Managing Editor

This summer, primary care NPs and PAs, who increasingly face the challenging clinical conundrum of metabolic and endocrine diseases, have a unique opportunity to enhance their knowledge—and therefore their patient care—in these areas. The first Metabolic and Endocrine Disease Summit (MEDS) will be held from July 28 to 30 at the Walt Disney World Swan and Dolphin in Orlando.

Sponsored by Clinician Reviews and the Primary Care Metabolic Group, MEDS is designed to provide “practical, case-based advice on how to really manage patients with diabetes” and other endocrinopathies, says Chris Sadler, MA, PA-C, CDE, Co-Chair of MEDS and President-Elect of the American Society of Endocrine PAs (ASEPA). “Attendees are not just going to get the typical statistics.”

MEDS is unique in that it was designed with primary care providers in mind. Other endocrinology-themed meetings may focus more on updating specialists about what is happening within the field.

“Those meetings don’t teach how to tackle the primary care presentation of an endocrine or metabolic disease—how to work it up and have a good thought process on how to manage it, whether the case needs to be referred out or can be handled in the primary care setting,” says Scott Urquhart, PA-C, DFAAPA, Chair of MEDS and Immediate Past President of ASEPA. “With the shortage of endocrinologists, we need to educate our primary care providers on how to manage these diseases, because we can’t do it all.”

DIABETES IN DEPTH, AND MORE
During the 2.5-day program, NPs and PAs can earn up to 18.5 hours of CE/CME credit while attending lectures on a variety of topics. As Christine Kessler, MN, CNS, ANP, BC-ADM, Co-Chair of MEDS, says, “What isn’t covered? There will be everything from the ‘big ones’—diabetes, thyroid disorders, obesity, and osteoporosis—all the way down to hypogonadism.”

“On Day 1 and on Day 3, which is a half-day, we want to focus on areas that may not get enough attention and that may need clarification on how to handle them,” Urquhart says, “because a lot of these conditions can be worked up in primary care offices.”

These areas include hypothyroidism, hyperthyroidism, hypercalcemia, adrenal dysfunctions, dyslipidemia, polycystic ovary syndrome, obesity, and vitamin D deficiency.

“A lot of primary care clinicians have expressed—at least in the past—a lack of comfort with managing some of these diagnoses,” Sadler says. “Considering how much disease we’re seeing in these areas, [this meeting] will really enhance their clinical practice and their ability to diagnose and treat these illnesses in an appropriate way.”

Day 2 of the meeting is what Urquhart calls “Diabetes Day” and will focus on this most common disorder “so people aren’t being pulled on track and off track again.” Both type 1 and type 2 diabetes will be covered, with lectures aimed at helping clinicians navigate the therapeutic agents used to treat type 2 diabetes (there are almost a dozen classes), become more comfortable with insulin, and understand the appropriate use of finger-stick versus continuous glucose monitoring.

Diabetes is a complex topic, in part because patients with type 2 diabetes are an extremely heterogeneous population. The “one size fits all” approach of most guidelines may not adequately address the needs of an individual patient, as Sadler explains:

“You have patients at one end of the spectrum who are extremely insulin-resistant and you have other patients at the other end who are extremely insulin-deficient—and you have everyone in between. That’s what is so complex—understanding the nuances of someone’s diabetes, in terms of what is the appropriate work-up to differentiate one patient from another and why you would use different agents in one patient versus another.”

It is the hope of the MEDS chairs that attendees will leave the meeting with “current and relevant information that they can use right away in practice,” Kessler says.

ALL TOGETHER NOW
In addition to the in-depth coverage of a wide variety of metabolic and endocrine disorders, another key component of MEDS is the interaction. The faculty is comprised of NPs and PAs who are experts in the field. While they may conduct clinical research or present at meetings, they are not researchers or lecturers by trade but rather clinicians who are in the field, seeing patients. This means they can provide “clinical pearls that you’ll never learn from a book; they come from dealing with these disorders day in and day out,” as Kessler says. And the faculty members do want attendees to ask questions; part of each session will be devoted to Q&A (not that queries must be limited to the classroom).

“It will be like having an endocrine consultant right there for you,” Kessler says. “So it’s not just didactic, with somebody speaking. Clinicians can approach us with certain of their own challenging cases, and then we can help them with that.”

“The faculty will be there the whole time,” Sadler adds, “so people will be around to converse with at breaks or in between sessions. I think there will be a lot more interaction with faculty than you typically get at conferences.”

In fact, Sadler hopes one of the things NPs and PAs will take from MEDS is a network of colleagues they can contact for “further dialogue” later. And those colleagues will be representatives of both professions, since MEDS brings PAs and NPs together to address common educational needs.

“There are physician meetings, PA meetings, and NP meetings, but in the office setting, we work together,” Urquhart says. “There are some differences in training and philosophy, but put in the same clinical setting, we are expected to have the same outcomes. Quality of care won’t be compromised based on the fact that you’re a PA, an NP, or an MD, as long as you have been trained and the practice you’re working with fully understands your competencies and skill set.”

Skill sets can be enhanced through educational initiatives such as MEDS, and if attendees leave the meeting with “confidence, and maybe even a bit of a passion for endocrinology,” as Kessler hopes, the end result will improve more than just their own professional lives.

