or close to it), Hooker also detects a growing sense of wanderlust among people in their 30s and younger. “These people, to me, seem to be delaying marriage, delaying commitment, very interested in going abroad,” he observes. “I wouldn’t be surprised if over the next 10 years we find young Americans emulating Canadians, Australians, the Swiss, and others, and wanting to go abroad—with their skills. I’m wondering if American PAs won’t want to bring their newly honed skills to the world stage and say, ‘I’m a PA, and I’d like to work in the Netherlands for two years’ or ‘I’d like to work in Australia for a few years. It’s a great country, and I want to see the world.’”

The chance that any or all of these factors could impact the supply of NPs and PAs in the coming years brings us back to Salsberg’s original point about creating a more effective health care team. Here, too, he says, research is needed. “I’m a very strong believer in expanding the use of NPs and PAs,” he says, “but I do believe that should really be driven by evidence. What kind of services does it make sense for someone with, say, six years of post–high school [education] to do, and what do you really need those 12 or 13 years of post–high school education for?”

Both Bednash and Hooker provide examples of how NPs and PAs already expand a practice’s capabilities. “You might have a cardiology practice with cardiologists providing the high-level, specialized care for patients with heart disease, and then have a team of NPs working with those physicians to oversee the other kinds of issues that patients have besides the cardiac ones,” Bednash says. “They are able to make sure that the care is very comprehensive and coordinated in a way that the other needs are not forgotten.”

Hooker describes a hypothetical urology clinic of four doctors who hire a PA. “The PA may say, ‘I’m a surgical PA’ but is never in the operating room,” he says. “He or she is taking care of the patients in the office. That either helps maintain continuity of care or tends to offload somewhat from primary care: ‘Oh, your blood pressure is up, let me get an ECG…. It looks like the ECG shows an ST depression. I think we’d better get you into your primary care doctor, but I’m going to start you on some antihypertensives today.’”

For Bednash, the larger issue involves “making sure that reasonable people in both disciplines [medicine and nursing] understand that there are tremendous access and care needs in this country that can only be met when physicians and nurses are allowed to practice to the highest level of their education, knowledge, and skills.

“To some extent, at some point, people are going to have to confront some of the biases about limiting scope of practice for NPs so they can do everything they are capable of doing,” she adds. “The old biases of some physicians have got to be laid to rest. The good news is, in a lot of places, they have been—but it needs to be more uniform.”

For his part, Salsberg agrees that mutual respect and understanding will be key. “We need to do more to prepare our practitioners, our physicians, to work in collaborative practice,” he says. “PAs, NPs, and physicians need to be educated and trained to work together, so that everyone coming out understands and respects the skills of all the other professions.”

So, have you heard about the physician shortage—how by 2020, it is estimated that the United States will have approximately 200,000 fewer practicing physicians than the nation will require to meet the increasing needs of a growing, aging, chronically ill population? The Association of American Medical Colleges (AAMC) has already called for a 30% increase in medical school enrollment, but “even with that increase, demand is going to be significantly higher than the supply,” says Edward S. Salsberg, MPA, Director of AAMC’s Center for Workforce Studies.

It may please NPs and PAs to know they are not alone in considering their professions an important part of the solution to the problem. Both groups “play a major role in our thinking about the future,” Salsberg says. “The only way we can balance the need for services and assure access [to care] is if we use more PAs and NPs, and use them more effectively.”

And the Numbers Are …
There is no doubt that the NP and PA professions are thriving. Data from the National Commission on the Certification of Physician Assistants indicate that the number of newly certified PAs in the US has increased from about 1,000 in 1990 to nearly 5,000 last year. “That fivefold increase is enormous,” Salsberg says, “and it means the number of PAs will be rising significantly over the next several decades.”

Data on NPs are a little harder to gather, since there are multiple training models and certification programs; if you consider advanced practice nurses as a group, there are nearly 10,000 new APNs each year. Geraldine Bednash, PhD, RN, FAAN, Executive Director of the American Association of Colleges of Nursing (AACN), says, “For the last decade, we’ve seen enormous growth in the number of individuals who have been educated as NPs and who are practicing as NPs.”

Salsberg is uncertain as to what impact the switch to the Doctor of Nursing Practice (DNP) degree will have on the NP supply. “That does have the potential to slow up the pipeline for several years. So I don’t know what [NPs’] growth rate will be,” he says. “I’m sure it will be significant. I just don’t know whether there will be a delay in the growth.”

Bednash considers that “a reasonable question” but says AACN believes the DNP will actually attract more candidates to NP programs. “We’re seeing people choose graduate school earlier in their careers, so it should expand the number of people who are entering the programs,” she observes. “The big issue for us will not be whether it takes longer [to get NPs educated and into the workforce] but whether we can continue to graduate the same or larger numbers of people every year.” So far, she says, the numbers have continued to rise.

Tweaking the Data
But sheer volume may not be enough to offset the physician shortage. Much like clinical trial results, the NP/PA workforce supply is subject to a number of variables. Roderick S. Hooker, PhD, PA, Director of Rheumatology Research at the Dallas Veterans Affairs Medical Center, who has done extensive analysis of health care supply and demand, tries to be conservative in his own estimates.

“When I look at what the outpatient productivity in the US is on an annual basis, it’s about 1.2 billion outpatient visits,” he explains. “And when we look at who’s minding the store—who’s seeing those patients—the provider of record in about 11% to 13% of cases is a PA or NP. So, while the head count is larger for both camps, the productivity number is small.”

Furthermore, Hooker notes, not all PAs or NPs who are certified (the basis on which most estimates are generated) may be seeing patients. They may have chosen an academic or leadership role that keeps them out of the clinic. Hooker estimates that the number of PAs who are in active practice could be as much as 12% lower than the stated figures.

Both Salsberg and Hooker say more research is needed to determine whether there will be enough NPs and PAs available to offset the physician shortage. “What is the optimal number?” Hooker asks. “Only when we have an optimal number, what people think is the right ratio of ‘doctor to population,’ will we be able to answer that question.”

Salsberg says “better information on the numbers and types and locations of practitioners … would help us do a lot more forecasting. Both professions are growing very rapidly, [but] I don’t know whether we need more [PAs and NPs] or whether the growth we’ve seen in the last 15 years is going to be sufficient.”

Faculty, Funding, and Preceptors
Then there are the practical obstacles to NP and PA education programs maintaining, let alone ramping up, “production.” These are the same problems that have plagued the nursing and medical education systems for years: faculty, funding, and preceptors.

AACN’s Bednash says her organization sees the DNP as part of the solution to the nursing faculty shortage: “To some extent, the work that’s being done to prepare people at the doctoral level for advanced practice will both produce a very high-quality clinician and expand the ability to have people who can serve in faculty roles.”

Foundations, individual institutions, and employers are also developing ways to support graduate nursing education; for example, AACN is working with the California Endowment to provide funding for minority nurses in California to pursue higher education. “The funding they receive from us is based on their commitment to us that they will stay in California and serve as a faculty member for several years,” Bednash says.

Meanwhile, “the bottleneck for the PA programs tends to be clinical sites, not the classroom,” Hooker notes. “You can teach a classroom of 200 people the same way you can teach a classroom of 20. It’s getting people dispersed into preceptorship sites that I think is the conundrum.”

Solutions to that problem have been slow in developing. Hooker, who describes himself as “more of an observer than an activist” (ie, he does not advocate for particular solutions but points out different ways of doing things as food for thought), notes that in Canada and Australia, preceptor sites are purchased as part of the tuition for a program. “They give some remuneration to the mentor, and while it’s not much, it is a very important price signal,” he says. “And that price signal says, ‘We value the time that you spend, and we’re willing to compensate you for it.’”

Whatever solutions are proposed or pursued, the bottom line involves funding: more of it. “[Policy makers] need to focus on graduate education,” Bednash says. “They need to fund the programs so that they can hire additional faculty to expand, and they need to understand that doctoral-level education is the only way somebody is going to be able to have a long-term career in a university and serve as a faculty member.”

Generation Next and the Evolution of Team Care
Finally, there is one other factor—a more sociological one—that could have an impact on the health care workforce supply. That is the younger generation’s desire for a better work/life balance than their parents and grandparents had. As Bednash observes, “The expectation [used to be] that you would work morning, noon, and night, weekends, ’round the clock, forget your family.”

That attitude toward work appears to be changing, regardless of profession. “So the question there is, who’s going to work those nights and weekends?” Salsberg asks. “Someone is going to need to be available, and it remains to be seen [who it will be].”

Bednash says practices will have to consider how to balance work schedules and patient care needs “so no one profession ends up having the right to preferential expectations about how that work life should play out. It probably means there will need to be more physicians and more nurses so that all the care needs can be met.”

Besides a greater interest in a 9-to-5 job (or close to it), Hooker also detects a growing sense of wanderlust among people in their 30s and younger. “These people, to me, seem to be delaying marriage, delaying commitment, very interested in going abroad,” he observes. “I wouldn’t be surprised if over the next 10 years we find young Americans emulating Canadians, Australians, the Swiss, and others, and wanting to go abroad—with their skills. I’m wondering if American PAs won’t want to bring their newly honed skills to the world stage and say, ‘I’m a PA, and I’d like to work in the Netherlands for two years’ or ‘I’d like to work in Australia for a few years. It’s a great country, and I want to see the world.’”

The chance that any or all of these factors could impact the supply of NPs and PAs in the coming years brings us back to Salsberg’s original point about creating a more effective health care team. Here, too, he says, research is needed. “I’m a very strong believer in expanding the use of NPs and PAs,” he says, “but I do believe that should really be driven by evidence. What kind of services does it make sense for someone with, say, six years of post–high school [education] to do, and what do you really need those 12 or 13 years of post–high school education for?”

Both Bednash and Hooker provide examples of how NPs and PAs already expand a practice’s capabilities. “You might have a cardiology practice with cardiologists providing the high-level, specialized care for patients with heart disease, and then have a team of NPs working with those physicians to oversee the other kinds of issues that patients have besides the cardiac ones,” Bednash says. “They are able to make sure that the care is very comprehensive and coordinated in a way that the other needs are not forgotten.”

Hooker describes a hypothetical urology clinic of four doctors who hire a PA. “The PA may say, ‘I’m a surgical PA’ but is never in the operating room,” he says. “He or she is taking care of the patients in the office. That either helps maintain continuity of care or tends to offload somewhat from primary care: ‘Oh, your blood pressure is up, let me get an ECG…. It looks like the ECG shows an ST depression. I think we’d better get you into your primary care doctor, but I’m going to start you on some antihypertensives today.’”

For Bednash, the larger issue involves “making sure that reasonable people in both disciplines [medicine and nursing] understand that there are tremendous access and care needs in this country that can only be met when physicians and nurses are allowed to practice to the highest level of their education, knowledge, and skills.

“To some extent, at some point, people are going to have to confront some of the biases about limiting scope of practice for NPs so they can do everything they are capable of doing,” she adds. “The old biases of some physicians have got to be laid to rest. The good news is, in a lot of places, they have been—but it needs to be more uniform.”

For his part, Salsberg agrees that mutual respect and understanding will be key. “We need to do more to prepare our practitioners, our physicians, to work in collaborative practice,” he says. “PAs, NPs, and physicians need to be educated and trained to work together, so that everyone coming out understands and respects the skills of all the other professions.”

So, have you heard about the physician shortage—how by 2020, it is estimated that the United States will have approximately 200,000 fewer practicing physicians than the nation will require to meet the increasing needs of a growing, aging, chronically ill population? The Association of American Medical Colleges (AAMC) has already called for a 30% increase in medical school enrollment, but “even with that increase, demand is going to be significantly higher than the supply,” says Edward S. Salsberg, MPA, Director of AAMC’s Center for Workforce Studies.

It may please NPs and PAs to know they are not alone in considering their professions an important part of the solution to the problem. Both groups “play a major role in our thinking about the future,” Salsberg says. “The only way we can balance the need for services and assure access [to care] is if we use more PAs and NPs, and use them more effectively.”

And the Numbers Are …
There is no doubt that the NP and PA professions are thriving. Data from the National Commission on the Certification of Physician Assistants indicate that the number of newly certified PAs in the US has increased from about 1,000 in 1990 to nearly 5,000 last year. “That fivefold increase is enormous,” Salsberg says, “and it means the number of PAs will be rising significantly over the next several decades.”

Data on NPs are a little harder to gather, since there are multiple training models and certification programs; if you consider advanced practice nurses as a group, there are nearly 10,000 new APNs each year. Geraldine Bednash, PhD, RN, FAAN, Executive Director of the American Association of Colleges of Nursing (AACN), says, “For the last decade, we’ve seen enormous growth in the number of individuals who have been educated as NPs and who are practicing as NPs.”

Salsberg is uncertain as to what impact the switch to the Doctor of Nursing Practice (DNP) degree will have on the NP supply. “That does have the potential to slow up the pipeline for several years. So I don’t know what [NPs’] growth rate will be,” he says. “I’m sure it will be significant. I just don’t know whether there will be a delay in the growth.”

Bednash considers that “a reasonable question” but says AACN believes the DNP will actually attract more candidates to NP programs. “We’re seeing people choose graduate school earlier in their careers, so it should expand the number of people who are entering the programs,” she observes. “The big issue for us will not be whether it takes longer [to get NPs educated and into the workforce] but whether we can continue to graduate the same or larger numbers of people every year.” So far, she says, the numbers have continued to rise.

Tweaking the Data
But sheer volume may not be enough to offset the physician shortage. Much like clinical trial results, the NP/PA workforce supply is subject to a number of variables. Roderick S. Hooker, PhD, PA, Director of Rheumatology Research at the Dallas Veterans Affairs Medical Center, who has done extensive analysis of health care supply and demand, tries to be conservative in his own estimates.

“When I look at what the outpatient productivity in the US is on an annual basis, it’s about 1.2 billion outpatient visits,” he explains. “And when we look at who’s minding the store—who’s seeing those patients—the provider of record in about 11% to 13% of cases is a PA or NP. So, while the head count is larger for both camps, the productivity number is small.”

Furthermore, Hooker notes, not all PAs or NPs who are certified (the basis on which most estimates are generated) may be seeing patients. They may have chosen an academic or leadership role that keeps them out of the clinic. Hooker estimates that the number of PAs who are in active practice could be as much as 12% lower than the stated figures.

Both Salsberg and Hooker say more research is needed to determine whether there will be enough NPs and PAs available to offset the physician shortage. “What is the optimal number?” Hooker asks. “Only when we have an optimal number, what people think is the right ratio of ‘doctor to population,’ will we be able to answer that question.”

Salsberg says “better information on the numbers and types and locations of practitioners … would help us do a lot more forecasting. Both professions are growing very rapidly, [but] I don’t know whether we need more [PAs and NPs] or whether the growth we’ve seen in the last 15 years is going to be sufficient.”

Faculty, Funding, and Preceptors
Then there are the practical obstacles to NP and PA education programs maintaining, let alone ramping up, “production.” These are the same problems that have plagued the nursing and medical education systems for years: faculty, funding, and preceptors.

AACN’s Bednash says her organization sees the DNP as part of the solution to the nursing faculty shortage: “To some extent, the work that’s being done to prepare people at the doctoral level for advanced practice will both produce a very high-quality clinician and expand the ability to have people who can serve in faculty roles.”

Foundations, individual institutions, and employers are also developing ways to support graduate nursing education; for example, AACN is working with the California Endowment to provide funding for minority nurses in California to pursue higher education. “The funding they receive from us is based on their commitment to us that they will stay in California and serve as a faculty member for several years,” Bednash says.

Meanwhile, “the bottleneck for the PA programs tends to be clinical sites, not the classroom,” Hooker notes. “You can teach a classroom of 200 people the same way you can teach a classroom of 20. It’s getting people dispersed into preceptorship sites that I think is the conundrum.”

Solutions to that problem have been slow in developing. Hooker, who describes himself as “more of an observer than an activist” (ie, he does not advocate for particular solutions but points out different ways of doing things as food for thought), notes that in Canada and Australia, preceptor sites are purchased as part of the tuition for a program. “They give some remuneration to the mentor, and while it’s not much, it is a very important price signal,” he says. “And that price signal says, ‘We value the time that you spend, and we’re willing to compensate you for it.’”

Whatever solutions are proposed or pursued, the bottom line involves funding: more of it. “[Policy makers] need to focus on graduate education,” Bednash says. “They need to fund the programs so that they can hire additional faculty to expand, and they need to understand that doctoral-level education is the only way somebody is going to be able to have a long-term career in a university and serve as a faculty member.”

Generation Next and the Evolution of Team Care
Finally, there is one other factor—a more sociological one—that could have an impact on the health care workforce supply. That is the younger generation’s desire for a better work/life balance than their parents and grandparents had. As Bednash observes, “The expectation [used to be] that you would work morning, noon, and night, weekends, ’round the clock, forget your family.”

