Platform : Changing Medical Roles: ‘Main Thing Is the Patient’

The Clinton Administration’s move to reform the American health-care system is fueling debate over who is qualified to deliver different levels of care to patients. Here some medical professionals share their views.

BENJAMIN SHWACHMAN

Anesthesiologist and past president, Medical Assn. of Los Angeles County

Nurse practitioners should think of practicing in the same light as physicians do: Proceed with great fear. Restrict yourself and accept the fact that you can’t do it all, and to the extent you want to do more, you should go back for more training.

There is no shame or harm in being supervised (by a physician). No one’s trying to stop nurse practitioners from working. The main thing is that the patient get the best from everybody.

DOROTHY CARUSO-HERMAN

Former nurse practitioner and co-founder of Hospice Nurses Assn.

I don’t think physicians should be threatened; NPs are not trying to take away their role. Nurse practitioners do pick up on a lot of things. NPs are much more aware psycho-socially, more conversant and take more time with patients.

Physicians are threatened that a nurse practitioner might make a decision that would not be what they would make. They have had a corner on the market and never wanted to accept the fact that the nurse was never more than their handmaiden.

I see the nurse and nurse practitioner and well-trained physician assistants moving into the area, in effect, of middle management, with physicians as upper management. More partnership, less hierarchy--neither threatens the other.

MARY KNUDTSON

Nurse practitioner, UC Irvine Medical Plaza

In general, most of the physicians who have worked with nurse practitioners are pleased with the quality of care and are supportive of the role of NPs.

With health-care reform, some things will be looked at. The Clinton proposal may remove barriers against NPs providing care--for example, not requiring them to be in a relationship with the physician as a supervisor; allowing them to be reimbursed by third parties and giving them prescription privileges. (In the future) NPs will become an integral part of the managed health-care system because they are cost-effective, provide quality care and patients are pleased.

VINCENT GUALTIERI

Urologist, secretary of Medical Assn. of L.A. County

Nurse practitioners and physician assistants are skilled, but there should be a doctor’s supervision. The American Society of Internal Medicine issued a memo strongly opposed to independent nurse practitioners. Organized medicine is concerned about patient care, not about cutting into physician incomes.

In the past, NPs were carefully supervised in clinics. When they leave this setting, there’s no control. I think an increased role for NPs would have to be done in coordination with organized medicine to set standards.

LES HOWARD

Physician assistant, USC faculty member

I believe in dependent practitioners working under a physician. Physician assistants are an extension of the physician. There needs to be a physician in the picture because of their (advanced) training. PAs do want prescription-writing privileges. We get tired of chasing down physicians for prescriptions. Prescription privileges would increase access to care for a lot of folks.

ELLEN McGRATH

Psychologist, executive director of the Psychology Center, Laguna Beach

Both sets of professions (medical health and mental health) are going through turf wars. Nurse practitioners’ and psychologists’ issues are very similar: People are desperately looking for alternative ways to keep healthy.

Psychiatrists (like other physicians) are forced more into treating with medication, while psychologists are trained to approach problems physically, psychologically and social-culturally. NPs’ and psychologists’ “mind-body” approaches are more likely to take those things into account.

NPs are a challenge to traditional models of health delivery controlled by white male physicians. Nursing professionals are females, often from diverse backgrounds and, as a profession, reflect society.