“This meeting brings providers together and focuses on our common interest,” Sadler says, “which is taking care of patients.”

Information about MEDS, including registration, can be found ­online at www.MEDSummit.qhc.com.               

This summer, primary care NPs and PAs, who increasingly face the challenging clinical conundrum of metabolic and endocrine diseases, have a unique opportunity to enhance their knowledge—and therefore their patient care—in these areas. The first Metabolic and Endocrine Disease Summit (MEDS) will be held from July 28 to 30 at the Walt Disney World Swan and Dolphin in Orlando.

Sponsored by Clinician Reviews and the Primary Care Metabolic Group, MEDS is designed to provide “practical, case-based advice on how to really manage patients with diabetes” and other endocrinopathies, says Chris Sadler, MA, PA-C, CDE, Co-Chair of MEDS and President-Elect of the American Society of Endocrine PAs (ASEPA). “Attendees are not just going to get the typical statistics.”

MEDS is unique in that it was designed with primary care providers in mind. Other endocrinology-themed meetings may focus more on updating specialists about what is happening within the field.

“Those meetings don’t teach how to tackle the primary care presentation of an endocrine or metabolic disease—how to work it up and have a good thought process on how to manage it, whether the case needs to be referred out or can be handled in the primary care setting,” says Scott Urquhart, PA-C, DFAAPA, Chair of MEDS and Immediate Past President of ASEPA. “With the shortage of endocrinologists, we need to educate our primary care providers on how to manage these diseases, because we can’t do it all.”

DIABETES IN DEPTH, AND MORE
During the 2.5-day program, NPs and PAs can earn up to 18.5 hours of CE/CME credit while attending lectures on a variety of topics. As Christine Kessler, MN, CNS, ANP, BC-ADM, Co-Chair of MEDS, says, “What isn’t covered? There will be everything from the ‘big ones’—diabetes, thyroid disorders, obesity, and osteoporosis—all the way down to hypogonadism.”

“On Day 1 and on Day 3, which is a half-day, we want to focus on areas that may not get enough attention and that may need clarification on how to handle them,” Urquhart says, “because a lot of these conditions can be worked up in primary care offices.”

These areas include hypothyroidism, hyperthyroidism, hypercalcemia, adrenal dysfunctions, dyslipidemia, polycystic ovary syndrome, obesity, and vitamin D deficiency.

“A lot of primary care clinicians have expressed—at least in the past—a lack of comfort with managing some of these diagnoses,” Sadler says. “Considering how much disease we’re seeing in these areas, [this meeting] will really enhance their clinical practice and their ability to diagnose and treat these illnesses in an appropriate way.”

Day 2 of the meeting is what Urquhart calls “Diabetes Day” and will focus on this most common disorder “so people aren’t being pulled on track and off track again.” Both type 1 and type 2 diabetes will be covered, with lectures aimed at helping clinicians navigate the therapeutic agents used to treat type 2 diabetes (there are almost a dozen classes), become more comfortable with insulin, and understand the appropriate use of finger-stick versus continuous glucose monitoring.

Diabetes is a complex topic, in part because patients with type 2 diabetes are an extremely heterogeneous population. The “one size fits all” approach of most guidelines may not adequately address the needs of an individual patient, as Sadler explains:

“You have patients at one end of the spectrum who are extremely insulin-resistant and you have other patients at the other end who are extremely insulin-deficient—and you have everyone in between. That’s what is so complex—understanding the nuances of someone’s diabetes, in terms of what is the appropriate work-up to differentiate one patient from another and why you would use different agents in one patient versus another.”

It is the hope of the MEDS chairs that attendees will leave the meeting with “current and relevant information that they can use right away in practice,” Kessler says.

ALL TOGETHER NOW
In addition to the in-depth coverage of a wide variety of metabolic and endocrine disorders, another key component of MEDS is the interaction. The faculty is comprised of NPs and PAs who are experts in the field. While they may conduct clinical research or present at meetings, they are not researchers or lecturers by trade but rather clinicians who are in the field, seeing patients. This means they can provide “clinical pearls that you’ll never learn from a book; they come from dealing with these disorders day in and day out,” as Kessler says. And the faculty members do want attendees to ask questions; part of each session will be devoted to Q&A (not that queries must be limited to the classroom).

“It will be like having an endocrine consultant right there for you,” Kessler says. “So it’s not just didactic, with somebody speaking. Clinicians can approach us with certain of their own challenging cases, and then we can help them with that.”

“The faculty will be there the whole time,” Sadler adds, “so people will be around to converse with at breaks or in between sessions. I think there will be a lot more interaction with faculty than you typically get at conferences.”

In fact, Sadler hopes one of the things NPs and PAs will take from MEDS is a network of colleagues they can contact for “further dialogue” later. And those colleagues will be representatives of both professions, since MEDS brings PAs and NPs together to address common educational needs.

“There are physician meetings, PA meetings, and NP meetings, but in the office setting, we work together,” Urquhart says. “There are some differences in training and philosophy, but put in the same clinical setting, we are expected to have the same outcomes. Quality of care won’t be compromised based on the fact that you’re a PA, an NP, or an MD, as long as you have been trained and the practice you’re working with fully understands your competencies and skill set.”