That attitude toward work appears to be changing, regardless of profession. “So the question there is, who’s going to work those nights and weekends?” Salsberg asks. “Someone is going to need to be available, and it remains to be seen [who it will be].”

Bednash says practices will have to consider how to balance work schedules and patient care needs “so no one profession ends up having the right to preferential expectations about how that work life should play out. It probably means there will need to be more physicians and more nurses so that all the care needs can be met.”

Besides a greater interest in a 9-to-5 job (or close to it), Hooker also detects a growing sense of wanderlust among people in their 30s and younger. “These people, to me, seem to be delaying marriage, delaying commitment, very interested in going abroad,” he observes. “I wouldn’t be surprised if over the next 10 years we find young Americans emulating Canadians, Australians, the Swiss, and others, and wanting to go abroad—with their skills. I’m wondering if American PAs won’t want to bring their newly honed skills to the world stage and say, ‘I’m a PA, and I’d like to work in the Netherlands for two years’ or ‘I’d like to work in Australia for a few years. It’s a great country, and I want to see the world.’”

The chance that any or all of these factors could impact the supply of NPs and PAs in the coming years brings us back to Salsberg’s original point about creating a more effective health care team. Here, too, he says, research is needed. “I’m a very strong believer in expanding the use of NPs and PAs,” he says, “but I do believe that should really be driven by evidence. What kind of services does it make sense for someone with, say, six years of post–high school [education] to do, and what do you really need those 12 or 13 years of post–high school education for?”

Both Bednash and Hooker provide examples of how NPs and PAs already expand a practice’s capabilities. “You might have a cardiology practice with cardiologists providing the high-level, specialized care for patients with heart disease, and then have a team of NPs working with those physicians to oversee the other kinds of issues that patients have besides the cardiac ones,” Bednash says. “They are able to make sure that the care is very comprehensive and coordinated in a way that the other needs are not forgotten.”

Hooker describes a hypothetical urology clinic of four doctors who hire a PA. “The PA may say, ‘I’m a surgical PA’ but is never in the operating room,” he says. “He or she is taking care of the patients in the office. That either helps maintain continuity of care or tends to offload somewhat from primary care: ‘Oh, your blood pressure is up, let me get an ECG…. It looks like the ECG shows an ST depression. I think we’d better get you into your primary care doctor, but I’m going to start you on some antihypertensives today.’”

For Bednash, the larger issue involves “making sure that reasonable people in both disciplines [medicine and nursing] understand that there are tremendous access and care needs in this country that can only be met when physicians and nurses are allowed to practice to the highest level of their education, knowledge, and skills.

“To some extent, at some point, people are going to have to confront some of the biases about limiting scope of practice for NPs so they can do everything they are capable of doing,” she adds. “The old biases of some physicians have got to be laid to rest. The good news is, in a lot of places, they have been—but it needs to be more uniform.”

For his part, Salsberg agrees that mutual respect and understanding will be key. “We need to do more to prepare our practitioners, our physicians, to work in collaborative practice,” he says. “PAs, NPs, and physicians need to be educated and trained to work together, so that everyone coming out understands and respects the skills of all the other professions.”

Almost three years after Hurricane Katrina, as natural disasters occur around the world with seemingly greater frequency, is the United States better prepared to respond to a disaster in our own backyard? And what improvements are still needed if health care providers, including NPs and PAs, are going to be utilized to the full extent of their capabilities?

Paul Bollinger, MPH, Emergency Medical Services Senior Advisor for the Portland, Oregon–based Medical Teams International (MTI), quotes MTI’s director of disaster response as saying, “It’s easier to send a doctor to Liberia than it was to Louisiana.” Bollinger adds, “That’s a huge issue, portability, in times of disaster—and yes, governors can change those laws, but I think by the time the bureaucracy wheels turn, it’s too late.”

Uniform Emergency Volunteer Health Practitioners Act
Greasing those bureaucratic wheels is the aim of the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA), a piece of model legislation drafted by the Uniform Law Commission (ULC). According to Eric Fish, Legislative Counsel for the ULC, the goal of the UEVHPA is “to facilitate a better response to large-scale disasters by getting rid of some of the red tape and paperwork and things that could slow down responders.”

The ULC decided to address this issue as a direct result of what happened during and after Hurricanes Katrina and Rita struck the US Gulf Coast, laying bare the many levels on which bureaucracy and disorganization stymied relief efforts. “A few of the commissioners had family members involved with the medical response [to Katrina],” Fish says, “and it was brought up that way. And then, working with groups such as the Red Cross, it became apparent that some quick action in this field of law would be beneficial.”

Usually, it takes three to four years for the ULC to produce model legislation, from the time an area of interest (such as emergency response) is proposed to the point at which the commissioners approve the final version. In the case of the UEVHPA, most of the act was approved the year after the Katrina disaster, with additional sections addressing liability and workers’ compensation approved last year.

Colorado, Kentucky, and Tennessee were the first states to enact the UEVHPA in 2006 and 2007. In 2008, the act has been introduced in 12 states; so far, Indiana and New Mexico have enacted it. (See map.)

So how does the UEVHPA address some of the problems experienced in the aftermath of Katrina? Two key points are outlined in the prefatory note to the act (available as a PDF at www.uevhpa.org):

• “To protect the public health and safety, the act requires that, prior to deployment, volunteers must be registered with public or private systems capable of determining that they have been properly licensed and are in good standing with their principal jurisdiction of practice” and

•  “To alleviate confusion and uncertainty regarding the types of services that may be provided by volunteer health practitioners, the act requires volunteers to limit their practice to activities for which they are licensed, properly trained, and qualified to perform. Further, volunteer health practitioners must conform to scope-of-practice authorizations and restrictions imposed by the laws of host states, disaster response agencies and organizations, and host entities.”

“It doesn’t supersede any existing state law,” Fish explains. “What this does is just set up a registry that a state can call upon in times of disaster.” He employs a baseball analogy for clarification: “It’s like having people in your bullpen. You know who’s in the bullpen, you know what they can do, you’ll bring them up for whatever situation.”

But is it enough?

Beyond the UEVHPA
No single piece of model legislation will iron out every wrinkle the nation faces in disaster response. PAs and NPs have particular issues when it comes to practicing outside the state in which they are licensed—supervision by and collaboration with physicians, respectively.

Long before Katrina, the American Academy of Physician Assistants (AAPA) drafted model language saying that “any PA who is licensed in the state or licensed in another state or authorized to practice by a federal employer as a physician assistant should be able to provide whatever care they are able to in a disaster or emergency situation, with whatever supervision is available,” summarizes Ann Davis, PA-C, AAPA Director of State Government Affairs. Five states (soon to be six) have adopted AAPA’s model language; overall, 38 states have some sort of provision for recognizing PAs in disasters or emergencies.

AAPA doesn’t have an official position on the UEVHPA, but Davis says, “In my opinion, the bill is fine as drafted, because it defines ‘health care practitioner’ as anybody who is licensed to provide health care services in a state. It’s broad enough that I don’t think anybody would question if PAs were meant to be included.”

While the UEVHPA does not specifically address PAs’ supervision requirements, it has provided opportunities for PAs in individual states to resolve those issues separately. When Indiana was considering passage of the UEVHPA, Davis says, “we flagged the issue and said, ‘You know, this might be a good time—while the legislators are thinking about disaster response—to talk to somebody about putting the PA language someplace.’”

That place didn’t have to be within the UEVHPA: “If you’re looking for a uniform law, you don’t necessarily stick your own provisions on it—that seems a little invasive,” Davis observes. Instead, the PA disaster response language was introduced through an omnibus bill that was in the works.

Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the American Academy of Nurse Practitioners, is a bit less sanguine about the UEVHPA. “They still haven’t fixed the issue,” she notes, which for NPs is “shedding the shackles of law that requires physician collaboration or delegation within some of the states that have obsolete laws.”

Section 8 of the UEVHPA, “Provision of Volunteer Health or Veterinary Services,” contains the following statements:

• “… a volunteer health practitioner shall adhere to the scope of practice for a similarly licensed practitioner established by the licensing provisions, practice acts, or other laws of this state” and

•  “Except as otherwise provided in subsection (c) [which allows states the right to modify or restrict services provided by a volunteer], this [act] does not authorize the volunteer health practitioner to provide services that are outside the practitioner’s scope of practice, even if a similarly licensed practitioner in this state would be permitted to provide the services.”

What concerns Towers is that “we’re still going to the lowest common denominator. Bottom line is, NPs are prepared [educationally] the same way across the board, and being tied to a physician in some states, while in other states they are not, is really limiting.”

Towers says it would have been “very helpful” if the UEVHPA had included language that expressly gave states the right to lift supervision or collaboration requirements. “There are some states that have actually passed regulations and statutes that speak to this by saying, ‘If there is a disaster, then the need to be tied to a physician is lifted, for the period of time of the disaster,’” she points out.

But, as with the PAs’ supervision requirements, “that’s happening state by state, and it’s something we’re going to have to work on,” according to Towers.

Wanted: Team Players
One thing that everyone seems to agree on is that preregistration, precredentialing, and involvement in emergency or disaster response teams should be encouraged. To this end, the UEVHPA requires that volunteer health care providers be registered with a system that can confirm their licenses and credentials before they are deployed in response to a disaster.

“The use of registration systems is intended to (1) discourage the uncoordinated use of ‘spontaneous volunteers’ who may independently travel to the scene of a disaster without the support of public or private emergency response agencies,” the preface to the draft legislation reads, “and (2) promote the recruitment and training of volunteers in advance of emergency declarations, while also allowing and facilitating additional registrations at the time of an emergency.”

The increased emphasis on teams, from the community level on up, has been one of the biggest lessons acted on since Katrina. “The amount of planning that’s gone on post-Katrina is incredible,” MTI’s Bollinger says. “A lot of states are looking at creating medical volunteer corps, looking at PAs, NPs, physicians, and paramedical personnel, and gathering them into a database that they can tap into. You know, ‘OK, we need four PAs to go to this clinic, or this displaced persons site, and provide care.’ Boom, that’s in the database; we can launch those folks.”

So-called spontaneous volunteers, though well intentioned, “can put burdens on a fragile infrastructure,” observes Bollinger. “In some ways, you’re relocating the disaster.”

That’s why PAs and NPs are encouraged to join a medical response team—whether a Red Cross unit, a Disaster Medical Assistance Team, or a private agency like MTI. “The best help is not the person who grabs their medical bag and goes down alone,” Davis says. “It’s folks who are part of an organized system that are the most helpful. They show up with their own water and tools and people that they know how to work with.”

Organized units will often handle credentialing and registration, but clinicians can also register on their own so that their licensing information can be verified in advance, allowing them to be mobilized quickly in the event of an emergency. “Having to do any kind of registration once a disaster happens, of course, slows down the process,” Towers observes.

Keeping documentation up to date—including passports if you’ll be responding overseas—is important. And while Davis strongly advocates for advance registration and credential verification “so you don’t show up someplace with a handful of papers,” she also suggests that “there should be a place where you keep all of your core licensing documents, CPR certification, graduation records from school, those things, so that if you’re in a spot where you need to leave quickly, you can.”

National Issue
There is a touch of irony to the fact that the obstacles to international disaster response often relate to travel and access to remote sites, while within the US the obstacles have more to do with regulatory issues. “That’s the big hiccup, I think, of responding within the US,” says Bollinger, whose vast experience includes working on the MTI team that went to Indonesia in response to the tsunami in 2006. “We have all these laws in place: You must have medical direction, you must have signatures on this, this, and this. And that, I think, is going to become the albatross around our neck in domestic response, particularly for medical personnel.”

The difference? “National scope of practice,” Bollinger says. “The Ministry of Health in most of the countries we respond to, they’re the ones that call the shots.” Within the US, he adds, “We’re looking at significant health system change to make that a reality.”

It’s a reality (however unlikely) that not everyone would want anyway. After observing that most of the countries Bollinger refers to “are about the size of each of our states,” Towers notes that NPs “already have a national scope of practice. The states have set limits on that.” (This may or may not reinforce Bollinger’s point about bureaucracy.) Furthermore, Towers says, “I don’t think that we’re going to be able to create national practice acts. I don’t know that we even want to, for other reasons.”

When asked about national scope of practice, Davis responds, “My joke about that is, ‘I’m a young woman with good health habits, but I’m not going to live that long.’” She provides a brief history lesson for context, citing a 19th-century court case in which “we decided, at the Supreme Court level, that states would regulate health professionals as part of their duty to protect their citizens. People could make a very good case for this being something that the federal government should do, but that’s a big debate.”

On whatever level changes are made, the true test of how well the US has learned the lessons imparted by Hurricane Katrina will come only in the wake of another large-scale disaster—something no one wants to happen. Yet, with two international natural disasters (in Myanmar and China) occurring within a week, and tornadoes inflicting destruction on a smaller but still devastating scale in the US, it seems likely that the nation will eventually have extensive need of emergency responders again. In that case, it seems appropriate to fall back on the traditional Boy Scout maxim, Be prepared.

“If we can raise awareness of how to respond to disasters on the clinician level, I think it makes us a stronger country,” Bollinger says. “If we’re better prepared, we’re better able to respond, and I think a lot of these other issues will kind of go by the wayside. Hopefully.”           

Almost three years after Hurricane Katrina, as natural disasters occur around the world with seemingly greater frequency, is the United States better prepared to respond to a disaster in our own backyard? And what improvements are still needed if health care providers, including NPs and PAs, are going to be utilized to the full extent of their capabilities?

Paul Bollinger, MPH, Emergency Medical Services Senior Advisor for the Portland, Oregon–based Medical Teams International (MTI), quotes MTI’s director of disaster response as saying, “It’s easier to send a doctor to Liberia than it was to Louisiana.” Bollinger adds, “That’s a huge issue, portability, in times of disaster—and yes, governors can change those laws, but I think by the time the bureaucracy wheels turn, it’s too late.”

Uniform Emergency Volunteer Health Practitioners Act
Greasing those bureaucratic wheels is the aim of the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA), a piece of model legislation drafted by the Uniform Law Commission (ULC). According to Eric Fish, Legislative Counsel for the ULC, the goal of the UEVHPA is “to facilitate a better response to large-scale disasters by getting rid of some of the red tape and paperwork and things that could slow down responders.”

The ULC decided to address this issue as a direct result of what happened during and after Hurricanes Katrina and Rita struck the US Gulf Coast, laying bare the many levels on which bureaucracy and disorganization stymied relief efforts. “A few of the commissioners had family members involved with the medical response [to Katrina],” Fish says, “and it was brought up that way. And then, working with groups such as the Red Cross, it became apparent that some quick action in this field of law would be beneficial.”

Usually, it takes three to four years for the ULC to produce model legislation, from the time an area of interest (such as emergency response) is proposed to the point at which the commissioners approve the final version. In the case of the UEVHPA, most of the act was approved the year after the Katrina disaster, with additional sections addressing liability and workers’ compensation approved last year.

Colorado, Kentucky, and Tennessee were the first states to enact the UEVHPA in 2006 and 2007. In 2008, the act has been introduced in 12 states; so far, Indiana and New Mexico have enacted it. (See map.)

So how does the UEVHPA address some of the problems experienced in the aftermath of Katrina? Two key points are outlined in the prefatory note to the act (available as a PDF at www.uevhpa.org):

• “To protect the public health and safety, the act requires that, prior to deployment, volunteers must be registered with public or private systems capable of determining that they have been properly licensed and are in good standing with their principal jurisdiction of practice” and

•  “To alleviate confusion and uncertainty regarding the types of services that may be provided by volunteer health practitioners, the act requires volunteers to limit their practice to activities for which they are licensed, properly trained, and qualified to perform. Further, volunteer health practitioners must conform to scope-of-practice authorizations and restrictions imposed by the laws of host states, disaster response agencies and organizations, and host entities.”

“It doesn’t supersede any existing state law,” Fish explains. “What this does is just set up a registry that a state can call upon in times of disaster.” He employs a baseball analogy for clarification: “It’s like having people in your bullpen. You know who’s in the bullpen, you know what they can do, you’ll bring them up for whatever situation.”

But is it enough?

Beyond the UEVHPA
No single piece of model legislation will iron out every wrinkle the nation faces in disaster response. PAs and NPs have particular issues when it comes to practicing outside the state in which they are licensed—supervision by and collaboration with physicians, respectively.

Long before Katrina, the American Academy of Physician Assistants (AAPA) drafted model language saying that “any PA who is licensed in the state or licensed in another state or authorized to practice by a federal employer as a physician assistant should be able to provide whatever care they are able to in a disaster or emergency situation, with whatever supervision is available,” summarizes Ann Davis, PA-C, AAPA Director of State Government Affairs. Five states (soon to be six) have adopted AAPA’s model language; overall, 38 states have some sort of provision for recognizing PAs in disasters or emergencies.

