Healing Powers

As Marlene Denicola sits on the examining table of the Centinela Medical Center in Lawndale, a woman with a white lab coat and a stethoscope takes her blood pressure, listens to her heart and lungs and reviews her medications.

“Let’s look at your peak flows,” the woman now says, and Denicola, who has severe asthma, pulls out a paper on which she’s jotted the results of a breathing machine test performed at home.

“You’re doing much better,” the white-frocked woman says, reviewing the figures.

After four years, the conversation is light and easy, and Denicola long ago stopped worrying about the fact that Jane Hickney is a nurse practitioner instead of a doctor. In fact, Denicola trusts Hickney so much that her 12-year-old daughter is now a patient, too.

These days, more patients are finding that a visit to the doctor may actually mean a visit to a nurse practitioner or a physician’s assistant.

Some of this is due to financial reasons, since nurse practitioners and physician assistants are paid less than doctors, and are thus less expensive for medical practices. But economics notwithstanding, other patients prefer to see these health-care experts, saying they are less intimidating than doctors and willing to spend more time listening to their problems.

“Doctors look at your chart, they take your blood pressure, they give you the medicine and they’re out the door in five minutes,” Denicola says. “Jane will stay 20 minutes and really find out what’s going on in your life. I was on 17 different medications when I came to her, and she said, ‘Wait, we’re going to try them one by one.’ And now I can breathe. I know she’s not a doctor, but she’s just as good.”

Although they approach medicine from different backgrounds and have less training than doctors, both nurse practitioners and physician assistants do many of the same things as doctors. But their growing presence in today’s medical landscape hasn’t escaped criticism--especially among doctors.

Physician assistants work specifically under a doctor’s supervision and are restricted to medical care that has been authorized by that doctor, who must be either in the room or available via telecommunications. The law generally gives doctors discretion about what their assistants may do, with the understanding that the physician holds ultimate liability for the actions of the assistant.

Across America, physician assistants perform physical exams, diagnose and treat illnesses, order and interpret lab tests and X-rays, assist in surgery and instruct patients in preventive health care. In 46 states, including California, they also prescribe medications. California, however, calls it “writing a drug order,” to distinguish between the authority of a doctor and that of a physician assistant.

By contrast, nurse practitioners are registered nurses with two extra years of medical training, usually in the form of a master’s degree. They function much like primary care doctors in treating and diagnosing illness, prescribing medication, doing preventive health care and counseling and referring patients to specialists. In some states--but not California, where nurse practitioners must have a doctor who is on site or within reach at all times--they work independently.

And that’s where the criticism arises. The American Medical Assn. believes that physicians should be responsible for supervising nurse practitioners and managing patient health care. It lobbies against laws that allow nurse practitioners to work independently.

“We’re not opposed to these people. We use them, we employ them--within the parameters they’re trained for,” says Dr. Randolph Smoak, president of the AMA. “If they want to do more, they should go to medical school. It’s that simple.”

Because physician assistants work directly under doctors, they are less controversial. However, the AMA also opposes legislation to increase public funding for programs to train physician assistants and opposes legislation authorizing physician assistants to make independent medical judgments as to the drug of choice for individual patients.

“We’re talking about a work force issue. Do you want to overrun the market with people who are less well-trained?” Smoak says. “Or do you want to have fully trained physicians doing most of the work?”

Physician assistant groups say the very structure of their profession safeguards against abuse.

“Patients should feel secure because a physician assistant is not doing anything a physician hasn’t delegated,” says Stephen Crane, executive vice president and chief executive of the American Academy of Physician Assistants in Alexandria, Va. “They work as a team. You’re not talking about someone with an independent license. What they do conforms to the prevailing standards in the medical community. It’s not like you’re going to find physicians delegating brain surgery.”

Filling a Need in Underserved Areas

Nurse practitioners and physician assistants say they aren’t taking jobs away from doctors--they’re expanding access to health care, especially in rural and underserved areas.

Fully one-third of all physician assistants, for instance, work in rural areas, says Crane. Both professions also say they offer an alternative to the 44 million Americans who currently lack health care.

“A lot of people fall through the cracks,” says Melanie Goodman, president of the California Coalition of Nurse Practitioners. “And so you find that a lot of nurse practitioners are working in clinics and in indigent areas. It’s that nurturing, caring background that got you into nursing school in the first place.”

Nurse practitioners have their roots in the 1960s. The first program, designed jointly by a pediatrics nurse and a physician, was started in Colorado in 1965. There are now about 67,000 nurse practitioners nationwide.

Although initially seen as an extension of nursing, the profession has continued to expand in scope while always retaining its emphasis on primary care, according to Judith Dempster, executive director of the American Academy of Nurse Practitioners, based in Austin, Texas.