Skill sets can be enhanced through educational initiatives such as MEDS, and if attendees leave the meeting with “confidence, and maybe even a bit of a passion for endocrinology,” as Kessler hopes, the end result will improve more than just their own professional lives.

“This meeting brings providers together and focuses on our common interest,” Sadler says, “which is taking care of patients.”

Information about MEDS, including registration, can be found ­online at www.MEDSummit.qhc.com.               

This summer, primary care NPs and PAs, who increasingly face the challenging clinical conundrum of metabolic and endocrine diseases, have a unique opportunity to enhance their knowledge—and therefore their patient care—in these areas. The first Metabolic and Endocrine Disease Summit (MEDS) will be held from July 28 to 30 at the Walt Disney World Swan and Dolphin in Orlando.

Sponsored by Clinician Reviews and the Primary Care Metabolic Group, MEDS is designed to provide “practical, case-based advice on how to really manage patients with diabetes” and other endocrinopathies, says Chris Sadler, MA, PA-C, CDE, Co-Chair of MEDS and President-Elect of the American Society of Endocrine PAs (ASEPA). “Attendees are not just going to get the typical statistics.”

MEDS is unique in that it was designed with primary care providers in mind. Other endocrinology-themed meetings may focus more on updating specialists about what is happening within the field.

“Those meetings don’t teach how to tackle the primary care presentation of an endocrine or metabolic disease—how to work it up and have a good thought process on how to manage it, whether the case needs to be referred out or can be handled in the primary care setting,” says Scott Urquhart, PA-C, DFAAPA, Chair of MEDS and Immediate Past President of ASEPA. “With the shortage of endocrinologists, we need to educate our primary care providers on how to manage these diseases, because we can’t do it all.”

DIABETES IN DEPTH, AND MORE
During the 2.5-day program, NPs and PAs can earn up to 18.5 hours of CE/CME credit while attending lectures on a variety of topics. As Christine Kessler, MN, CNS, ANP, BC-ADM, Co-Chair of MEDS, says, “What isn’t covered? There will be everything from the ‘big ones’—diabetes, thyroid disorders, obesity, and osteoporosis—all the way down to hypogonadism.”

“On Day 1 and on Day 3, which is a half-day, we want to focus on areas that may not get enough attention and that may need clarification on how to handle them,” Urquhart says, “because a lot of these conditions can be worked up in primary care offices.”

These areas include hypothyroidism, hyperthyroidism, hypercalcemia, adrenal dysfunctions, dyslipidemia, polycystic ovary syndrome, obesity, and vitamin D deficiency.

“A lot of primary care clinicians have expressed—at least in the past—a lack of comfort with managing some of these diagnoses,” Sadler says. “Considering how much disease we’re seeing in these areas, [this meeting] will really enhance their clinical practice and their ability to diagnose and treat these illnesses in an appropriate way.”

Day 2 of the meeting is what Urquhart calls “Diabetes Day” and will focus on this most common disorder “so people aren’t being pulled on track and off track again.” Both type 1 and type 2 diabetes will be covered, with lectures aimed at helping clinicians navigate the therapeutic agents used to treat type 2 diabetes (there are almost a dozen classes), become more comfortable with insulin, and understand the appropriate use of finger-stick versus continuous glucose monitoring.

Diabetes is a complex topic, in part because patients with type 2 diabetes are an extremely heterogeneous population. The “one size fits all” approach of most guidelines may not adequately address the needs of an individual patient, as Sadler explains:

“You have patients at one end of the spectrum who are extremely insulin-resistant and you have other patients at the other end who are extremely insulin-deficient—and you have everyone in between. That’s what is so complex—understanding the nuances of someone’s diabetes, in terms of what is the appropriate work-up to differentiate one patient from another and why you would use different agents in one patient versus another.”

It is the hope of the MEDS chairs that attendees will leave the meeting with “current and relevant information that they can use right away in practice,” Kessler says.

ALL TOGETHER NOW
In addition to the in-depth coverage of a wide variety of metabolic and endocrine disorders, another key component of MEDS is the interaction. The faculty is comprised of NPs and PAs who are experts in the field. While they may conduct clinical research or present at meetings, they are not researchers or lecturers by trade but rather clinicians who are in the field, seeing patients. This means they can provide “clinical pearls that you’ll never learn from a book; they come from dealing with these disorders day in and day out,” as Kessler says. And the faculty members do want attendees to ask questions; part of each session will be devoted to Q&A (not that queries must be limited to the classroom).

“It will be like having an endocrine consultant right there for you,” Kessler says. “So it’s not just didactic, with somebody speaking. Clinicians can approach us with certain of their own challenging cases, and then we can help them with that.”

“The faculty will be there the whole time,” Sadler adds, “so people will be around to converse with at breaks or in between sessions. I think there will be a lot more interaction with faculty than you typically get at conferences.”

In fact, Sadler hopes one of the things NPs and PAs will take from MEDS is a network of colleagues they can contact for “further dialogue” later. And those colleagues will be representatives of both professions, since MEDS brings PAs and NPs together to address common educational needs.