AAPA doesn’t have an official position on the UEVHPA, but Davis says, “In my opinion, the bill is fine as drafted, because it defines ‘health care practitioner’ as anybody who is licensed to provide health care services in a state. It’s broad enough that I don’t think anybody would question if PAs were meant to be included.”

While the UEVHPA does not specifically address PAs’ supervision requirements, it has provided opportunities for PAs in individual states to resolve those issues separately. When Indiana was considering passage of the UEVHPA, Davis says, “we flagged the issue and said, ‘You know, this might be a good time—while the legislators are thinking about disaster response—to talk to somebody about putting the PA language someplace.’”

That place didn’t have to be within the UEVHPA: “If you’re looking for a uniform law, you don’t necessarily stick your own provisions on it—that seems a little invasive,” Davis observes. Instead, the PA disaster response language was introduced through an omnibus bill that was in the works.

Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the American Academy of Nurse Practitioners, is a bit less sanguine about the UEVHPA. “They still haven’t fixed the issue,” she notes, which for NPs is “shedding the shackles of law that requires physician collaboration or delegation within some of the states that have obsolete laws.”

Section 8 of the UEVHPA, “Provision of Volunteer Health or Veterinary Services,” contains the following statements:

• “… a volunteer health practitioner shall adhere to the scope of practice for a similarly licensed practitioner established by the licensing provisions, practice acts, or other laws of this state” and

•  “Except as otherwise provided in subsection (c) [which allows states the right to modify or restrict services provided by a volunteer], this [act] does not authorize the volunteer health practitioner to provide services that are outside the practitioner’s scope of practice, even if a similarly licensed practitioner in this state would be permitted to provide the services.”

What concerns Towers is that “we’re still going to the lowest common denominator. Bottom line is, NPs are prepared [educationally] the same way across the board, and being tied to a physician in some states, while in other states they are not, is really limiting.”

Towers says it would have been “very helpful” if the UEVHPA had included language that expressly gave states the right to lift supervision or collaboration requirements. “There are some states that have actually passed regulations and statutes that speak to this by saying, ‘If there is a disaster, then the need to be tied to a physician is lifted, for the period of time of the disaster,’” she points out.

But, as with the PAs’ supervision requirements, “that’s happening state by state, and it’s something we’re going to have to work on,” according to Towers.

Wanted: Team Players
One thing that everyone seems to agree on is that preregistration, precredentialing, and involvement in emergency or disaster response teams should be encouraged. To this end, the UEVHPA requires that volunteer health care providers be registered with a system that can confirm their licenses and credentials before they are deployed in response to a disaster.

“The use of registration systems is intended to (1) discourage the uncoordinated use of ‘spontaneous volunteers’ who may independently travel to the scene of a disaster without the support of public or private emergency response agencies,” the preface to the draft legislation reads, “and (2) promote the recruitment and training of volunteers in advance of emergency declarations, while also allowing and facilitating additional registrations at the time of an emergency.”

The increased emphasis on teams, from the community level on up, has been one of the biggest lessons acted on since Katrina. “The amount of planning that’s gone on post-Katrina is incredible,” MTI’s Bollinger says. “A lot of states are looking at creating medical volunteer corps, looking at PAs, NPs, physicians, and paramedical personnel, and gathering them into a database that they can tap into. You know, ‘OK, we need four PAs to go to this clinic, or this displaced persons site, and provide care.’ Boom, that’s in the database; we can launch those folks.”

So-called spontaneous volunteers, though well intentioned, “can put burdens on a fragile infrastructure,” observes Bollinger. “In some ways, you’re relocating the disaster.”

That’s why PAs and NPs are encouraged to join a medical response team—whether a Red Cross unit, a Disaster Medical Assistance Team, or a private agency like MTI. “The best help is not the person who grabs their medical bag and goes down alone,” Davis says. “It’s folks who are part of an organized system that are the most helpful. They show up with their own water and tools and people that they know how to work with.”

Organized units will often handle credentialing and registration, but clinicians can also register on their own so that their licensing information can be verified in advance, allowing them to be mobilized quickly in the event of an emergency. “Having to do any kind of registration once a disaster happens, of course, slows down the process,” Towers observes.

Keeping documentation up to date—including passports if you’ll be responding overseas—is important. And while Davis strongly advocates for advance registration and credential verification “so you don’t show up someplace with a handful of papers,” she also suggests that “there should be a place where you keep all of your core licensing documents, CPR certification, graduation records from school, those things, so that if you’re in a spot where you need to leave quickly, you can.”

National Issue
There is a touch of irony to the fact that the obstacles to international disaster response often relate to travel and access to remote sites, while within the US the obstacles have more to do with regulatory issues. “That’s the big hiccup, I think, of responding within the US,” says Bollinger, whose vast experience includes working on the MTI team that went to Indonesia in response to the tsunami in 2006. “We have all these laws in place: You must have medical direction, you must have signatures on this, this, and this. And that, I think, is going to become the albatross around our neck in domestic response, particularly for medical personnel.”

The difference? “National scope of practice,” Bollinger says. “The Ministry of Health in most of the countries we respond to, they’re the ones that call the shots.” Within the US, he adds, “We’re looking at significant health system change to make that a reality.”

It’s a reality (however unlikely) that not everyone would want anyway. After observing that most of the countries Bollinger refers to “are about the size of each of our states,” Towers notes that NPs “already have a national scope of practice. The states have set limits on that.” (This may or may not reinforce Bollinger’s point about bureaucracy.) Furthermore, Towers says, “I don’t think that we’re going to be able to create national practice acts. I don’t know that we even want to, for other reasons.”

When asked about national scope of practice, Davis responds, “My joke about that is, ‘I’m a young woman with good health habits, but I’m not going to live that long.’” She provides a brief history lesson for context, citing a 19th-century court case in which “we decided, at the Supreme Court level, that states would regulate health professionals as part of their duty to protect their citizens. People could make a very good case for this being something that the federal government should do, but that’s a big debate.”

On whatever level changes are made, the true test of how well the US has learned the lessons imparted by Hurricane Katrina will come only in the wake of another large-scale disaster—something no one wants to happen. Yet, with two international natural disasters (in Myanmar and China) occurring within a week, and tornadoes inflicting destruction on a smaller but still devastating scale in the US, it seems likely that the nation will eventually have extensive need of emergency responders again. In that case, it seems appropriate to fall back on the traditional Boy Scout maxim, Be prepared.

“If we can raise awareness of how to respond to disasters on the clinician level, I think it makes us a stronger country,” Bollinger says. “If we’re better prepared, we’re better able to respond, and I think a lot of these other issues will kind of go by the wayside. Hopefully.”           

Almost three years after Hurricane Katrina, as natural disasters occur around the world with seemingly greater frequency, is the United States better prepared to respond to a disaster in our own backyard? And what improvements are still needed if health care providers, including NPs and PAs, are going to be utilized to the full extent of their capabilities?

Paul Bollinger, MPH, Emergency Medical Services Senior Advisor for the Portland, Oregon–based Medical Teams International (MTI), quotes MTI’s director of disaster response as saying, “It’s easier to send a doctor to Liberia than it was to Louisiana.” Bollinger adds, “That’s a huge issue, portability, in times of disaster—and yes, governors can change those laws, but I think by the time the bureaucracy wheels turn, it’s too late.”

Uniform Emergency Volunteer Health Practitioners Act
Greasing those bureaucratic wheels is the aim of the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA), a piece of model legislation drafted by the Uniform Law Commission (ULC). According to Eric Fish, Legislative Counsel for the ULC, the goal of the UEVHPA is “to facilitate a better response to large-scale disasters by getting rid of some of the red tape and paperwork and things that could slow down responders.”

The ULC decided to address this issue as a direct result of what happened during and after Hurricanes Katrina and Rita struck the US Gulf Coast, laying bare the many levels on which bureaucracy and disorganization stymied relief efforts. “A few of the commissioners had family members involved with the medical response [to Katrina],” Fish says, “and it was brought up that way. And then, working with groups such as the Red Cross, it became apparent that some quick action in this field of law would be beneficial.”

Usually, it takes three to four years for the ULC to produce model legislation, from the time an area of interest (such as emergency response) is proposed to the point at which the commissioners approve the final version. In the case of the UEVHPA, most of the act was approved the year after the Katrina disaster, with additional sections addressing liability and workers’ compensation approved last year.

Colorado, Kentucky, and Tennessee were the first states to enact the UEVHPA in 2006 and 2007. In 2008, the act has been introduced in 12 states; so far, Indiana and New Mexico have enacted it. (See map.)

So how does the UEVHPA address some of the problems experienced in the aftermath of Katrina? Two key points are outlined in the prefatory note to the act (available as a PDF at www.uevhpa.org):

• “To protect the public health and safety, the act requires that, prior to deployment, volunteers must be registered with public or private systems capable of determining that they have been properly licensed and are in good standing with their principal jurisdiction of practice” and

•  “To alleviate confusion and uncertainty regarding the types of services that may be provided by volunteer health practitioners, the act requires volunteers to limit their practice to activities for which they are licensed, properly trained, and qualified to perform. Further, volunteer health practitioners must conform to scope-of-practice authorizations and restrictions imposed by the laws of host states, disaster response agencies and organizations, and host entities.”

“It doesn’t supersede any existing state law,” Fish explains. “What this does is just set up a registry that a state can call upon in times of disaster.” He employs a baseball analogy for clarification: “It’s like having people in your bullpen. You know who’s in the bullpen, you know what they can do, you’ll bring them up for whatever situation.”

But is it enough?

Beyond the UEVHPA
No single piece of model legislation will iron out every wrinkle the nation faces in disaster response. PAs and NPs have particular issues when it comes to practicing outside the state in which they are licensed—supervision by and collaboration with physicians, respectively.

Long before Katrina, the American Academy of Physician Assistants (AAPA) drafted model language saying that “any PA who is licensed in the state or licensed in another state or authorized to practice by a federal employer as a physician assistant should be able to provide whatever care they are able to in a disaster or emergency situation, with whatever supervision is available,” summarizes Ann Davis, PA-C, AAPA Director of State Government Affairs. Five states (soon to be six) have adopted AAPA’s model language; overall, 38 states have some sort of provision for recognizing PAs in disasters or emergencies.

AAPA doesn’t have an official position on the UEVHPA, but Davis says, “In my opinion, the bill is fine as drafted, because it defines ‘health care practitioner’ as anybody who is licensed to provide health care services in a state. It’s broad enough that I don’t think anybody would question if PAs were meant to be included.”

While the UEVHPA does not specifically address PAs’ supervision requirements, it has provided opportunities for PAs in individual states to resolve those issues separately. When Indiana was considering passage of the UEVHPA, Davis says, “we flagged the issue and said, ‘You know, this might be a good time—while the legislators are thinking about disaster response—to talk to somebody about putting the PA language someplace.’”

That place didn’t have to be within the UEVHPA: “If you’re looking for a uniform law, you don’t necessarily stick your own provisions on it—that seems a little invasive,” Davis observes. Instead, the PA disaster response language was introduced through an omnibus bill that was in the works.

Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the American Academy of Nurse Practitioners, is a bit less sanguine about the UEVHPA. “They still haven’t fixed the issue,” she notes, which for NPs is “shedding the shackles of law that requires physician collaboration or delegation within some of the states that have obsolete laws.”

Section 8 of the UEVHPA, “Provision of Volunteer Health or Veterinary Services,” contains the following statements:

• “… a volunteer health practitioner shall adhere to the scope of practice for a similarly licensed practitioner established by the licensing provisions, practice acts, or other laws of this state” and

•  “Except as otherwise provided in subsection (c) [which allows states the right to modify or restrict services provided by a volunteer], this [act] does not authorize the volunteer health practitioner to provide services that are outside the practitioner’s scope of practice, even if a similarly licensed practitioner in this state would be permitted to provide the services.”

What concerns Towers is that “we’re still going to the lowest common denominator. Bottom line is, NPs are prepared [educationally] the same way across the board, and being tied to a physician in some states, while in other states they are not, is really limiting.”

Towers says it would have been “very helpful” if the UEVHPA had included language that expressly gave states the right to lift supervision or collaboration requirements. “There are some states that have actually passed regulations and statutes that speak to this by saying, ‘If there is a disaster, then the need to be tied to a physician is lifted, for the period of time of the disaster,’” she points out.

But, as with the PAs’ supervision requirements, “that’s happening state by state, and it’s something we’re going to have to work on,” according to Towers.

Wanted: Team Players
One thing that everyone seems to agree on is that preregistration, precredentialing, and involvement in emergency or disaster response teams should be encouraged. To this end, the UEVHPA requires that volunteer health care providers be registered with a system that can confirm their licenses and credentials before they are deployed in response to a disaster.

“The use of registration systems is intended to (1) discourage the uncoordinated use of ‘spontaneous volunteers’ who may independently travel to the scene of a disaster without the support of public or private emergency response agencies,” the preface to the draft legislation reads, “and (2) promote the recruitment and training of volunteers in advance of emergency declarations, while also allowing and facilitating additional registrations at the time of an emergency.”

The increased emphasis on teams, from the community level on up, has been one of the biggest lessons acted on since Katrina. “The amount of planning that’s gone on post-Katrina is incredible,” MTI’s Bollinger says. “A lot of states are looking at creating medical volunteer corps, looking at PAs, NPs, physicians, and paramedical personnel, and gathering them into a database that they can tap into. You know, ‘OK, we need four PAs to go to this clinic, or this displaced persons site, and provide care.’ Boom, that’s in the database; we can launch those folks.”

So-called spontaneous volunteers, though well intentioned, “can put burdens on a fragile infrastructure,” observes Bollinger. “In some ways, you’re relocating the disaster.”

That’s why PAs and NPs are encouraged to join a medical response team—whether a Red Cross unit, a Disaster Medical Assistance Team, or a private agency like MTI. “The best help is not the person who grabs their medical bag and goes down alone,” Davis says. “It’s folks who are part of an organized system that are the most helpful. They show up with their own water and tools and people that they know how to work with.”

Organized units will often handle credentialing and registration, but clinicians can also register on their own so that their licensing information can be verified in advance, allowing them to be mobilized quickly in the event of an emergency. “Having to do any kind of registration once a disaster happens, of course, slows down the process,” Towers observes.

Keeping documentation up to date—including passports if you’ll be responding overseas—is important. And while Davis strongly advocates for advance registration and credential verification “so you don’t show up someplace with a handful of papers,” she also suggests that “there should be a place where you keep all of your core licensing documents, CPR certification, graduation records from school, those things, so that if you’re in a spot where you need to leave quickly, you can.”

National Issue
There is a touch of irony to the fact that the obstacles to international disaster response often relate to travel and access to remote sites, while within the US the obstacles have more to do with regulatory issues. “That’s the big hiccup, I think, of responding within the US,” says Bollinger, whose vast experience includes working on the MTI team that went to Indonesia in response to the tsunami in 2006. “We have all these laws in place: You must have medical direction, you must have signatures on this, this, and this. And that, I think, is going to become the albatross around our neck in domestic response, particularly for medical personnel.”

The difference? “National scope of practice,” Bollinger says. “The Ministry of Health in most of the countries we respond to, they’re the ones that call the shots.” Within the US, he adds, “We’re looking at significant health system change to make that a reality.”

It’s a reality (however unlikely) that not everyone would want anyway. After observing that most of the countries Bollinger refers to “are about the size of each of our states,” Towers notes that NPs “already have a national scope of practice. The states have set limits on that.” (This may or may not reinforce Bollinger’s point about bureaucracy.) Furthermore, Towers says, “I don’t think that we’re going to be able to create national practice acts. I don’t know that we even want to, for other reasons.”

When asked about national scope of practice, Davis responds, “My joke about that is, ‘I’m a young woman with good health habits, but I’m not going to live that long.’” She provides a brief history lesson for context, citing a 19th-century court case in which “we decided, at the Supreme Court level, that states would regulate health professionals as part of their duty to protect their citizens. People could make a very good case for this being something that the federal government should do, but that’s a big debate.”

On whatever level changes are made, the true test of how well the US has learned the lessons imparted by Hurricane Katrina will come only in the wake of another large-scale disaster—something no one wants to happen. Yet, with two international natural disasters (in Myanmar and China) occurring within a week, and tornadoes inflicting destruction on a smaller but still devastating scale in the US, it seems likely that the nation will eventually have extensive need of emergency responders again. In that case, it seems appropriate to fall back on the traditional Boy Scout maxim, Be prepared.

“If we can raise awareness of how to respond to disasters on the clinician level, I think it makes us a stronger country,” Bollinger says. “If we’re better prepared, we’re better able to respond, and I think a lot of these other issues will kind of go by the wayside. Hopefully.”           