Laws governing nurse practitioners vary slightly from state to state. Several states do not allow them to prescribe controlled substances such as codeine, and there is wide variation in their supervision. States such as Washington, Oregon, New Mexico and Arizona allow them to practice independently, although most others require that nurse practitioners work under the supervision of a doctor who must review and sign off on patient medical charts and be available, either in person or via telecommunications as needed.

A study published in the Jan. 5 edition of the Journal of the American Medical Assn. supports nurse practitioners’ contention that they provide the same quality of care as doctors. Although some have criticized its narrow scope, the study found that, among 3,397 patients who visited four clinics, outcomes were similar regardless of whether patients saw a doctor or a nurse practitioner.

Over six months, researchers reported, there was no difference in health or level of satisfaction about the medical care, even among patients with chronic diseases such as high blood pressure or asthma, according to Mary Mundinger, the study’s chief author and dean of the Columbia University School of Nursing.

“Nurse practitioners have the same skills in detecting and managing illness as primary care physicians,” Mundinger says. “What patients get in addition to that is a specialist in health education and promotion and illness prevention.”

Physician assistants say they too provide care similar to that offered by doctors. Before they treat patients, they must complete one of the nation’s accredited physician assistant programs, which are highly competitive and receive up to 10 applications for each available opening. Many programs are housed at universities alongside medical schools, Crane says.

While a degree isn’t a prerequisite, most who enroll already have bachelor’s degrees and an average of four years of health-care experience in fields such as emergency medical services, registered nursing, occupational therapy or physical therapy. The 27-month program is divided into academic course work in the medical sciences and working rotations.

Physician assistants must then pass a national certification exam and apply for and receive a state license. “It’s a mini-medical school,” Crane says. “Classes are often taught by physicians, and sometimes you have medical students and physician assistant students together in the same classes.”

The first handful of physician assistants graduated from Duke University Medical School in North Carolina in 1967. There are now 38,000 physician assistants nationwide and 126 physician assistant programs.

In both fields, the majority are second-career professionals. Hickney worked as an intensive care hospital nurse for 17 years before deciding to move into a less physically taxing and more autonomous job. Bob Boucher, president of the California Academy of Physician Assistants, was an emergency medical technician prior to going back to school and then finding a physician assistant position in general and orthopedic surgery at Rancho Los Amigos National Rehabilitation Center in Downey.

“Physicians have more responsibility,” says Boucher, explaining why he opted not to go to medical school. “It seems like their pagers are on 24 hours a day. I didn’t want that type of lifestyle.”

Leaders in both professions say that the public often still doesn’t understand what they do. “Patients will call me doctor, and I have to correct then and say, ‘I’m not a doctor, I’m a physician assistant, you can call me Bob,’ ” says Boucher. “And most of the time, that’s fine, they recognize that I’m giving them good medical care, and that’s their primary concern.”

Working as a Health-Care Team

At the Centinela Medical Clinic, one of several clinics affiliated with Centinela Hospital Medical Center in Inglewood, medical director Dr. Ronald Woods, who has worked with Hickney for three years, says he considers her a partner.

“I’m especially pleased when my patients are pleased. Some of the patients I’ve seen for 35 years, and she’s won them over. To have her mesh like that is wonderful.”

Woods says he has no reservations about working with nurse practitioners. “The health-care team is what we’re all stressing nowadays, and she’s an integral part,” Woods says. “At all levels, there are certain doctors who perhaps feel uncomfortable that nurse practitioners are seeing patients they thought they’d be seeing. Maybe they haven’t actually worked with one.”

“I confer with Dr. Woods on several patients each day,” Hickney adds. “It results in much better treatment to the patients to have two minds working on a problem.”

Consider Jennifer Burl Edwards, who has seen Hickney for several years and also referred her husband and son to the nurse practitioner. Edwards suffers from deep vein thrombosis, or severe blood clots, in her left leg. Realizing the gravity of Edwards’ condition was beyond her abilities, Hickney has referred the 37-year-old to two specialists for her thrombosis, including a hematologist at USC Medical Center.

“There’s a fine line where you’ve maxed out what you’re comfortable with and you want to refer to a specialist,” Hickney says.

But Hickney continues to be Edwards’ primary care provider. On this recent day, Hickney checks Edwards’ blood pressure, heart rate and breathing and measures the circumference of her left thigh, since swelling can indicate problems. She also reviews Edwards’ medication--she takes an anticoagulant and must give herself shots twice a day.

Sitting in the examination room, Edwards reflects on why she keeps coming back to the nondescript clinic on Manhattan Beach Boulevard. “Some doctors make you feel so on edge, and Jane was so friendly and nice from the beginning,” Edwards says. “My husband and son are very comfortable with her too. I ask myself, ‘Is she better than a doctor?’ But she does pretty much what they do.”