“There are physician meetings, PA meetings, and NP meetings, but in the office setting, we work together,” Urquhart says. “There are some differences in training and philosophy, but put in the same clinical setting, we are expected to have the same outcomes. Quality of care won’t be compromised based on the fact that you’re a PA, an NP, or an MD, as long as you have been trained and the practice you’re working with fully understands your competencies and skill set.”

Skill sets can be enhanced through educational initiatives such as MEDS, and if attendees leave the meeting with “confidence, and maybe even a bit of a passion for endocrinology,” as Kessler hopes, the end result will improve more than just their own professional lives.

“This meeting brings providers together and focuses on our common interest,” Sadler says, “which is taking care of patients.”

Information about MEDS, including registration, can be found ­online at www.MEDSummit.qhc.com.               

This year’s Oscar-winning film The King’s Speech delivered the important message that each of us has a voice and deserves to be heard. Thanks to two passionate, driven clinicians, satellite radio—specifically, ReachMD (XM160)—is providing another venue for NPs and PAs to reach new audiences and expand their message, not only to their colleagues but also to physicians and the general public.

Lisa Dandrea Lenell, MPAS, PA-C, and Mimi Secor, MS, MEd, APRN, BC, FNP, FAANP, are the co-hosts of Partners in Practice. They are also Clinician Reviews Editorial Board members, so we decided to turn the tables and put them in the interview chair.

CR: How and when did you get involved with ReachMD?

LENELL: Dr. David Preskill, who started ReachMD, is in our practice’s referral chain. He was advised that if he wanted to expand the listening audience, he needed to get an NP or a PA on board. So, one day he called and asked me if I wanted to get involved. At first, I wasn’t interested, because I had a lot on my plate and I wasn’t really experienced in radio. But he said, “Well, just try.” So I contacted Ed Lopez, PA-C, for my guest, and we put together a demo, and they said, “OK, we’ll   get back to you.” And a month later, I was in my car listening to ReachMD, and my show came on! That was October 2007.

I did the show myself—we just called it “The PA Show” then—until Mimi came on board. There had always been talk about expanding the show and bringing out the roles that different people play in health care. Having an NP was always on the agenda.

SECOR: When I got involved was just about a year ago, and how was with the help of a PA [Clinician Reviews Publisher Gary Falcetano, PA-C] who gave my name as a possible host when he heard that ReachMD might be considering adding an NP host. So I actually have a PA to thank for that!

Lisa was so gracious and helpful in assisting me to “get up to speed” as a national radio host. She was supportive, offered constructive suggestions, and wasn’t intimidated when I was added to what had, to that point, been “her” show.

CR: What is your approach to the show, in terms of choosing topics or guests?

SECOR: I have two reasons for doing the show: One is to enhance the visibility of NPs in a positive way, to show how smart they are, how expert they are, what a difference they make in health care, really showcasing the profession in a positive light to the world. And the second is to get good content out there. So the good content is actually used to illustrate how great NPs are.

As far as topics, number one, I have to have my finger on the pulse of what’s going on in my profession. So I’m constantly scanning the literature and keeping an eye on the national monthly occurrences so I can try to coordinate some of the programs we do with, say, Breast Cancer Awareness Month or whatever is going on in the world. Often when I’m interacting with my colleagues at conferences, I’m looking for “the expert.”

LENELL: My goal is to provide a forum where people can get simple answers to simple questions that they might want to ask but for whatever reason won’t ask or don’t know who to ask or how to find out. The goal from the beginning has always been to educate the public, medical professionals, and anyone we can about what a PA is and what we can do, to move the myths and misconceptions out of the way and do a professional, responsible job.

If I hear someone say something about PAs, and I didn’t know that bit of information, I’ll start researching it for a show. I’ve done several on coding and reimbursement for PAs, because I think it’s super important and I get those questions all the time. It’s confusing, and there’s no really great source for PAs. So I’ve had great people on the show to help us walk through that. I’ve done malpractice shows several times, because that’s another one that is really confusing for PAs. So I ask the questions that people want to ask but don’t know how.

I’ve seen a progression from the early shows. Some of the original topics, I knew only what I needed to know. But as I started peeling the onion of the PA profession, something new would come out that interested me, and we’d go after that for a show. It became almost like detective work to get interesting stories that were different.

CR: What are some of the memorable moments from Partners in Practice?

LENELL: My favorite shows, always, are the personal interest stories. My favorite was Vic Germino, one of the original four PAs from Duke. He is such a humble, amazing man, and he came on and told his story in a beautiful, personal way. I had goosebumps when it was over.

Another favorite is Russ Dorr, the medical writer for Stephen King. He’s a PA who still works full-time in pediatrics and he’s “Russ Dorr, the man behind the gore.” I got so many comments after that show, because who knew that the guy who writes all the medical info for Stephen King is a PA?

The only time we did a “breaking news” show was in Haiti. There were many, many PAs there, and of course no one talked about them. So I really wanted to get a PA who was in Haiti on the air. Eric Holden was in Haiti, and he managed to get a phone—we waited for him at the studio for a couple hours, in the hope that he could reach us. Anyway, Eric got a phone from a military operation that was assisting his group of responders. And you could hear in the background, while he was talking to us, everything that was going on. I was really grateful for him to come on.