Who knew a little tick could cause so much trouble? When Lyme disease was first described in 1977, did anyone suspect that three decades later, a battle would be raging between two professional organizations about how to treat it? Today, the “war” between the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS) leaves clinicians wondering whose guidelines they should follow.

Is it a case of David versus Goliath—the “upstart” ILADS challenging the established IDSA—or evidence-based medicine versus questionable practice? The more you listen to the parties involved, the more difficult it can be to determine the answer.

Chronic Problem
The crux of the Lyme disease treatment debate is whether the condition exists in a chronic form. ILADS practitioners insist that it does; how else to explain the lingering symptoms many patients experience, which they say resolve only with long-term, high-dose antibiotic therapy? IDSA, however, takes the viewpoint that these patients—whose symptoms of fatigue, cognitive dysfunction, and musculoskeletal pain are subjective and vague (belonging on the symptom list for chronic fatigue syndrome and fibromyalgia as well)—never had Lyme disease in the first place, and this is why standard therapy for the condition appears not to work for them.

“It’s true that those kinds of symptoms can occur in Lyme disease,” says Gary P. Wormser, MD, Chief of the Division of Infectious Diseases at New York Medical College in Valhalla, and lead author of IDSA’s guidelines. “But where the disconnect occurs is when people want to ascribe everybody with those symptoms as having Lyme disease, when they have no bona fide evidence [ie, validated laboratory results] of the disease.”

ILADS clinicians counter that the IDSA underestimates Borrelia burgdorferi (Bb), the spirochete that causes Lyme disease. “What we’re dealing with is way more sophisticated bacteria than any other bacteria we know,” says Ginger R. Savely, RN, FNP-C, a Lyme disease specialist at Union Square Medical Associates in San Francisco. “The more you really study the bacteria and how it works, the more you become incredibly impressed by how many mechanisms this bacteria has for survival and how difficult it is to get rid of it.”

Furthermore, Lyme disease specialists contend that the currently available diagnostic tools, the ELISA and the Western blot test, do not have sufficient sensitivity to reliably detect the presence of Bb (see Savely GR. Update on Lyme disease. Clinician Reviews. 2006;16[4]:44-51). This, they say, is why it can be difficult to validate the diagnosis.

Bottom line: If you can’t agree on what you’re treating, you certainly won’t agree on how to treat it.

Prolonged Antibiotic Therapy
IDSA’s guidelines on the treatment of Lyme disease recommend, in general, 14-day courses of oral antibiotics, with the option of a longer course (28 days) or retreatment where deemed appropriate. “We don’t treat bacterial infections with prolonged antibiotics,” Wormser points out, citing as examples cystitis, strep throat, and sinusitis. “So when you see 14 days recommended, that’s a long course relative to many bacterial infections.”

At issue in the Lyme “war” is the fact that ILADS, in the words of President Daniel Cameron, MD, MPH, “likes to offer options to patients who find themselves still sick after 30 days of treatment”—specifically, long-term (sometimes indefinite) high-dose antibiotic therapy.

Wormser is quick to point out that “our guidelines don’t really discuss how any individual patient is to be treated. They just tell you a general approach that we think is scientifically based and makes sense, based on all other infectious diseases.” In the IDSA’s estimation, the research does not support the efficacy of long-term antibiotic therapy for Lyme disease—and in the absence of that support, the risks involved are just too great.

Those risks include the growing problem of antibiotic-resistant bacteria, the possibility of coinfection with an organism such as Clostridium difficile, and the potential for sepsis and other complications associated with prolonged IV therapy. “Would you really dialyze somebody who didn’t need dialysis?” Wormser asks. “That’s an extreme example. But we say to ourselves every time we use them, ‘Do we really need antibiotics here, and what’s the shortest period of time we can give them, not the longest?’”

“The IDSA loves to say that what we’re doing is harmful or dangerous,” says Savely, who has treated more than 1,000 patients according to the ILADS recommendations. “The data have not shown that to be true. We have not had problems or complications—certainly not mortality—from the kind of treatment that we do.”

Furthermore, ILADS clinicians say they restore hope to patients whom “mainstream” medicine has failed. “People were coming to me with just terrible, terrible conditions, where they had been to so many specialists and every one had told them, ‘There’s no hope. We can’t do anything for you,’” Savely says. “And then I’d start treating them with high-dose long-term antibiotics, and they would get their lives back.”

Wormser understands that many patients feel let down by practitioners who can’t provide definitive answers about their condition. “And I know people will turn to whoever says they think they can help—I can’t blame them for that,” he says. Nonetheless, “it is remarkable the difference that patients with real Lyme have, in terms of their experience with antibiotics, compared to people who probably don’t have Lyme but feel they do.”

Risky Business?
So, how should clinicians handle patient inquiries about Lyme disease treatment? ILADS President Cameron believes that all options should be presented. “The patient should be involved in the decision, rather than just offered only one answer,” he says, although he respects every clinician’s right to say, “There are other options, but I choose this one.”

Clinician Reviews Editorial Board member Julia Pallentino, MSN, JD, ARNP, sees patients in her gastroenterology practice in Tallahassee, Florida, who are being treated by other clinicians with long-term antibiotic therapy for Lyme disease. “I respect their right to seek care from where they wish to seek it, and if they feel it has been helpful, I support that,” she says. Even so, if she were the one treating them for Lyme disease, “I certainly would not take on a different way of treatment because they want it. I would say, ‘I understand that you think this will help you, and I certainly respect your opinion. However, that’s not the method I use. If you want to use a different method, then I would recommend you find a practitioner who does that.’”

Of course, in this day and age, the specter of malpractice hangs over everyone. “As an attorney, I can tell you I’d much rather my client had been using IDSA guidelines than ILADS,” Pallentino says. “If you treat a patient according to CDC guidelines [which are the IDSA guidelines, in this case], then it would be very difficult to say that you weren’t doing what was accepted, appropriate treatment.”

Savely understands all too well how risky treating Lyme disease can be. In 2004, she was voted Texas NP of the Year. Two years later, she says, her supervising physician was more or less intimidated by the medical board into terminating their collaborative agreement. Finding another supervising physician proved so difficult that she accepted an offer from an ILADS doctor to work with him, requiring her to relocate her practice to San Francisco. The changes impacted every area of her life—and yet, she persists in caring for Lyme disease patients according to the ILADS guidelines.

Why? “Somebody’s got to take care of these people,” she says. “Every time I have a patient saying ‘I cannot even tell you how grateful I am to you for listening to me when no one else would, and for treating me when nobody else would, and for letting me live again,’ I just go, ‘Gosh, I have to do this. I have to.’”

Whether other clinicians will feel they have to treat Lyme disease using one of the competing regimens is for them alone to decide.

Who knew a little tick could cause so much trouble? When Lyme disease was first described in 1977, did anyone suspect that three decades later, a battle would be raging between two professional organizations about how to treat it? Today, the “war” between the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS) leaves clinicians wondering whose guidelines they should follow.

Is it a case of David versus Goliath—the “upstart” ILADS challenging the established IDSA—or evidence-based medicine versus questionable practice? The more you listen to the parties involved, the more difficult it can be to determine the answer.

Chronic Problem
The crux of the Lyme disease treatment debate is whether the condition exists in a chronic form. ILADS practitioners insist that it does; how else to explain the lingering symptoms many patients experience, which they say resolve only with long-term, high-dose antibiotic therapy? IDSA, however, takes the viewpoint that these patients—whose symptoms of fatigue, cognitive dysfunction, and musculoskeletal pain are subjective and vague (belonging on the symptom list for chronic fatigue syndrome and fibromyalgia as well)—never had Lyme disease in the first place, and this is why standard therapy for the condition appears not to work for them.

“It’s true that those kinds of symptoms can occur in Lyme disease,” says Gary P. Wormser, MD, Chief of the Division of Infectious Diseases at New York Medical College in Valhalla, and lead author of IDSA’s guidelines. “But where the disconnect occurs is when people want to ascribe everybody with those symptoms as having Lyme disease, when they have no bona fide evidence [ie, validated laboratory results] of the disease.”

ILADS clinicians counter that the IDSA underestimates Borrelia burgdorferi (Bb), the spirochete that causes Lyme disease. “What we’re dealing with is way more sophisticated bacteria than any other bacteria we know,” says Ginger R. Savely, RN, FNP-C, a Lyme disease specialist at Union Square Medical Associates in San Francisco. “The more you really study the bacteria and how it works, the more you become incredibly impressed by how many mechanisms this bacteria has for survival and how difficult it is to get rid of it.”

Furthermore, Lyme disease specialists contend that the currently available diagnostic tools, the ELISA and the Western blot test, do not have sufficient sensitivity to reliably detect the presence of Bb (see Savely GR. Update on Lyme disease. Clinician Reviews. 2006;16[4]:44-51). This, they say, is why it can be difficult to validate the diagnosis.

Bottom line: If you can’t agree on what you’re treating, you certainly won’t agree on how to treat it.

Prolonged Antibiotic Therapy
IDSA’s guidelines on the treatment of Lyme disease recommend, in general, 14-day courses of oral antibiotics, with the option of a longer course (28 days) or retreatment where deemed appropriate. “We don’t treat bacterial infections with prolonged antibiotics,” Wormser points out, citing as examples cystitis, strep throat, and sinusitis. “So when you see 14 days recommended, that’s a long course relative to many bacterial infections.”

At issue in the Lyme “war” is the fact that ILADS, in the words of President Daniel Cameron, MD, MPH, “likes to offer options to patients who find themselves still sick after 30 days of treatment”—specifically, long-term (sometimes indefinite) high-dose antibiotic therapy.

Wormser is quick to point out that “our guidelines don’t really discuss how any individual patient is to be treated. They just tell you a general approach that we think is scientifically based and makes sense, based on all other infectious diseases.” In the IDSA’s estimation, the research does not support the efficacy of long-term antibiotic therapy for Lyme disease—and in the absence of that support, the risks involved are just too great.

Those risks include the growing problem of antibiotic-resistant bacteria, the possibility of coinfection with an organism such as Clostridium difficile, and the potential for sepsis and other complications associated with prolonged IV therapy. “Would you really dialyze somebody who didn’t need dialysis?” Wormser asks. “That’s an extreme example. But we say to ourselves every time we use them, ‘Do we really need antibiotics here, and what’s the shortest period of time we can give them, not the longest?’”

“The IDSA loves to say that what we’re doing is harmful or dangerous,” says Savely, who has treated more than 1,000 patients according to the ILADS recommendations. “The data have not shown that to be true. We have not had problems or complications—certainly not mortality—from the kind of treatment that we do.”

Furthermore, ILADS clinicians say they restore hope to patients whom “mainstream” medicine has failed. “People were coming to me with just terrible, terrible conditions, where they had been to so many specialists and every one had told them, ‘There’s no hope. We can’t do anything for you,’” Savely says. “And then I’d start treating them with high-dose long-term antibiotics, and they would get their lives back.”

Wormser understands that many patients feel let down by practitioners who can’t provide definitive answers about their condition. “And I know people will turn to whoever says they think they can help—I can’t blame them for that,” he says. Nonetheless, “it is remarkable the difference that patients with real Lyme have, in terms of their experience with antibiotics, compared to people who probably don’t have Lyme but feel they do.”

Risky Business?
So, how should clinicians handle patient inquiries about Lyme disease treatment? ILADS President Cameron believes that all options should be presented. “The patient should be involved in the decision, rather than just offered only one answer,” he says, although he respects every clinician’s right to say, “There are other options, but I choose this one.”

Clinician Reviews Editorial Board member Julia Pallentino, MSN, JD, ARNP, sees patients in her gastroenterology practice in Tallahassee, Florida, who are being treated by other clinicians with long-term antibiotic therapy for Lyme disease. “I respect their right to seek care from where they wish to seek it, and if they feel it has been helpful, I support that,” she says. Even so, if she were the one treating them for Lyme disease, “I certainly would not take on a different way of treatment because they want it. I would say, ‘I understand that you think this will help you, and I certainly respect your opinion. However, that’s not the method I use. If you want to use a different method, then I would recommend you find a practitioner who does that.’”

Of course, in this day and age, the specter of malpractice hangs over everyone. “As an attorney, I can tell you I’d much rather my client had been using IDSA guidelines than ILADS,” Pallentino says. “If you treat a patient according to CDC guidelines [which are the IDSA guidelines, in this case], then it would be very difficult to say that you weren’t doing what was accepted, appropriate treatment.”

Savely understands all too well how risky treating Lyme disease can be. In 2004, she was voted Texas NP of the Year. Two years later, she says, her supervising physician was more or less intimidated by the medical board into terminating their collaborative agreement. Finding another supervising physician proved so difficult that she accepted an offer from an ILADS doctor to work with him, requiring her to relocate her practice to San Francisco. The changes impacted every area of her life—and yet, she persists in caring for Lyme disease patients according to the ILADS guidelines.

Why? “Somebody’s got to take care of these people,” she says. “Every time I have a patient saying ‘I cannot even tell you how grateful I am to you for listening to me when no one else would, and for treating me when nobody else would, and for letting me live again,’ I just go, ‘Gosh, I have to do this. I have to.’”

Whether other clinicians will feel they have to treat Lyme disease using one of the competing regimens is for them alone to decide.

Who knew a little tick could cause so much trouble? When Lyme disease was first described in 1977, did anyone suspect that three decades later, a battle would be raging between two professional organizations about how to treat it? Today, the “war” between the Infectious Diseases Society of America (IDSA) and the International Lyme and Associated Diseases Society (ILADS) leaves clinicians wondering whose guidelines they should follow.

Is it a case of David versus Goliath—the “upstart” ILADS challenging the established IDSA—or evidence-based medicine versus questionable practice? The more you listen to the parties involved, the more difficult it can be to determine the answer.

Chronic Problem
The crux of the Lyme disease treatment debate is whether the condition exists in a chronic form. ILADS practitioners insist that it does; how else to explain the lingering symptoms many patients experience, which they say resolve only with long-term, high-dose antibiotic therapy? IDSA, however, takes the viewpoint that these patients—whose symptoms of fatigue, cognitive dysfunction, and musculoskeletal pain are subjective and vague (belonging on the symptom list for chronic fatigue syndrome and fibromyalgia as well)—never had Lyme disease in the first place, and this is why standard therapy for the condition appears not to work for them.

“It’s true that those kinds of symptoms can occur in Lyme disease,” says Gary P. Wormser, MD, Chief of the Division of Infectious Diseases at New York Medical College in Valhalla, and lead author of IDSA’s guidelines. “But where the disconnect occurs is when people want to ascribe everybody with those symptoms as having Lyme disease, when they have no bona fide evidence [ie, validated laboratory results] of the disease.”

ILADS clinicians counter that the IDSA underestimates Borrelia burgdorferi (Bb), the spirochete that causes Lyme disease. “What we’re dealing with is way more sophisticated bacteria than any other bacteria we know,” says Ginger R. Savely, RN, FNP-C, a Lyme disease specialist at Union Square Medical Associates in San Francisco. “The more you really study the bacteria and how it works, the more you become incredibly impressed by how many mechanisms this bacteria has for survival and how difficult it is to get rid of it.”

Furthermore, Lyme disease specialists contend that the currently available diagnostic tools, the ELISA and the Western blot test, do not have sufficient sensitivity to reliably detect the presence of Bb (see Savely GR. Update on Lyme disease. Clinician Reviews. 2006;16[4]:44-51). This, they say, is why it can be difficult to validate the diagnosis.

Bottom line: If you can’t agree on what you’re treating, you certainly won’t agree on how to treat it.

Prolonged Antibiotic Therapy
IDSA’s guidelines on the treatment of Lyme disease recommend, in general, 14-day courses of oral antibiotics, with the option of a longer course (28 days) or retreatment where deemed appropriate. “We don’t treat bacterial infections with prolonged antibiotics,” Wormser points out, citing as examples cystitis, strep throat, and sinusitis. “So when you see 14 days recommended, that’s a long course relative to many bacterial infections.”

At issue in the Lyme “war” is the fact that ILADS, in the words of President Daniel Cameron, MD, MPH, “likes to offer options to patients who find themselves still sick after 30 days of treatment”—specifically, long-term (sometimes indefinite) high-dose antibiotic therapy.

Wormser is quick to point out that “our guidelines don’t really discuss how any individual patient is to be treated. They just tell you a general approach that we think is scientifically based and makes sense, based on all other infectious diseases.” In the IDSA’s estimation, the research does not support the efficacy of long-term antibiotic therapy for Lyme disease—and in the absence of that support, the risks involved are just too great.