My favorite topics in the past two years have been the global developments of the PA profession; I’ve become a little bit of an addict. I decided I was going to interview someone from every single country where there was a PA program. [These segments covered programs in Ghana, Canada, Australia, Scotland, England, Puerto Rico, and the Netherlands; Lenell has also interviewed PAs who did humanitarian work in Sudan and coordinated an exchange program with Thailand.]

SECOR: I think the most touching interview I have done was with Maryana McGlasson, who had just come back from working with Doctors Without Borders on the Nigerian cholera epidemic. That interview is just wrenching—how she found herself in the midst of hundreds of people suffering from cholera and she was basically put in charge, she had nothing to work with, and people were dying around her.

She also discussed how she had changed her life—she sold her house and moved back with her parents so that she could have the flexibility to, with two days’ notice, be dispatched wherever she’s needed in the world, to work for Doctors Without Borders. She described feeling like this was the reason she went into health care and became an NP, to make that kind of difference. It’s a poignant interview about how much of an impact we can have.

The most surprising guest was probably CAPT Linnea Axman, one of the top-ranked NPs in the Navy. I expected her to be a little more formal, but actually, she was so humanistic and so real in how she described her commitment to her service in the military, that it was just beautiful. She was so articulate and so personally motivated. She described her family history of multiple family members being in the military. I just didn’t expect to be moved that much.

CR: Who is on your wish list of future guests?

SECOR: My wish list includes the incredibly overachieving fellows in the American Academy of Nurse Practitioners. I would like to do a radio show with every single one of them. I consider them the top-ranked NPs in the country. And I would need to do a live radio show every day to get through; there are several hundred now!

LENELL: One is Richard (Dick) Smith, who many consider one of, if not the, founders of the PA profession. He agreed to come on the show a while back, but then he had to cancel due to illness. So I still think it would be the capstone of my radio career to have Dick Smith on.

I would love to have President Obama on, but that’s probably not going to work out. We’ve reached out to Michelle Obama a few times for her diabetes work, so we’re hopeful that might work out at some point.

CR: What do you find most rewarding about your work on Partners in Practice?

LENELL: For me, it has always been about the opportunity to meet so many people. Along the way, I have learned more from the show than I’ve learned in any school or practice in life. I do my own writing—so does Mimi—and for a while I produced the show myself, so to do a good show, you have to know your topic. It forced me to learn about everyone and everything I was going to talk about.

SECOR: When I talk to groups, I always say, “You all have a story, and I can help you be successful in the media.” I am dedicated to media success for NPs, and my show is a way of coaching my peers to prepare for media opportunities that might not be so supportive. My job is to be a coach, and unlike Howard Stern, I’m not going to try to trip people up; I’m going to try to make them successful.

CR: All segments of Partners in Practice are archived on the ReachMD Web site (www.reachmd.com). Tune in next time to see what Lisa and Mimi have in store!

This year’s Oscar-winning film The King’s Speech delivered the important message that each of us has a voice and deserves to be heard. Thanks to two passionate, driven clinicians, satellite radio—specifically, ReachMD (XM160)—is providing another venue for NPs and PAs to reach new audiences and expand their message, not only to their colleagues but also to physicians and the general public.

Lisa Dandrea Lenell, MPAS, PA-C, and Mimi Secor, MS, MEd, APRN, BC, FNP, FAANP, are the co-hosts of Partners in Practice. They are also Clinician Reviews Editorial Board members, so we decided to turn the tables and put them in the interview chair.

CR: How and when did you get involved with ReachMD?

LENELL: Dr. David Preskill, who started ReachMD, is in our practice’s referral chain. He was advised that if he wanted to expand the listening audience, he needed to get an NP or a PA on board. So, one day he called and asked me if I wanted to get involved. At first, I wasn’t interested, because I had a lot on my plate and I wasn’t really experienced in radio. But he said, “Well, just try.” So I contacted Ed Lopez, PA-C, for my guest, and we put together a demo, and they said, “OK, we’ll   get back to you.” And a month later, I was in my car listening to ReachMD, and my show came on! That was October 2007.

I did the show myself—we just called it “The PA Show” then—until Mimi came on board. There had always been talk about expanding the show and bringing out the roles that different people play in health care. Having an NP was always on the agenda.

SECOR: When I got involved was just about a year ago, and how was with the help of a PA [Clinician Reviews Publisher Gary Falcetano, PA-C] who gave my name as a possible host when he heard that ReachMD might be considering adding an NP host. So I actually have a PA to thank for that!

Lisa was so gracious and helpful in assisting me to “get up to speed” as a national radio host. She was supportive, offered constructive suggestions, and wasn’t intimidated when I was added to what had, to that point, been “her” show.

CR: What is your approach to the show, in terms of choosing topics or guests?

SECOR: I have two reasons for doing the show: One is to enhance the visibility of NPs in a positive way, to show how smart they are, how expert they are, what a difference they make in health care, really showcasing the profession in a positive light to the world. And the second is to get good content out there. So the good content is actually used to illustrate how great NPs are.

As far as topics, number one, I have to have my finger on the pulse of what’s going on in my profession. So I’m constantly scanning the literature and keeping an eye on the national monthly occurrences so I can try to coordinate some of the programs we do with, say, Breast Cancer Awareness Month or whatever is going on in the world. Often when I’m interacting with my colleagues at conferences, I’m looking for “the expert.”