Those risks include the growing problem of antibiotic-resistant bacteria, the possibility of coinfection with an organism such as Clostridium difficile, and the potential for sepsis and other complications associated with prolonged IV therapy. “Would you really dialyze somebody who didn’t need dialysis?” Wormser asks. “That’s an extreme example. But we say to ourselves every time we use them, ‘Do we really need antibiotics here, and what’s the shortest period of time we can give them, not the longest?’”

“The IDSA loves to say that what we’re doing is harmful or dangerous,” says Savely, who has treated more than 1,000 patients according to the ILADS recommendations. “The data have not shown that to be true. We have not had problems or complications—certainly not mortality—from the kind of treatment that we do.”

Furthermore, ILADS clinicians say they restore hope to patients whom “mainstream” medicine has failed. “People were coming to me with just terrible, terrible conditions, where they had been to so many specialists and every one had told them, ‘There’s no hope. We can’t do anything for you,’” Savely says. “And then I’d start treating them with high-dose long-term antibiotics, and they would get their lives back.”

Wormser understands that many patients feel let down by practitioners who can’t provide definitive answers about their condition. “And I know people will turn to whoever says they think they can help—I can’t blame them for that,” he says. Nonetheless, “it is remarkable the difference that patients with real Lyme have, in terms of their experience with antibiotics, compared to people who probably don’t have Lyme but feel they do.”

Risky Business?
So, how should clinicians handle patient inquiries about Lyme disease treatment? ILADS President Cameron believes that all options should be presented. “The patient should be involved in the decision, rather than just offered only one answer,” he says, although he respects every clinician’s right to say, “There are other options, but I choose this one.”

Clinician Reviews Editorial Board member Julia Pallentino, MSN, JD, ARNP, sees patients in her gastroenterology practice in Tallahassee, Florida, who are being treated by other clinicians with long-term antibiotic therapy for Lyme disease. “I respect their right to seek care from where they wish to seek it, and if they feel it has been helpful, I support that,” she says. Even so, if she were the one treating them for Lyme disease, “I certainly would not take on a different way of treatment because they want it. I would say, ‘I understand that you think this will help you, and I certainly respect your opinion. However, that’s not the method I use. If you want to use a different method, then I would recommend you find a practitioner who does that.’”

Of course, in this day and age, the specter of malpractice hangs over everyone. “As an attorney, I can tell you I’d much rather my client had been using IDSA guidelines than ILADS,” Pallentino says. “If you treat a patient according to CDC guidelines [which are the IDSA guidelines, in this case], then it would be very difficult to say that you weren’t doing what was accepted, appropriate treatment.”

Savely understands all too well how risky treating Lyme disease can be. In 2004, she was voted Texas NP of the Year. Two years later, she says, her supervising physician was more or less intimidated by the medical board into terminating their collaborative agreement. Finding another supervising physician proved so difficult that she accepted an offer from an ILADS doctor to work with him, requiring her to relocate her practice to San Francisco. The changes impacted every area of her life—and yet, she persists in caring for Lyme disease patients according to the ILADS guidelines.

Why? “Somebody’s got to take care of these people,” she says. “Every time I have a patient saying ‘I cannot even tell you how grateful I am to you for listening to me when no one else would, and for treating me when nobody else would, and for letting me live again,’ I just go, ‘Gosh, I have to do this. I have to.’”

Whether other clinicians will feel they have to treat Lyme disease using one of the competing regimens is for them alone to decide.

It’s no secret that America is facing a shortage of physicians—or that the supply is expected to dwindle by another 85,000 to 200,000 by 2015. Nor is it a surprise that “physicians are leaving primary care in droves,” in the words of Mary O’Neil Mundinger, DrPH, RN, Centennial Professor in Health Policy and Dean of the Columbia University School of Nursing in New York City. Couple these factors with a growing patient population with special, long-term needs, and you have the potential for a crisis.

Who is going to provide care not only to the increasing elderly population in the United States but also to the patients—from neonates to young adults—who are living with chronic conditions that would have prematurely killed their parents or grandparents? And how can NPs and PAs be better equipped to fill the gaps in the health care system?

Proponents say the clinical doctorate—or, more accurately, the level of training commensurate with a doctorate—is the answer.

A Doctorate by Any Other Name
Mention “clinical doctorate” to PAs or NPs, and there’s a good chance you’ll ignite a debate. For PAs, the furor kicked into high gear in December, when the first group of Doctor of Science Physician Assistant recipients graduated from the US Army/Baylor University postgraduate program. Suddenly, online forums were abuzz with speculation about whether such a program could or should be introduced into the civilian world.

“The only thing that’s got people hung up is the doctorate degree,” says MAJ Leonard Q. Gruppo Jr, MPAS, PA-C, Director of the Emergency Medicine Fellowship Program at Brooke Army Medical Center, Fort Sam Houston, Texas. He adds that the degree designation “was almost an afterthought. The training was the most important thing.”

The Army, faced with the same physician shortage as the rest of the country—perhaps more so because the nation is at war—decided to introduce residency training for PAs in a number of specialty areas, such as emergency medicine, orthopedics, and surgery. “That residency training is going to be very closely based upon the training that physicians do, to the extent that it’s reasonable,” Gruppo says. “For instance, a PA doing orthopedic residency is not going to learn how to do orthopedic surgery. But he’ll learn how to do all the nonoperative management—the pre-op, post-op, first assist, the clinic, the ER call. So he can free up our shrinking number of surgeons so they can do more surgery.”

More intensive training will be necessary, advocates say, if NPs and PAs are going to alleviate some of the health care problems the country currently faces. For one thing, right now, 26% of the physicians working in the US are foreign medical graduates.

“Now, many of them are excellent physicians, and I’m very glad that they came here to be doctors in America,” Gruppo says. “But it indicates that there’s a problem with the management of our entry-level medical schools, that we need to import 26% of our physicians. We also need to have NPs and PAs filling a significant role in the workforce—again, but there aren’t enough doctors.”

This is why, Gruppo says, “we need PAs who are significantly more clinically capable to step up to the plate and fill that gap. Not to become physicians, but to become better physician extenders.”

Nursing/Medicine Hybrid
Mundinger also sees a widening gap between patients in need of care and practitioners to provide it. “The category of patients who need specialists is growing so much faster than our medical education system can provide physicians to care for them,” she says. “We need to address the physician shortage at the same time we need to address that whole category of medical providers that used to be called ‘primary care.’”

That’s one reason behind the decision for the Doctor of Nursing Practice (DNP) to become the standard in the preparation of advanced practice nurses, a goal that the American Association of Colleges of Nursing would like to see accomplished by 2015.

Nurses who earn a DNP can be seen as “a hybrid,” Mundinger says, of nursing and medicine. Combined with the traditional nursing model of care, which includes evaluating patients’ resources and teaching them to provide self-care, the clinical decision-making skills taught in the medical model of education would enhance NPs’ role in patient care.

Doctoral programs will provide “critical skills that go well beyond adequate care on an appointment basis in the office,” Mundinger says. In addition to more differential diagnosis and pathophysiology, these skills include handling hospital admissions and discharges, conducting emergency department evaluations, and taking call—things that master’s-trained NPs may be capable of learning ad hoc. “But what we’ve done is standardized and formalized what that training ought to look like,” she explains, “so that every nurse who gets a clinical doctorate will have that skill set and won’t depend on somebody helping them learn it in a certain site over time.”

These competencies “need to be learned and practiced if nurses are going to be recognized and paid on a par with physicians as primary care providers,” Mundinger says. As evidence, she notes that of the 400 NPs working at Columbia’s medical center, only the 50 DNPs are included in contracts with commercial insurers.

“So we can independently bill any commercial insurer with which Columbia physicians have a contract—there are 12—and we get the same reimbursement. It’s clear to me that if you catch [the insurers’] eye and show them that you have the training comparable to physicians to do this work, they’re going to pay you the same amount of money.”

Motivation Is Everything
That, unfortunately, is the point at which the clinical doctorate debate diverges. Despite the desire to fill a similar need within the country, the political issues surrounding doctoral training are distinct for PAs and NPs.

“There’s a deeper issue here, and it’s not even related to degrees,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C. “And that is the autonomy of nurse practitioners versus the requirement of PAs to be linked with physicians and the whole issue of third-party reimbursement and the whole issue of liability. Having a doctorate doesn’t make that go away for PAs.”

This does not mean that Danielsen doesn’t see value in postgraduate education for PAs. “More than 50% of PAs in this country are in specialty practice,” he notes, “and many of them would like to have additional training, because the PA programs, with the amount of education that’s required now, are just scratching the surface.”

But, he adds, education and improved patient care should be the motivation for advanced training. “I sort of wonder what the underlying reason for this [would be]. If it’s getting the doctorate so that you can have ‘doctor’ before your name, that just seems ludicrous to me,” he says. “I think the whole idea of why the PA did it is going to be important in the relationship between the doctor and the PA.”

Gruppo has also noticed the politicizing of the debate. “We get caught up in this doctorate degree,” he says. “Look, every other allied health profession in the country trains to the doctorate level—every single one, except PAs. Until now. And the world still rotates on its axis, the sun still rises and sets, and dogs and cats are not sleeping with each other. And you know what? It’s going to be the same way for PAs.”

Danielsen acknowledges an external pressure for PAs to stay on par with other allied health professions. At A. T. Still University in Mesa, where he is Dean of the Arizona School of Health Sciences, physical therapists and audiologists train to the doctorate level, occupational therapists are moving in that direction, and even athletic trainers are considering the idea.

But, as he points out, “The elephant in the room here is that there are some PAs who want to bridge that gap, bring that gap closer, between what a PA is and what a physician is. There may be some PAs out there who say we need to have more autonomy, we need to distance ourselves from the supervising physician, much like the nurse practitioners are doing.”

Perhaps, Danielsen says, “We ought to find a pathway between PA and physician—a way to have medical schools recognize the training and clinical experience of PAs and provide them a pathway into year 3 of medical school.” He adds that NPs who want to become physicians would also benefit from such a program.

Gruppo adamantly believes that PAs can handle having a doctorate without impinging on the traditional physician-PA relationship. But he encourages leaders from the American Medical Association, the American Academy of Physician Assistants, and various specialty organizations to examine what the Army is doing with its postgraduate program. “See if maybe it’s something that could be transferable in some fashion to the civilian side,” he says. “And maybe the answer will be, ‘No, it’s a bad idea—but we’ve got this other idea that’s even better.’ Well, great! But we’d better do something. To do nothing is irresponsible and does a disservice to patients in this country.”

As the discussion continues, Danielsen too hopes the focus will remain where it belongs. “Sometimes we lose sight of the bottom line, which is patient care,” he says. “If we lose sight of that, what does it matter?”

It’s no secret that America is facing a shortage of physicians—or that the supply is expected to dwindle by another 85,000 to 200,000 by 2015. Nor is it a surprise that “physicians are leaving primary care in droves,” in the words of Mary O’Neil Mundinger, DrPH, RN, Centennial Professor in Health Policy and Dean of the Columbia University School of Nursing in New York City. Couple these factors with a growing patient population with special, long-term needs, and you have the potential for a crisis.

Who is going to provide care not only to the increasing elderly population in the United States but also to the patients—from neonates to young adults—who are living with chronic conditions that would have prematurely killed their parents or grandparents? And how can NPs and PAs be better equipped to fill the gaps in the health care system?

Proponents say the clinical doctorate—or, more accurately, the level of training commensurate with a doctorate—is the answer.

A Doctorate by Any Other Name
Mention “clinical doctorate” to PAs or NPs, and there’s a good chance you’ll ignite a debate. For PAs, the furor kicked into high gear in December, when the first group of Doctor of Science Physician Assistant recipients graduated from the US Army/Baylor University postgraduate program. Suddenly, online forums were abuzz with speculation about whether such a program could or should be introduced into the civilian world.

“The only thing that’s got people hung up is the doctorate degree,” says MAJ Leonard Q. Gruppo Jr, MPAS, PA-C, Director of the Emergency Medicine Fellowship Program at Brooke Army Medical Center, Fort Sam Houston, Texas. He adds that the degree designation “was almost an afterthought. The training was the most important thing.”

The Army, faced with the same physician shortage as the rest of the country—perhaps more so because the nation is at war—decided to introduce residency training for PAs in a number of specialty areas, such as emergency medicine, orthopedics, and surgery. “That residency training is going to be very closely based upon the training that physicians do, to the extent that it’s reasonable,” Gruppo says. “For instance, a PA doing orthopedic residency is not going to learn how to do orthopedic surgery. But he’ll learn how to do all the nonoperative management—the pre-op, post-op, first assist, the clinic, the ER call. So he can free up our shrinking number of surgeons so they can do more surgery.”

More intensive training will be necessary, advocates say, if NPs and PAs are going to alleviate some of the health care problems the country currently faces. For one thing, right now, 26% of the physicians working in the US are foreign medical graduates.

“Now, many of them are excellent physicians, and I’m very glad that they came here to be doctors in America,” Gruppo says. “But it indicates that there’s a problem with the management of our entry-level medical schools, that we need to import 26% of our physicians. We also need to have NPs and PAs filling a significant role in the workforce—again, but there aren’t enough doctors.”

This is why, Gruppo says, “we need PAs who are significantly more clinically capable to step up to the plate and fill that gap. Not to become physicians, but to become better physician extenders.”

Nursing/Medicine Hybrid
Mundinger also sees a widening gap between patients in need of care and practitioners to provide it. “The category of patients who need specialists is growing so much faster than our medical education system can provide physicians to care for them,” she says. “We need to address the physician shortage at the same time we need to address that whole category of medical providers that used to be called ‘primary care.’”

That’s one reason behind the decision for the Doctor of Nursing Practice (DNP) to become the standard in the preparation of advanced practice nurses, a goal that the American Association of Colleges of Nursing would like to see accomplished by 2015.

Nurses who earn a DNP can be seen as “a hybrid,” Mundinger says, of nursing and medicine. Combined with the traditional nursing model of care, which includes evaluating patients’ resources and teaching them to provide self-care, the clinical decision-making skills taught in the medical model of education would enhance NPs’ role in patient care.

Doctoral programs will provide “critical skills that go well beyond adequate care on an appointment basis in the office,” Mundinger says. In addition to more differential diagnosis and pathophysiology, these skills include handling hospital admissions and discharges, conducting emergency department evaluations, and taking call—things that master’s-trained NPs may be capable of learning ad hoc. “But what we’ve done is standardized and formalized what that training ought to look like,” she explains, “so that every nurse who gets a clinical doctorate will have that skill set and won’t depend on somebody helping them learn it in a certain site over time.”

These competencies “need to be learned and practiced if nurses are going to be recognized and paid on a par with physicians as primary care providers,” Mundinger says. As evidence, she notes that of the 400 NPs working at Columbia’s medical center, only the 50 DNPs are included in contracts with commercial insurers.

“So we can independently bill any commercial insurer with which Columbia physicians have a contract—there are 12—and we get the same reimbursement. It’s clear to me that if you catch [the insurers’] eye and show them that you have the training comparable to physicians to do this work, they’re going to pay you the same amount of money.”

Motivation Is Everything
That, unfortunately, is the point at which the clinical doctorate debate diverges. Despite the desire to fill a similar need within the country, the political issues surrounding doctoral training are distinct for PAs and NPs.

“There’s a deeper issue here, and it’s not even related to degrees,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C. “And that is the autonomy of nurse practitioners versus the requirement of PAs to be linked with physicians and the whole issue of third-party reimbursement and the whole issue of liability. Having a doctorate doesn’t make that go away for PAs.”

This does not mean that Danielsen doesn’t see value in postgraduate education for PAs. “More than 50% of PAs in this country are in specialty practice,” he notes, “and many of them would like to have additional training, because the PA programs, with the amount of education that’s required now, are just scratching the surface.”

But, he adds, education and improved patient care should be the motivation for advanced training. “I sort of wonder what the underlying reason for this [would be]. If it’s getting the doctorate so that you can have ‘doctor’ before your name, that just seems ludicrous to me,” he says. “I think the whole idea of why the PA did it is going to be important in the relationship between the doctor and the PA.”

Gruppo has also noticed the politicizing of the debate. “We get caught up in this doctorate degree,” he says. “Look, every other allied health profession in the country trains to the doctorate level—every single one, except PAs. Until now. And the world still rotates on its axis, the sun still rises and sets, and dogs and cats are not sleeping with each other. And you know what? It’s going to be the same way for PAs.”

Danielsen acknowledges an external pressure for PAs to stay on par with other allied health professions. At A. T. Still University in Mesa, where he is Dean of the Arizona School of Health Sciences, physical therapists and audiologists train to the doctorate level, occupational therapists are moving in that direction, and even athletic trainers are considering the idea.

But, as he points out, “The elephant in the room here is that there are some PAs who want to bridge that gap, bring that gap closer, between what a PA is and what a physician is. There may be some PAs out there who say we need to have more autonomy, we need to distance ourselves from the supervising physician, much like the nurse practitioners are doing.”

Perhaps, Danielsen says, “We ought to find a pathway between PA and physician—a way to have medical schools recognize the training and clinical experience of PAs and provide them a pathway into year 3 of medical school.” He adds that NPs who want to become physicians would also benefit from such a program.

Gruppo adamantly believes that PAs can handle having a doctorate without impinging on the traditional physician-PA relationship. But he encourages leaders from the American Medical Association, the American Academy of Physician Assistants, and various specialty organizations to examine what the Army is doing with its postgraduate program. “See if maybe it’s something that could be transferable in some fashion to the civilian side,” he says. “And maybe the answer will be, ‘No, it’s a bad idea—but we’ve got this other idea that’s even better.’ Well, great! But we’d better do something. To do nothing is irresponsible and does a disservice to patients in this country.”

As the discussion continues, Danielsen too hopes the focus will remain where it belongs. “Sometimes we lose sight of the bottom line, which is patient care,” he says. “If we lose sight of that, what does it matter?”

It’s no secret that America is facing a shortage of physicians—or that the supply is expected to dwindle by another 85,000 to 200,000 by 2015. Nor is it a surprise that “physicians are leaving primary care in droves,” in the words of Mary O’Neil Mundinger, DrPH, RN, Centennial Professor in Health Policy and Dean of the Columbia University School of Nursing in New York City. Couple these factors with a growing patient population with special, long-term needs, and you have the potential for a crisis.

Who is going to provide care not only to the increasing elderly population in the United States but also to the patients—from neonates to young adults—who are living with chronic conditions that would have prematurely killed their parents or grandparents? And how can NPs and PAs be better equipped to fill the gaps in the health care system?

Proponents say the clinical doctorate—or, more accurately, the level of training commensurate with a doctorate—is the answer.

A Doctorate by Any Other Name
Mention “clinical doctorate” to PAs or NPs, and there’s a good chance you’ll ignite a debate. For PAs, the furor kicked into high gear in December, when the first group of Doctor of Science Physician Assistant recipients graduated from the US Army/Baylor University postgraduate program. Suddenly, online forums were abuzz with speculation about whether such a program could or should be introduced into the civilian world.

“The only thing that’s got people hung up is the doctorate degree,” says MAJ Leonard Q. Gruppo Jr, MPAS, PA-C, Director of the Emergency Medicine Fellowship Program at Brooke Army Medical Center, Fort Sam Houston, Texas. He adds that the degree designation “was almost an afterthought. The training was the most important thing.”

The Army, faced with the same physician shortage as the rest of the country—perhaps more so because the nation is at war—decided to introduce residency training for PAs in a number of specialty areas, such as emergency medicine, orthopedics, and surgery. “That residency training is going to be very closely based upon the training that physicians do, to the extent that it’s reasonable,” Gruppo says. “For instance, a PA doing orthopedic residency is not going to learn how to do orthopedic surgery. But he’ll learn how to do all the nonoperative management—the pre-op, post-op, first assist, the clinic, the ER call. So he can free up our shrinking number of surgeons so they can do more surgery.”

More intensive training will be necessary, advocates say, if NPs and PAs are going to alleviate some of the health care problems the country currently faces. For one thing, right now, 26% of the physicians working in the US are foreign medical graduates.

“Now, many of them are excellent physicians, and I’m very glad that they came here to be doctors in America,” Gruppo says. “But it indicates that there’s a problem with the management of our entry-level medical schools, that we need to import 26% of our physicians. We also need to have NPs and PAs filling a significant role in the workforce—again, but there aren’t enough doctors.”

This is why, Gruppo says, “we need PAs who are significantly more clinically capable to step up to the plate and fill that gap. Not to become physicians, but to become better physician extenders.”

Nursing/Medicine Hybrid
Mundinger also sees a widening gap between patients in need of care and practitioners to provide it. “The category of patients who need specialists is growing so much faster than our medical education system can provide physicians to care for them,” she says. “We need to address the physician shortage at the same time we need to address that whole category of medical providers that used to be called ‘primary care.’”

That’s one reason behind the decision for the Doctor of Nursing Practice (DNP) to become the standard in the preparation of advanced practice nurses, a goal that the American Association of Colleges of Nursing would like to see accomplished by 2015.

Nurses who earn a DNP can be seen as “a hybrid,” Mundinger says, of nursing and medicine. Combined with the traditional nursing model of care, which includes evaluating patients’ resources and teaching them to provide self-care, the clinical decision-making skills taught in the medical model of education would enhance NPs’ role in patient care.

Doctoral programs will provide “critical skills that go well beyond adequate care on an appointment basis in the office,” Mundinger says. In addition to more differential diagnosis and pathophysiology, these skills include handling hospital admissions and discharges, conducting emergency department evaluations, and taking call—things that master’s-trained NPs may be capable of learning ad hoc. “But what we’ve done is standardized and formalized what that training ought to look like,” she explains, “so that every nurse who gets a clinical doctorate will have that skill set and won’t depend on somebody helping them learn it in a certain site over time.”

These competencies “need to be learned and practiced if nurses are going to be recognized and paid on a par with physicians as primary care providers,” Mundinger says. As evidence, she notes that of the 400 NPs working at Columbia’s medical center, only the 50 DNPs are included in contracts with commercial insurers.

“So we can independently bill any commercial insurer with which Columbia physicians have a contract—there are 12—and we get the same reimbursement. It’s clear to me that if you catch [the insurers’] eye and show them that you have the training comparable to physicians to do this work, they’re going to pay you the same amount of money.”

Motivation Is Everything
That, unfortunately, is the point at which the clinical doctorate debate diverges. Despite the desire to fill a similar need within the country, the political issues surrounding doctoral training are distinct for PAs and NPs.

“There’s a deeper issue here, and it’s not even related to degrees,” says Clinician Reviews PA Editor-in-Chief Randy D. Danielsen, PhD, PA-C. “And that is the autonomy of nurse practitioners versus the requirement of PAs to be linked with physicians and the whole issue of third-party reimbursement and the whole issue of liability. Having a doctorate doesn’t make that go away for PAs.”

This does not mean that Danielsen doesn’t see value in postgraduate education for PAs. “More than 50% of PAs in this country are in specialty practice,” he notes, “and many of them would like to have additional training, because the PA programs, with the amount of education that’s required now, are just scratching the surface.”

But, he adds, education and improved patient care should be the motivation for advanced training. “I sort of wonder what the underlying reason for this [would be]. If it’s getting the doctorate so that you can have ‘doctor’ before your name, that just seems ludicrous to me,” he says. “I think the whole idea of why the PA did it is going to be important in the relationship between the doctor and the PA.”

Gruppo has also noticed the politicizing of the debate. “We get caught up in this doctorate degree,” he says. “Look, every other allied health profession in the country trains to the doctorate level—every single one, except PAs. Until now. And the world still rotates on its axis, the sun still rises and sets, and dogs and cats are not sleeping with each other. And you know what? It’s going to be the same way for PAs.”

Danielsen acknowledges an external pressure for PAs to stay on par with other allied health professions. At A. T. Still University in Mesa, where he is Dean of the Arizona School of Health Sciences, physical therapists and audiologists train to the doctorate level, occupational therapists are moving in that direction, and even athletic trainers are considering the idea.

But, as he points out, “The elephant in the room here is that there are some PAs who want to bridge that gap, bring that gap closer, between what a PA is and what a physician is. There may be some PAs out there who say we need to have more autonomy, we need to distance ourselves from the supervising physician, much like the nurse practitioners are doing.”

Perhaps, Danielsen says, “We ought to find a pathway between PA and physician—a way to have medical schools recognize the training and clinical experience of PAs and provide them a pathway into year 3 of medical school.” He adds that NPs who want to become physicians would also benefit from such a program.

Gruppo adamantly believes that PAs can handle having a doctorate without impinging on the traditional physician-PA relationship. But he encourages leaders from the American Medical Association, the American Academy of Physician Assistants, and various specialty organizations to examine what the Army is doing with its postgraduate program. “See if maybe it’s something that could be transferable in some fashion to the civilian side,” he says. “And maybe the answer will be, ‘No, it’s a bad idea—but we’ve got this other idea that’s even better.’ Well, great! But we’d better do something. To do nothing is irresponsible and does a disservice to patients in this country.”

As the discussion continues, Danielsen too hopes the focus will remain where it belongs. “Sometimes we lose sight of the bottom line, which is patient care,” he says. “If we lose sight of that, what does it matter?”

Researchers have discovered a new genetic cause of autism—a finding that provides additional knowledge about a complex condition but also highlights how far the scientific community is from fully explaining the disorder. The chromosome 16 abnormality identified by Weiss and colleagues and reported in the New England Journal of Medicine appears to account for about 1% of autism cases.

“This is going to help a small percentage of parents, and it’s going to frustrate the other 99%,” says Chantelle Wolpert, MBA, PA-C, CGC, Research Assistant, Department of Human Development and Family Studies, University of North Carolina (UNC) at Greensboro. “We’re in this area where none of these findings is going to be simple. We’re just not at the point where it’s one gene, one disease anymore.”

The “16p Form” of Autism
This particular finding eventually will enable clinicians to test children diagnosed as having autism spectrum disorder to determine whether their condition is caused by the chromosomal change. As with all genetic testing, the results will not provide definitive answers for every parent of a child with autism: The patient might not have the abnormality tested for, but that does not preclude the possibility that the child’s autism is caused by another, as-yet-unidentified, genetic change—or by something else entirely.

For parents whose children do receive a positive test result for “the 16p form of autism,” as it will likely be called in the literature, the greatest benefit may be an ounce of certainty about what is otherwise an uncertain and not-fully-understood disorder. Because autism spectrum disorder actually encompasses many different, behaviorally defined conditions, diagnosis is based on clinical judgment. The standardized method of evaluation enables clinicians to make the diagnosis, but until recently, Wolpert notes, “there wasn’t something black and white that a parent could grasp. Now there will be—at least for this 1% of people.”

Approximately 10% to 15% of children with autism have a condition that is identifiable; for example, clinicians can test for fragile X syndrome or the previously reported chromosome 15 anomaly associated with autism. Offering answers to another 1% of patients and parents “sounds small,” Wolpert observes. “Big deal, you can [provide results] in all specialties. But you can’t in autism, and that’s why” these findings are significant.

What Weiss and colleagues actually identified is a section at the top of chromosome 16 that is either duplicated or deleted in some autistic patients. The strength of the research lies in the fact that this chromosomal anomaly was found in patients from three distinct populations. There are many genes within that section of chromosome 16, so geneticists will have to map them to determine what those particular genes do or don’t do and how their multiplication or deletion can impact human development. Someday, these genes might provide a therapeutic target for patients with this type of autism—but such a day remains far in the future.

A Genetic Risk Factor
Meanwhile, an article and two reports recently published in the American Journal of Human Genetics describe a different type of genetic association with autism. In the study led by Alarcón, a variant on chromosome 7 was identified as a risk factor for autism. Chromosome 7 and the specific gene (contactin associated protein-like 2, or CNTNAP2) have been associated with language development. Now, based on these new findings, CNTNAP2 may be considered an autism susceptibility gene.

“This is a risk for autism,” Wolpert stresses. “It’s not enough to have this genetic variant. If you have a copy of this particular gene, it doesn’t mean you’re going to develop autism.”

Reports by Arking et al and Bakkaloglu et al provide an additional line of evidence for CNTNAP2 as an autism susceptibility candidate. Furthermore, one of the reports also identified a genetic heritability component: Autistic children were significantly more likely to inherit the gene variation from their mothers than from their fathers.

“Again, we’re one step closer,” Wolpert says. But “there is no genetic testing for this right now”—whereas, for the 16p form of autism, “there will be genetic testing for that sooner rather than later.”

Still, clinicians should not expect a flurry of test ordering. Parents who have heard about these findings, and who have long wished for answers about their children’s condition, may approach the topic at an office visit (or even demand that their child be tested). Clinicians will have to explain to parents the likelihood of finding a definitive explanation.

“If they know that ahead of time, they’re usually fine,” says Wolpert, who spent 12 years at Duke University’s Center for Human Genetics before entering the PhD program at UNC–Greensboro. “It’s when you send off a genetic test and you don’t explain what it means” that parents can feel a deeper sense of frustration at receiving a negative test result. “They may leave the office thinking, ‘OK, it wasn’t this thing that the researchers discovered, so it’s not genetic!’” Or they might have their own personal theories about what caused their children’s autism, including blaming themselves in some way.

Recommendations will have to be developed so clinicians have a guideline of who should be tested for genetic causes of autism. With the average test costing $2,000 to $5,000, insurers may question the validity of testing for a chromosomal anomaly that occurs in a mere 1% of autistic persons.

Looking Beyond Thimerosal
One of the most persistent theories about autism is that it is caused, at least in some cases, by exposure to thimerosal, which was used as a preservative in many vaccines until about 10 years ago, when manufacturers started removing it from their products. Numerous studies have failed to identify such a link, but many parents remain unconvinced.

A study by Schechter and Grether in the Archives of General Psychiatry is among the most recent to dispel the autism-thimerosal link. The researchers discovered that rates of autism continued to rise in California even after thimerosal had been removed from vaccines. “[T]ime trends are inconsistent with the hypothesis that thimerosal exposure is a primary cause of autism in California,” the authors write. However, “we support the continued quest for the timely discovery of modifiable risk factors for autism and related conditions.”

Eric Fombonne, MD, from the Department of Psychiatry at Montreal Children’s Hospital, expressed frustration in his accompanying editorial: “How many more negative study results are required for the belief to go away, and how much more spending of public funds on this issue could even be justified?”

While remaining neutral about thimerosal, Wolpert acknowledges the “need [for] more research funding—for all aspects, not just genetics.”

Since pharmacologic therapy for autism, let alone a cure, is little more than a dream at this stage, it might be beneficial to explore ways to address the issues experienced by patients and parents living with autism. “How are we going to help the parents and patients who already have this [diagnosis]?” Wolpert asks. “What factors in a family or educational system help a child to achieve his or her highest level of ability?”

Identification of additional genetic factors will also open the doorway to exploring the role of environmental factors in autism. “If you can control for one variable in a study, then you can examine the others,” Wolpert points out.

Progress may be slow, but clinicians, parents, and patients have reason to hope. “The bad news is 85% to 90% of autism is still unexplained,” Wolpert says. “Then again, what great progress! Ten years ago, we knew autism had a genetic basis, but that’s all we knew. Now, we have causative genes and genes that increase risk. We’re making headway.” 

Researchers have discovered a new genetic cause of autism—a finding that provides additional knowledge about a complex condition but also highlights how far the scientific community is from fully explaining the disorder. The chromosome 16 abnormality identified by Weiss and colleagues and reported in the New England Journal of Medicine appears to account for about 1% of autism cases.

“This is going to help a small percentage of parents, and it’s going to frustrate the other 99%,” says Chantelle Wolpert, MBA, PA-C, CGC, Research Assistant, Department of Human Development and Family Studies, University of North Carolina (UNC) at Greensboro. “We’re in this area where none of these findings is going to be simple. We’re just not at the point where it’s one gene, one disease anymore.”

The “16p Form” of Autism
This particular finding eventually will enable clinicians to test children diagnosed as having autism spectrum disorder to determine whether their condition is caused by the chromosomal change. As with all genetic testing, the results will not provide definitive answers for every parent of a child with autism: The patient might not have the abnormality tested for, but that does not preclude the possibility that the child’s autism is caused by another, as-yet-unidentified, genetic change—or by something else entirely.

For parents whose children do receive a positive test result for “the 16p form of autism,” as it will likely be called in the literature, the greatest benefit may be an ounce of certainty about what is otherwise an uncertain and not-fully-understood disorder. Because autism spectrum disorder actually encompasses many different, behaviorally defined conditions, diagnosis is based on clinical judgment. The standardized method of evaluation enables clinicians to make the diagnosis, but until recently, Wolpert notes, “there wasn’t something black and white that a parent could grasp. Now there will be—at least for this 1% of people.”

Approximately 10% to 15% of children with autism have a condition that is identifiable; for example, clinicians can test for fragile X syndrome or the previously reported chromosome 15 anomaly associated with autism. Offering answers to another 1% of patients and parents “sounds small,” Wolpert observes. “Big deal, you can [provide results] in all specialties. But you can’t in autism, and that’s why” these findings are significant.

What Weiss and colleagues actually identified is a section at the top of chromosome 16 that is either duplicated or deleted in some autistic patients. The strength of the research lies in the fact that this chromosomal anomaly was found in patients from three distinct populations. There are many genes within that section of chromosome 16, so geneticists will have to map them to determine what those particular genes do or don’t do and how their multiplication or deletion can impact human development. Someday, these genes might provide a therapeutic target for patients with this type of autism—but such a day remains far in the future.