LENELL: My goal is to provide a forum where people can get simple answers to simple questions that they might want to ask but for whatever reason won’t ask or don’t know who to ask or how to find out. The goal from the beginning has always been to educate the public, medical professionals, and anyone we can about what a PA is and what we can do, to move the myths and misconceptions out of the way and do a professional, responsible job.

If I hear someone say something about PAs, and I didn’t know that bit of information, I’ll start researching it for a show. I’ve done several on coding and reimbursement for PAs, because I think it’s super important and I get those questions all the time. It’s confusing, and there’s no really great source for PAs. So I’ve had great people on the show to help us walk through that. I’ve done malpractice shows several times, because that’s another one that is really confusing for PAs. So I ask the questions that people want to ask but don’t know how.

I’ve seen a progression from the early shows. Some of the original topics, I knew only what I needed to know. But as I started peeling the onion of the PA profession, something new would come out that interested me, and we’d go after that for a show. It became almost like detective work to get interesting stories that were different.

CR: What are some of the memorable moments from Partners in Practice?

LENELL: My favorite shows, always, are the personal interest stories. My favorite was Vic Germino, one of the original four PAs from Duke. He is such a humble, amazing man, and he came on and told his story in a beautiful, personal way. I had goosebumps when it was over.

Another favorite is Russ Dorr, the medical writer for Stephen King. He’s a PA who still works full-time in pediatrics and he’s “Russ Dorr, the man behind the gore.” I got so many comments after that show, because who knew that the guy who writes all the medical info for Stephen King is a PA?

The only time we did a “breaking news” show was in Haiti. There were many, many PAs there, and of course no one talked about them. So I really wanted to get a PA who was in Haiti on the air. Eric Holden was in Haiti, and he managed to get a phone—we waited for him at the studio for a couple hours, in the hope that he could reach us. Anyway, Eric got a phone from a military operation that was assisting his group of responders. And you could hear in the background, while he was talking to us, everything that was going on. I was really grateful for him to come on.

My favorite topics in the past two years have been the global developments of the PA profession; I’ve become a little bit of an addict. I decided I was going to interview someone from every single country where there was a PA program. [These segments covered programs in Ghana, Canada, Australia, Scotland, England, Puerto Rico, and the Netherlands; Lenell has also interviewed PAs who did humanitarian work in Sudan and coordinated an exchange program with Thailand.]

SECOR: I think the most touching interview I have done was with Maryana McGlasson, who had just come back from working with Doctors Without Borders on the Nigerian cholera epidemic. That interview is just wrenching—how she found herself in the midst of hundreds of people suffering from cholera and she was basically put in charge, she had nothing to work with, and people were dying around her.

She also discussed how she had changed her life—she sold her house and moved back with her parents so that she could have the flexibility to, with two days’ notice, be dispatched wherever she’s needed in the world, to work for Doctors Without Borders. She described feeling like this was the reason she went into health care and became an NP, to make that kind of difference. It’s a poignant interview about how much of an impact we can have.

The most surprising guest was probably CAPT Linnea Axman, one of the top-ranked NPs in the Navy. I expected her to be a little more formal, but actually, she was so humanistic and so real in how she described her commitment to her service in the military, that it was just beautiful. She was so articulate and so personally motivated. She described her family history of multiple family members being in the military. I just didn’t expect to be moved that much.

CR: Who is on your wish list of future guests?

SECOR: My wish list includes the incredibly overachieving fellows in the American Academy of Nurse Practitioners. I would like to do a radio show with every single one of them. I consider them the top-ranked NPs in the country. And I would need to do a live radio show every day to get through; there are several hundred now!

LENELL: One is Richard (Dick) Smith, who many consider one of, if not the, founders of the PA profession. He agreed to come on the show a while back, but then he had to cancel due to illness. So I still think it would be the capstone of my radio career to have Dick Smith on.

I would love to have President Obama on, but that’s probably not going to work out. We’ve reached out to Michelle Obama a few times for her diabetes work, so we’re hopeful that might work out at some point.

CR: What do you find most rewarding about your work on Partners in Practice?

LENELL: For me, it has always been about the opportunity to meet so many people. Along the way, I have learned more from the show than I’ve learned in any school or practice in life. I do my own writing—so does Mimi—and for a while I produced the show myself, so to do a good show, you have to know your topic. It forced me to learn about everyone and everything I was going to talk about.

SECOR: When I talk to groups, I always say, “You all have a story, and I can help you be successful in the media.” I am dedicated to media success for NPs, and my show is a way of coaching my peers to prepare for media opportunities that might not be so supportive. My job is to be a coach, and unlike Howard Stern, I’m not going to try to trip people up; I’m going to try to make them successful.

CR: All segments of Partners in Practice are archived on the ReachMD Web site (www.reachmd.com). Tune in next time to see what Lisa and Mimi have in store!

This year’s Oscar-winning film The King’s Speech delivered the important message that each of us has a voice and deserves to be heard. Thanks to two passionate, driven clinicians, satellite radio—specifically, ReachMD (XM160)—is providing another venue for NPs and PAs to reach new audiences and expand their message, not only to their colleagues but also to physicians and the general public.

Lisa Dandrea Lenell, MPAS, PA-C, and Mimi Secor, MS, MEd, APRN, BC, FNP, FAANP, are the co-hosts of Partners in Practice. They are also Clinician Reviews Editorial Board members, so we decided to turn the tables and put them in the interview chair.

CR: How and when did you get involved with ReachMD?

LENELL: Dr. David Preskill, who started ReachMD, is in our practice’s referral chain. He was advised that if he wanted to expand the listening audience, he needed to get an NP or a PA on board. So, one day he called and asked me if I wanted to get involved. At first, I wasn’t interested, because I had a lot on my plate and I wasn’t really experienced in radio. But he said, “Well, just try.” So I contacted Ed Lopez, PA-C, for my guest, and we put together a demo, and they said, “OK, we’ll   get back to you.” And a month later, I was in my car listening to ReachMD, and my show came on! That was October 2007.

I did the show myself—we just called it “The PA Show” then—until Mimi came on board. There had always been talk about expanding the show and bringing out the roles that different people play in health care. Having an NP was always on the agenda.

SECOR: When I got involved was just about a year ago, and how was with the help of a PA [Clinician Reviews Publisher Gary Falcetano, PA-C] who gave my name as a possible host when he heard that ReachMD might be considering adding an NP host. So I actually have a PA to thank for that!

Lisa was so gracious and helpful in assisting me to “get up to speed” as a national radio host. She was supportive, offered constructive suggestions, and wasn’t intimidated when I was added to what had, to that point, been “her” show.

CR: What is your approach to the show, in terms of choosing topics or guests?

SECOR: I have two reasons for doing the show: One is to enhance the visibility of NPs in a positive way, to show how smart they are, how expert they are, what a difference they make in health care, really showcasing the profession in a positive light to the world. And the second is to get good content out there. So the good content is actually used to illustrate how great NPs are.

As far as topics, number one, I have to have my finger on the pulse of what’s going on in my profession. So I’m constantly scanning the literature and keeping an eye on the national monthly occurrences so I can try to coordinate some of the programs we do with, say, Breast Cancer Awareness Month or whatever is going on in the world. Often when I’m interacting with my colleagues at conferences, I’m looking for “the expert.”

LENELL: My goal is to provide a forum where people can get simple answers to simple questions that they might want to ask but for whatever reason won’t ask or don’t know who to ask or how to find out. The goal from the beginning has always been to educate the public, medical professionals, and anyone we can about what a PA is and what we can do, to move the myths and misconceptions out of the way and do a professional, responsible job.

If I hear someone say something about PAs, and I didn’t know that bit of information, I’ll start researching it for a show. I’ve done several on coding and reimbursement for PAs, because I think it’s super important and I get those questions all the time. It’s confusing, and there’s no really great source for PAs. So I’ve had great people on the show to help us walk through that. I’ve done malpractice shows several times, because that’s another one that is really confusing for PAs. So I ask the questions that people want to ask but don’t know how.

I’ve seen a progression from the early shows. Some of the original topics, I knew only what I needed to know. But as I started peeling the onion of the PA profession, something new would come out that interested me, and we’d go after that for a show. It became almost like detective work to get interesting stories that were different.

CR: What are some of the memorable moments from Partners in Practice?

LENELL: My favorite shows, always, are the personal interest stories. My favorite was Vic Germino, one of the original four PAs from Duke. He is such a humble, amazing man, and he came on and told his story in a beautiful, personal way. I had goosebumps when it was over.

Another favorite is Russ Dorr, the medical writer for Stephen King. He’s a PA who still works full-time in pediatrics and he’s “Russ Dorr, the man behind the gore.” I got so many comments after that show, because who knew that the guy who writes all the medical info for Stephen King is a PA?

The only time we did a “breaking news” show was in Haiti. There were many, many PAs there, and of course no one talked about them. So I really wanted to get a PA who was in Haiti on the air. Eric Holden was in Haiti, and he managed to get a phone—we waited for him at the studio for a couple hours, in the hope that he could reach us. Anyway, Eric got a phone from a military operation that was assisting his group of responders. And you could hear in the background, while he was talking to us, everything that was going on. I was really grateful for him to come on.

My favorite topics in the past two years have been the global developments of the PA profession; I’ve become a little bit of an addict. I decided I was going to interview someone from every single country where there was a PA program. [These segments covered programs in Ghana, Canada, Australia, Scotland, England, Puerto Rico, and the Netherlands; Lenell has also interviewed PAs who did humanitarian work in Sudan and coordinated an exchange program with Thailand.]

SECOR: I think the most touching interview I have done was with Maryana McGlasson, who had just come back from working with Doctors Without Borders on the Nigerian cholera epidemic. That interview is just wrenching—how she found herself in the midst of hundreds of people suffering from cholera and she was basically put in charge, she had nothing to work with, and people were dying around her.

She also discussed how she had changed her life—she sold her house and moved back with her parents so that she could have the flexibility to, with two days’ notice, be dispatched wherever she’s needed in the world, to work for Doctors Without Borders. She described feeling like this was the reason she went into health care and became an NP, to make that kind of difference. It’s a poignant interview about how much of an impact we can have.