A Genetic Risk Factor
Meanwhile, an article and two reports recently published in the American Journal of Human Genetics describe a different type of genetic association with autism. In the study led by Alarcón, a variant on chromosome 7 was identified as a risk factor for autism. Chromosome 7 and the specific gene (contactin associated protein-like 2, or CNTNAP2) have been associated with language development. Now, based on these new findings, CNTNAP2 may be considered an autism susceptibility gene.

“This is a risk for autism,” Wolpert stresses. “It’s not enough to have this genetic variant. If you have a copy of this particular gene, it doesn’t mean you’re going to develop autism.”

Reports by Arking et al and Bakkaloglu et al provide an additional line of evidence for CNTNAP2 as an autism susceptibility candidate. Furthermore, one of the reports also identified a genetic heritability component: Autistic children were significantly more likely to inherit the gene variation from their mothers than from their fathers.

“Again, we’re one step closer,” Wolpert says. But “there is no genetic testing for this right now”—whereas, for the 16p form of autism, “there will be genetic testing for that sooner rather than later.”

Still, clinicians should not expect a flurry of test ordering. Parents who have heard about these findings, and who have long wished for answers about their children’s condition, may approach the topic at an office visit (or even demand that their child be tested). Clinicians will have to explain to parents the likelihood of finding a definitive explanation.

“If they know that ahead of time, they’re usually fine,” says Wolpert, who spent 12 years at Duke University’s Center for Human Genetics before entering the PhD program at UNC–Greensboro. “It’s when you send off a genetic test and you don’t explain what it means” that parents can feel a deeper sense of frustration at receiving a negative test result. “They may leave the office thinking, ‘OK, it wasn’t this thing that the researchers discovered, so it’s not genetic!’” Or they might have their own personal theories about what caused their children’s autism, including blaming themselves in some way.

Recommendations will have to be developed so clinicians have a guideline of who should be tested for genetic causes of autism. With the average test costing $2,000 to $5,000, insurers may question the validity of testing for a chromosomal anomaly that occurs in a mere 1% of autistic persons.

Looking Beyond Thimerosal
One of the most persistent theories about autism is that it is caused, at least in some cases, by exposure to thimerosal, which was used as a preservative in many vaccines until about 10 years ago, when manufacturers started removing it from their products. Numerous studies have failed to identify such a link, but many parents remain unconvinced.

A study by Schechter and Grether in the Archives of General Psychiatry is among the most recent to dispel the autism-thimerosal link. The researchers discovered that rates of autism continued to rise in California even after thimerosal had been removed from vaccines. “[T]ime trends are inconsistent with the hypothesis that thimerosal exposure is a primary cause of autism in California,” the authors write. However, “we support the continued quest for the timely discovery of modifiable risk factors for autism and related conditions.”

Eric Fombonne, MD, from the Department of Psychiatry at Montreal Children’s Hospital, expressed frustration in his accompanying editorial: “How many more negative study results are required for the belief to go away, and how much more spending of public funds on this issue could even be justified?”

While remaining neutral about thimerosal, Wolpert acknowledges the “need [for] more research funding—for all aspects, not just genetics.”

Since pharmacologic therapy for autism, let alone a cure, is little more than a dream at this stage, it might be beneficial to explore ways to address the issues experienced by patients and parents living with autism. “How are we going to help the parents and patients who already have this [diagnosis]?” Wolpert asks. “What factors in a family or educational system help a child to achieve his or her highest level of ability?”

Identification of additional genetic factors will also open the doorway to exploring the role of environmental factors in autism. “If you can control for one variable in a study, then you can examine the others,” Wolpert points out.

Progress may be slow, but clinicians, parents, and patients have reason to hope. “The bad news is 85% to 90% of autism is still unexplained,” Wolpert says. “Then again, what great progress! Ten years ago, we knew autism had a genetic basis, but that’s all we knew. Now, we have causative genes and genes that increase risk. We’re making headway.” 

Researchers have discovered a new genetic cause of autism—a finding that provides additional knowledge about a complex condition but also highlights how far the scientific community is from fully explaining the disorder. The chromosome 16 abnormality identified by Weiss and colleagues and reported in the New England Journal of Medicine appears to account for about 1% of autism cases.

“This is going to help a small percentage of parents, and it’s going to frustrate the other 99%,” says Chantelle Wolpert, MBA, PA-C, CGC, Research Assistant, Department of Human Development and Family Studies, University of North Carolina (UNC) at Greensboro. “We’re in this area where none of these findings is going to be simple. We’re just not at the point where it’s one gene, one disease anymore.”

The “16p Form” of Autism
This particular finding eventually will enable clinicians to test children diagnosed as having autism spectrum disorder to determine whether their condition is caused by the chromosomal change. As with all genetic testing, the results will not provide definitive answers for every parent of a child with autism: The patient might not have the abnormality tested for, but that does not preclude the possibility that the child’s autism is caused by another, as-yet-unidentified, genetic change—or by something else entirely.

For parents whose children do receive a positive test result for “the 16p form of autism,” as it will likely be called in the literature, the greatest benefit may be an ounce of certainty about what is otherwise an uncertain and not-fully-understood disorder. Because autism spectrum disorder actually encompasses many different, behaviorally defined conditions, diagnosis is based on clinical judgment. The standardized method of evaluation enables clinicians to make the diagnosis, but until recently, Wolpert notes, “there wasn’t something black and white that a parent could grasp. Now there will be—at least for this 1% of people.”

Approximately 10% to 15% of children with autism have a condition that is identifiable; for example, clinicians can test for fragile X syndrome or the previously reported chromosome 15 anomaly associated with autism. Offering answers to another 1% of patients and parents “sounds small,” Wolpert observes. “Big deal, you can [provide results] in all specialties. But you can’t in autism, and that’s why” these findings are significant.

What Weiss and colleagues actually identified is a section at the top of chromosome 16 that is either duplicated or deleted in some autistic patients. The strength of the research lies in the fact that this chromosomal anomaly was found in patients from three distinct populations. There are many genes within that section of chromosome 16, so geneticists will have to map them to determine what those particular genes do or don’t do and how their multiplication or deletion can impact human development. Someday, these genes might provide a therapeutic target for patients with this type of autism—but such a day remains far in the future.

A Genetic Risk Factor
Meanwhile, an article and two reports recently published in the American Journal of Human Genetics describe a different type of genetic association with autism. In the study led by Alarcón, a variant on chromosome 7 was identified as a risk factor for autism. Chromosome 7 and the specific gene (contactin associated protein-like 2, or CNTNAP2) have been associated with language development. Now, based on these new findings, CNTNAP2 may be considered an autism susceptibility gene.

“This is a risk for autism,” Wolpert stresses. “It’s not enough to have this genetic variant. If you have a copy of this particular gene, it doesn’t mean you’re going to develop autism.”

Reports by Arking et al and Bakkaloglu et al provide an additional line of evidence for CNTNAP2 as an autism susceptibility candidate. Furthermore, one of the reports also identified a genetic heritability component: Autistic children were significantly more likely to inherit the gene variation from their mothers than from their fathers.

“Again, we’re one step closer,” Wolpert says. But “there is no genetic testing for this right now”—whereas, for the 16p form of autism, “there will be genetic testing for that sooner rather than later.”

Still, clinicians should not expect a flurry of test ordering. Parents who have heard about these findings, and who have long wished for answers about their children’s condition, may approach the topic at an office visit (or even demand that their child be tested). Clinicians will have to explain to parents the likelihood of finding a definitive explanation.

“If they know that ahead of time, they’re usually fine,” says Wolpert, who spent 12 years at Duke University’s Center for Human Genetics before entering the PhD program at UNC–Greensboro. “It’s when you send off a genetic test and you don’t explain what it means” that parents can feel a deeper sense of frustration at receiving a negative test result. “They may leave the office thinking, ‘OK, it wasn’t this thing that the researchers discovered, so it’s not genetic!’” Or they might have their own personal theories about what caused their children’s autism, including blaming themselves in some way.

Recommendations will have to be developed so clinicians have a guideline of who should be tested for genetic causes of autism. With the average test costing $2,000 to $5,000, insurers may question the validity of testing for a chromosomal anomaly that occurs in a mere 1% of autistic persons.

Looking Beyond Thimerosal
One of the most persistent theories about autism is that it is caused, at least in some cases, by exposure to thimerosal, which was used as a preservative in many vaccines until about 10 years ago, when manufacturers started removing it from their products. Numerous studies have failed to identify such a link, but many parents remain unconvinced.

A study by Schechter and Grether in the Archives of General Psychiatry is among the most recent to dispel the autism-thimerosal link. The researchers discovered that rates of autism continued to rise in California even after thimerosal had been removed from vaccines. “[T]ime trends are inconsistent with the hypothesis that thimerosal exposure is a primary cause of autism in California,” the authors write. However, “we support the continued quest for the timely discovery of modifiable risk factors for autism and related conditions.”

Eric Fombonne, MD, from the Department of Psychiatry at Montreal Children’s Hospital, expressed frustration in his accompanying editorial: “How many more negative study results are required for the belief to go away, and how much more spending of public funds on this issue could even be justified?”

While remaining neutral about thimerosal, Wolpert acknowledges the “need [for] more research funding—for all aspects, not just genetics.”

Since pharmacologic therapy for autism, let alone a cure, is little more than a dream at this stage, it might be beneficial to explore ways to address the issues experienced by patients and parents living with autism. “How are we going to help the parents and patients who already have this [diagnosis]?” Wolpert asks. “What factors in a family or educational system help a child to achieve his or her highest level of ability?”

Identification of additional genetic factors will also open the doorway to exploring the role of environmental factors in autism. “If you can control for one variable in a study, then you can examine the others,” Wolpert points out.

Progress may be slow, but clinicians, parents, and patients have reason to hope. “The bad news is 85% to 90% of autism is still unexplained,” Wolpert says. “Then again, what great progress! Ten years ago, we knew autism had a genetic basis, but that’s all we knew. Now, we have causative genes and genes that increase risk. We’re making headway.” 

Forty years after the establishment of their professions, PAs and NPs can look back with pride at the advances they have made. Yet each year, on both state and national levels, new legislation is proposed that will impact—for better or worse—their ability to provide high-quality patient care.

Staying on top of the issues can be a full-time job, and the one thing practicing clinicians never seem to have is enough time. It leaves many to wonder, “Can’t someone else take care of those details?”

Therein lies folly, say leaders from both the American Academy of Nurse Practitioners (AANP) and the American Academy of Physician Assistants (AAPA). “If you don’t participate, then you are at the mercy of those who choose to,” says Ann Davis, PA-C, Director of State Government Affairs for AAPA. “And they may not make decisions that you like.”

Furthermore, clinicians’ livelihoods depend on the policy decisions of local, state, and federal governments. The bottom line, according to Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for AANP, is “you’re not going to keep your ‘real’ job if you don’t have laws and regulations and policies that allow us to function.”

A Matter of Priorities
Lest anyone suspect Towers is exaggerating, a case in point: Last year, the PA Practice Act in Illinois—which, in a nutshell, gives PAs the right to practice in the state—was due for renewal. The Illinois Academy of Physician Assistants (IAPA) set to work at the start of 2007, contacting other organizations and state departments to iron out any potential areas of conflict in advance; the organization purposely avoided any controversial requests in SB149. In March, the bill made it through the Senate without difficulty and moved to the House.

However, in a crowded legislative session, the bill languished there—and the addition of five separate amendments further delayed its progress. (Each time an amendment is proposed, a bill must go back to committee for review and approval.) Salvation came only when a senator added the renewal of the PA Practice Act (along with those of many other professions) to HB1284, which had passed in the House and was under consideration by the Senate. Thanks to the persistent efforts of IAPA and many individual PAs, the bill zipped through three committees in one day, was placed on the agenda, and passed on November 2.

“Could it have happened without everybody calling? Maybe,” says IAPA President Sherie Turner, PA-C. “But we’ve never seen anything happen that rapidly before.”

Turner was informed by her local representative that “there was so much pending legislation in Illinois at the end of the year that our bill could certainly have gotten lost.” [After another nail-biting wait, Gov. Rod Blagojevich signed the bill into law on December 31—just in time.]

While opposition to a bill is perhaps a more obvious cause for concern, matters of priority are increasingly common. “Our issues, on the scale of things like a trillion-dollar budget, are relatively small, so it’s hard to get them to rise to the surface unless there’s a lot of push from the constituencies,” Towers observes.

This emphasizes the importance of PAs and NPs—collectively and individually—to the success of a legislative initiative.

If You Don’t, Who Will?
Turner understands the complacency that many feel when it comes to politics. “I can tell you I didn’t do anything much legislatively, or actively contact my representatives, before I was in this position and felt it was my responsibility,” she admits.

There are things that every clinician can do, “even when you have newborn twins with colic and your hair is on fire,” as AAPA’s Davis says. She adds that everyone should “become involved personally in the political process, to whatever extent you are able.”

Political activism can range from putting up a yard sign in support of a candidate at election time or occasionally attending a forum at which candidates discuss issues, to hosting a fundraiser or contributing to a political action committee “that is aligned with your interests or the interests of patients,” Davis says. Staying on top of issues related to clinical practice or other aspects of patient care is as easy as reading the newspaper, surfing the Internet, or staying in contact with your state professional organization.

“Every state is its own little country,” Davis says. “That’s the really great thing about having state chapters—those folks know what works here, who you can talk to.”

Yet, state professional organizations struggle with membership. The financial support from membership dues can enable a group to establish an office and have a full-time director who can monitor legislative and regulatory issues. More fiscally solvent professional groups can afford to have full-time lobbyists.

This is not to suggest that only full-time staff can make a difference. When resources are limited, Towers says, “Volunteers have done an excellent job of monitoring state board meetings, advocating for legislation in the state.”

Strong membership numbers can also impact legislators’ perceptions. If, for example, an organization professes to represent PAs in New York, a legislator may want to know what percentage of the state’s PAs belong to the group. “And you don’t want to have to say it’s five,” Davis says. “You want to be able to say it’s the majority.”

Did We Mention Networking?
Active involvement is the best way to make a difference. While letter-writing and cold-calling campaigns can help when legislation is on the table, everyone agrees that establishing long-term relationships is most beneficial.

“The more you have a rapport with a legislator or regulator, so they understand the issues when you really need them, then they’re going to be there for you,” Towers says. She adds that frequent staff turnover in legislators’ offices often necessitates repeat visits or calls to ensure that the legislator stays on top of health care issues.

It may be an arduous process, but connections can pay off in the long run—as NPs in Oregon learned last year when legislation to establish a “scope-of-practice review board” was proposed. The original bill was intended to evaluate new scope-of-practice requests from a variety of health care providers, and was not viewed by the sponsoring senator—herself an RN—as a threat to established practitioners, according to Bunny Lewis, NM, NP, Chair, Nurse Practitioners of Oregon (NPO; a special interest group affiliated with the Oregon Nurses Association [ONA]).

“What became a problem was when they were trying to fund it, the Board of Medical Examiners stepped up and said, ‘Hey, we’ll be glad to do this,’” Lewis explains. At that point, concern among NPs escalated. “We would not be comfortable with that,” Lewis says—especially if future amendments to the bill allowed reconsideration of already-approved practice parameters.

The NPO and ONA capitalized on their long-standing relationship with the sponsoring senator to find ways to water down and eventually stifle the bill. What made the difference, Lewis says, was “meeting one-on-one with the senator, going to her and saying, ‘You’ve got to stop this. This is threatening every NP in the state.’”

It didn’t hurt that NPO and ONA “have a reputation for being honest and trustworthy and supporting those issues that are truly important,” Lewis adds. “We’ve worked for a lot of years; this is not something that just happened overnight.”

Of course, legislators are not the only people PAs and NPs need to connect with if they want to continue to advance their practice. “You really need to be in tune with what’s going on with the department of insurance in your state, with the state boards of nursing [or medicine]—the people who make the rules, not just the statutes,” Towers points out.

And never underestimate the power of forming coalitions with like-minded groups. “The more you can reach out to groups that are interested in the same issues, whether it be other health care professional groups or other citizen groups, such as AARP, and create coalitions there, the better it is,” Towers says.

Davis agrees. If the state legislature is considering legislation to allow parents to administer insulin on school grounds, for example, PAs alone may have a modest influence. However, she says, “if we show up with the pediatricians and the certified diabetes educators and the nurses association and the emergency room physicians and the American Diabetes Association local chapter to talk about the same issue, that’s pretty good—we’ll get their attention.”

At the Heart of It
Perhaps the most important thing to remember, when legislative initiatives seem too difficult or time-consuming to tackle, is that patients are at the heart of them all. “It’s very important to look at it from the perspective of patient care and not just ‘me, me, me,’” Towers says. “This has to do with our ability to provide care to our patients and has to do with access and quality of care.”

Clinicians cannot practice at all without laws and regulations that allow them to do so, and each additional privilege they receive enhances their ability to help someone else. Asking the state legislature to open the formulary isn’t about résumé enhancement for clinicians; it’s about providing patients with the medications they need. But even local issues that may not directly relate to PAs and NPs—such as the closure of an adult day care facility in the area—can impact patients’ well-being, and these may provide a small but vital opportunity to speak up. “If something is good for patients, then of course we must endorse it,” Davis says.

“We truly are in the trenches,” NPO’s Lewis says. “And we have a responsibility to make sure that our patients get safe health care and that it’s also the best health care they can get. So it’s more than just us.”

Towers says advocating for patients “needs to go beyond the walls of where you’re providing your care. Everyone should see themselves as someone who does advocate for their patients in this way.”

This is why, even when the odds seem to be against you and you have to make repeated attempts to get legislation passed, “you don’t give up,” Lewis says. “You just keep building relationships with those in power, and then those relationships will hold in the long run for you.”     

Forty years after the establishment of their professions, PAs and NPs can look back with pride at the advances they have made. Yet each year, on both state and national levels, new legislation is proposed that will impact—for better or worse—their ability to provide high-quality patient care.

Staying on top of the issues can be a full-time job, and the one thing practicing clinicians never seem to have is enough time. It leaves many to wonder, “Can’t someone else take care of those details?”

Therein lies folly, say leaders from both the American Academy of Nurse Practitioners (AANP) and the American Academy of Physician Assistants (AAPA). “If you don’t participate, then you are at the mercy of those who choose to,” says Ann Davis, PA-C, Director of State Government Affairs for AAPA. “And they may not make decisions that you like.”

Furthermore, clinicians’ livelihoods depend on the policy decisions of local, state, and federal governments. The bottom line, according to Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for AANP, is “you’re not going to keep your ‘real’ job if you don’t have laws and regulations and policies that allow us to function.”

A Matter of Priorities
Lest anyone suspect Towers is exaggerating, a case in point: Last year, the PA Practice Act in Illinois—which, in a nutshell, gives PAs the right to practice in the state—was due for renewal. The Illinois Academy of Physician Assistants (IAPA) set to work at the start of 2007, contacting other organizations and state departments to iron out any potential areas of conflict in advance; the organization purposely avoided any controversial requests in SB149. In March, the bill made it through the Senate without difficulty and moved to the House.

However, in a crowded legislative session, the bill languished there—and the addition of five separate amendments further delayed its progress. (Each time an amendment is proposed, a bill must go back to committee for review and approval.) Salvation came only when a senator added the renewal of the PA Practice Act (along with those of many other professions) to HB1284, which had passed in the House and was under consideration by the Senate. Thanks to the persistent efforts of IAPA and many individual PAs, the bill zipped through three committees in one day, was placed on the agenda, and passed on November 2.

“Could it have happened without everybody calling? Maybe,” says IAPA President Sherie Turner, PA-C. “But we’ve never seen anything happen that rapidly before.”

Turner was informed by her local representative that “there was so much pending legislation in Illinois at the end of the year that our bill could certainly have gotten lost.” [After another nail-biting wait, Gov. Rod Blagojevich signed the bill into law on December 31—just in time.]

While opposition to a bill is perhaps a more obvious cause for concern, matters of priority are increasingly common. “Our issues, on the scale of things like a trillion-dollar budget, are relatively small, so it’s hard to get them to rise to the surface unless there’s a lot of push from the constituencies,” Towers observes.

This emphasizes the importance of PAs and NPs—collectively and individually—to the success of a legislative initiative.

If You Don’t, Who Will?
Turner understands the complacency that many feel when it comes to politics. “I can tell you I didn’t do anything much legislatively, or actively contact my representatives, before I was in this position and felt it was my responsibility,” she admits.

There are things that every clinician can do, “even when you have newborn twins with colic and your hair is on fire,” as AAPA’s Davis says. She adds that everyone should “become involved personally in the political process, to whatever extent you are able.”

Political activism can range from putting up a yard sign in support of a candidate at election time or occasionally attending a forum at which candidates discuss issues, to hosting a fundraiser or contributing to a political action committee “that is aligned with your interests or the interests of patients,” Davis says. Staying on top of issues related to clinical practice or other aspects of patient care is as easy as reading the newspaper, surfing the Internet, or staying in contact with your state professional organization.

“Every state is its own little country,” Davis says. “That’s the really great thing about having state chapters—those folks know what works here, who you can talk to.”

Yet, state professional organizations struggle with membership. The financial support from membership dues can enable a group to establish an office and have a full-time director who can monitor legislative and regulatory issues. More fiscally solvent professional groups can afford to have full-time lobbyists.

This is not to suggest that only full-time staff can make a difference. When resources are limited, Towers says, “Volunteers have done an excellent job of monitoring state board meetings, advocating for legislation in the state.”

Strong membership numbers can also impact legislators’ perceptions. If, for example, an organization professes to represent PAs in New York, a legislator may want to know what percentage of the state’s PAs belong to the group. “And you don’t want to have to say it’s five,” Davis says. “You want to be able to say it’s the majority.”

Did We Mention Networking?
Active involvement is the best way to make a difference. While letter-writing and cold-calling campaigns can help when legislation is on the table, everyone agrees that establishing long-term relationships is most beneficial.

“The more you have a rapport with a legislator or regulator, so they understand the issues when you really need them, then they’re going to be there for you,” Towers says. She adds that frequent staff turnover in legislators’ offices often necessitates repeat visits or calls to ensure that the legislator stays on top of health care issues.

It may be an arduous process, but connections can pay off in the long run—as NPs in Oregon learned last year when legislation to establish a “scope-of-practice review board” was proposed. The original bill was intended to evaluate new scope-of-practice requests from a variety of health care providers, and was not viewed by the sponsoring senator—herself an RN—as a threat to established practitioners, according to Bunny Lewis, NM, NP, Chair, Nurse Practitioners of Oregon (NPO; a special interest group affiliated with the Oregon Nurses Association [ONA]).

“What became a problem was when they were trying to fund it, the Board of Medical Examiners stepped up and said, ‘Hey, we’ll be glad to do this,’” Lewis explains. At that point, concern among NPs escalated. “We would not be comfortable with that,” Lewis says—especially if future amendments to the bill allowed reconsideration of already-approved practice parameters.

The NPO and ONA capitalized on their long-standing relationship with the sponsoring senator to find ways to water down and eventually stifle the bill. What made the difference, Lewis says, was “meeting one-on-one with the senator, going to her and saying, ‘You’ve got to stop this. This is threatening every NP in the state.’”

It didn’t hurt that NPO and ONA “have a reputation for being honest and trustworthy and supporting those issues that are truly important,” Lewis adds. “We’ve worked for a lot of years; this is not something that just happened overnight.”

Of course, legislators are not the only people PAs and NPs need to connect with if they want to continue to advance their practice. “You really need to be in tune with what’s going on with the department of insurance in your state, with the state boards of nursing [or medicine]—the people who make the rules, not just the statutes,” Towers points out.

And never underestimate the power of forming coalitions with like-minded groups. “The more you can reach out to groups that are interested in the same issues, whether it be other health care professional groups or other citizen groups, such as AARP, and create coalitions there, the better it is,” Towers says.

Davis agrees. If the state legislature is considering legislation to allow parents to administer insulin on school grounds, for example, PAs alone may have a modest influence. However, she says, “if we show up with the pediatricians and the certified diabetes educators and the nurses association and the emergency room physicians and the American Diabetes Association local chapter to talk about the same issue, that’s pretty good—we’ll get their attention.”

At the Heart of It
Perhaps the most important thing to remember, when legislative initiatives seem too difficult or time-consuming to tackle, is that patients are at the heart of them all. “It’s very important to look at it from the perspective of patient care and not just ‘me, me, me,’” Towers says. “This has to do with our ability to provide care to our patients and has to do with access and quality of care.”

Clinicians cannot practice at all without laws and regulations that allow them to do so, and each additional privilege they receive enhances their ability to help someone else. Asking the state legislature to open the formulary isn’t about résumé enhancement for clinicians; it’s about providing patients with the medications they need. But even local issues that may not directly relate to PAs and NPs—such as the closure of an adult day care facility in the area—can impact patients’ well-being, and these may provide a small but vital opportunity to speak up. “If something is good for patients, then of course we must endorse it,” Davis says.

“We truly are in the trenches,” NPO’s Lewis says. “And we have a responsibility to make sure that our patients get safe health care and that it’s also the best health care they can get. So it’s more than just us.”

Towers says advocating for patients “needs to go beyond the walls of where you’re providing your care. Everyone should see themselves as someone who does advocate for their patients in this way.”

This is why, even when the odds seem to be against you and you have to make repeated attempts to get legislation passed, “you don’t give up,” Lewis says. “You just keep building relationships with those in power, and then those relationships will hold in the long run for you.”     

Forty years after the establishment of their professions, PAs and NPs can look back with pride at the advances they have made. Yet each year, on both state and national levels, new legislation is proposed that will impact—for better or worse—their ability to provide high-quality patient care.

Staying on top of the issues can be a full-time job, and the one thing practicing clinicians never seem to have is enough time. It leaves many to wonder, “Can’t someone else take care of those details?”

Therein lies folly, say leaders from both the American Academy of Nurse Practitioners (AANP) and the American Academy of Physician Assistants (AAPA). “If you don’t participate, then you are at the mercy of those who choose to,” says Ann Davis, PA-C, Director of State Government Affairs for AAPA. “And they may not make decisions that you like.”

Furthermore, clinicians’ livelihoods depend on the policy decisions of local, state, and federal governments. The bottom line, according to Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for AANP, is “you’re not going to keep your ‘real’ job if you don’t have laws and regulations and policies that allow us to function.”

A Matter of Priorities
Lest anyone suspect Towers is exaggerating, a case in point: Last year, the PA Practice Act in Illinois—which, in a nutshell, gives PAs the right to practice in the state—was due for renewal. The Illinois Academy of Physician Assistants (IAPA) set to work at the start of 2007, contacting other organizations and state departments to iron out any potential areas of conflict in advance; the organization purposely avoided any controversial requests in SB149. In March, the bill made it through the Senate without difficulty and moved to the House.

However, in a crowded legislative session, the bill languished there—and the addition of five separate amendments further delayed its progress. (Each time an amendment is proposed, a bill must go back to committee for review and approval.) Salvation came only when a senator added the renewal of the PA Practice Act (along with those of many other professions) to HB1284, which had passed in the House and was under consideration by the Senate. Thanks to the persistent efforts of IAPA and many individual PAs, the bill zipped through three committees in one day, was placed on the agenda, and passed on November 2.

“Could it have happened without everybody calling? Maybe,” says IAPA President Sherie Turner, PA-C. “But we’ve never seen anything happen that rapidly before.”

Turner was informed by her local representative that “there was so much pending legislation in Illinois at the end of the year that our bill could certainly have gotten lost.” [After another nail-biting wait, Gov. Rod Blagojevich signed the bill into law on December 31—just in time.]

While opposition to a bill is perhaps a more obvious cause for concern, matters of priority are increasingly common. “Our issues, on the scale of things like a trillion-dollar budget, are relatively small, so it’s hard to get them to rise to the surface unless there’s a lot of push from the constituencies,” Towers observes.

This emphasizes the importance of PAs and NPs—collectively and individually—to the success of a legislative initiative.

If You Don’t, Who Will?
Turner understands the complacency that many feel when it comes to politics. “I can tell you I didn’t do anything much legislatively, or actively contact my representatives, before I was in this position and felt it was my responsibility,” she admits.

There are things that every clinician can do, “even when you have newborn twins with colic and your hair is on fire,” as AAPA’s Davis says. She adds that everyone should “become involved personally in the political process, to whatever extent you are able.”

Political activism can range from putting up a yard sign in support of a candidate at election time or occasionally attending a forum at which candidates discuss issues, to hosting a fundraiser or contributing to a political action committee “that is aligned with your interests or the interests of patients,” Davis says. Staying on top of issues related to clinical practice or other aspects of patient care is as easy as reading the newspaper, surfing the Internet, or staying in contact with your state professional organization.

“Every state is its own little country,” Davis says. “That’s the really great thing about having state chapters—those folks know what works here, who you can talk to.”

Yet, state professional organizations struggle with membership. The financial support from membership dues can enable a group to establish an office and have a full-time director who can monitor legislative and regulatory issues. More fiscally solvent professional groups can afford to have full-time lobbyists.

This is not to suggest that only full-time staff can make a difference. When resources are limited, Towers says, “Volunteers have done an excellent job of monitoring state board meetings, advocating for legislation in the state.”

Strong membership numbers can also impact legislators’ perceptions. If, for example, an organization professes to represent PAs in New York, a legislator may want to know what percentage of the state’s PAs belong to the group. “And you don’t want to have to say it’s five,” Davis says. “You want to be able to say it’s the majority.”

Did We Mention Networking?
Active involvement is the best way to make a difference. While letter-writing and cold-calling campaigns can help when legislation is on the table, everyone agrees that establishing long-term relationships is most beneficial.

“The more you have a rapport with a legislator or regulator, so they understand the issues when you really need them, then they’re going to be there for you,” Towers says. She adds that frequent staff turnover in legislators’ offices often necessitates repeat visits or calls to ensure that the legislator stays on top of health care issues.

It may be an arduous process, but connections can pay off in the long run—as NPs in Oregon learned last year when legislation to establish a “scope-of-practice review board” was proposed. The original bill was intended to evaluate new scope-of-practice requests from a variety of health care providers, and was not viewed by the sponsoring senator—herself an RN—as a threat to established practitioners, according to Bunny Lewis, NM, NP, Chair, Nurse Practitioners of Oregon (NPO; a special interest group affiliated with the Oregon Nurses Association [ONA]).

“What became a problem was when they were trying to fund it, the Board of Medical Examiners stepped up and said, ‘Hey, we’ll be glad to do this,’” Lewis explains. At that point, concern among NPs escalated. “We would not be comfortable with that,” Lewis says—especially if future amendments to the bill allowed reconsideration of already-approved practice parameters.

The NPO and ONA capitalized on their long-standing relationship with the sponsoring senator to find ways to water down and eventually stifle the bill. What made the difference, Lewis says, was “meeting one-on-one with the senator, going to her and saying, ‘You’ve got to stop this. This is threatening every NP in the state.’”

It didn’t hurt that NPO and ONA “have a reputation for being honest and trustworthy and supporting those issues that are truly important,” Lewis adds. “We’ve worked for a lot of years; this is not something that just happened overnight.”

Of course, legislators are not the only people PAs and NPs need to connect with if they want to continue to advance their practice. “You really need to be in tune with what’s going on with the department of insurance in your state, with the state boards of nursing [or medicine]—the people who make the rules, not just the statutes,” Towers points out.

And never underestimate the power of forming coalitions with like-minded groups. “The more you can reach out to groups that are interested in the same issues, whether it be other health care professional groups or other citizen groups, such as AARP, and create coalitions there, the better it is,” Towers says.

Davis agrees. If the state legislature is considering legislation to allow parents to administer insulin on school grounds, for example, PAs alone may have a modest influence. However, she says, “if we show up with the pediatricians and the certified diabetes educators and the nurses association and the emergency room physicians and the American Diabetes Association local chapter to talk about the same issue, that’s pretty good—we’ll get their attention.”

At the Heart of It
Perhaps the most important thing to remember, when legislative initiatives seem too difficult or time-consuming to tackle, is that patients are at the heart of them all. “It’s very important to look at it from the perspective of patient care and not just ‘me, me, me,’” Towers says. “This has to do with our ability to provide care to our patients and has to do with access and quality of care.”

Clinicians cannot practice at all without laws and regulations that allow them to do so, and each additional privilege they receive enhances their ability to help someone else. Asking the state legislature to open the formulary isn’t about résumé enhancement for clinicians; it’s about providing patients with the medications they need. But even local issues that may not directly relate to PAs and NPs—such as the closure of an adult day care facility in the area—can impact patients’ well-being, and these may provide a small but vital opportunity to speak up. “If something is good for patients, then of course we must endorse it,” Davis says.

“We truly are in the trenches,” NPO’s Lewis says. “And we have a responsibility to make sure that our patients get safe health care and that it’s also the best health care they can get. So it’s more than just us.”

Towers says advocating for patients “needs to go beyond the walls of where you’re providing your care. Everyone should see themselves as someone who does advocate for their patients in this way.”

This is why, even when the odds seem to be against you and you have to make repeated attempts to get legislation passed, “you don’t give up,” Lewis says. “You just keep building relationships with those in power, and then those relationships will hold in the long run for you.”