The most surprising guest was probably CAPT Linnea Axman, one of the top-ranked NPs in the Navy. I expected her to be a little more formal, but actually, she was so humanistic and so real in how she described her commitment to her service in the military, that it was just beautiful. She was so articulate and so personally motivated. She described her family history of multiple family members being in the military. I just didn’t expect to be moved that much.

CR: Who is on your wish list of future guests?

SECOR: My wish list includes the incredibly overachieving fellows in the American Academy of Nurse Practitioners. I would like to do a radio show with every single one of them. I consider them the top-ranked NPs in the country. And I would need to do a live radio show every day to get through; there are several hundred now!

LENELL: One is Richard (Dick) Smith, who many consider one of, if not the, founders of the PA profession. He agreed to come on the show a while back, but then he had to cancel due to illness. So I still think it would be the capstone of my radio career to have Dick Smith on.

I would love to have President Obama on, but that’s probably not going to work out. We’ve reached out to Michelle Obama a few times for her diabetes work, so we’re hopeful that might work out at some point.

CR: What do you find most rewarding about your work on Partners in Practice?

LENELL: For me, it has always been about the opportunity to meet so many people. Along the way, I have learned more from the show than I’ve learned in any school or practice in life. I do my own writing—so does Mimi—and for a while I produced the show myself, so to do a good show, you have to know your topic. It forced me to learn about everyone and everything I was going to talk about.

SECOR: When I talk to groups, I always say, “You all have a story, and I can help you be successful in the media.” I am dedicated to media success for NPs, and my show is a way of coaching my peers to prepare for media opportunities that might not be so supportive. My job is to be a coach, and unlike Howard Stern, I’m not going to try to trip people up; I’m going to try to make them successful.

CR: All segments of Partners in Practice are archived on the ReachMD Web site (www.reachmd.com). Tune in next time to see what Lisa and Mimi have in store!

Between 1995 and 2008, the number of pediatric visits to an emergency department (ED) that included computed tomography (CT) increased fivefold, according to study results published online ahead of print by the journal Radiology. The researchers, led by David B. Larson, MD, MBA, Director of Quality Improvement in the Department of Radiology at Cincinnati Children's Hospital Medical Center in Ohio, say the substantial growth in CT use "is explained by increasing frequency of use, not by an increase in the number of pediatric visits to the ED."

Larson and colleagues also reported that about 90% of the visits associated with CT in children were made to nonpediatric-focused EDs (ie, those in which the average patient was older than 10). Given what is understood about the increased risks of radiation exposure in children, this finding raises additional questions and concerns about whether children received a radiation dose that was scaled to their body size or an adult dose. (The study was not designed to assess that.)

Whether to order CT in a child may be a daunting proposition for a clinician, particularly if he or she does not have subspecialty training in pediatrics. Ordering an unnecessary test may needlessly expose the patient to radiation, but missing a diagnosis that results in a negative outcome is also fraught with peril.

"This is the fine line that we walk in this conversation: On the one hand, CT uses radiation, so we should use it cautiously," Larson says. "On the other hand, the risk is very low, and we don't want to scare people out of getting CT."

Boom Years for CT Use
The National Cancer Institute reports that four to seven million CT exams are performed in children annually in the US, and that the use of CT (in both adults and children) has increased significantly since 1980, growing at an estimated rate of 10% per year. Larson attributes much of the increase observed in his study—an annual growth rate of about 13%—to the fact that the technology "improved significantly" during the time period examined.

"This is a time when the technology moved from basically axial scanning to helical scanning, and also from single detector to multichannel detectors," he says. "So, that translates into a much faster scan and a much higher-resolution scan. This is especially important in children, because it means less sedation, and in the ED, it means you can come to a decision very quickly."

Another factor driving the increased use of CT has been the ready availability of the equipment. A decade ago, major hospitals might have had a scanner, but it was not necessarily located adjacent to, let alone within, the ED. Smaller facilities may not have had a scanner, period.

"The availability of CT has increased exponentially over the past 10 years, and it has been a very reliable diagnostic tool," says John J. Graykoski, MPAS, PA-C, President of the Society of Emergency Medicine PAs and ER PA Supervisor at Luther Midelfort Mayo Health System in Colfax, Wisconsin. "It has tremendously enhanced our ability to identify problems much earlier and with much greater accuracy than our old plain films could do."

Speed and accuracy are particularly valuable in the emergency department, where, in the words of Michael P. Poirier, MD, Associate Professor of Pediatrics, Eastern Virginia Medical School, and Fellowship Director, Division of Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, Virginia, "you have one chance to get it right."

That time pressure to make an accurate diagnosis, coupled with the ever-present fear of litigation if the wrong decision is made or a negative outcome occurs despite the clinician's best efforts, may lead to the ordering of a CT scan that is not truly necessary. The prevailing wisdom might be "It's better to rule out the worst-case scenario and have that reassurance than to take the chance of missing something."

The drawback to that philosophy is that CT uses radiation—more of it than the average x-ray. The effective dose of radiation in the average CT scan of the head is equivalent to approximately 100 x-rays and in the average abdominal CT scan, 400 x-rays. Granted, these doses are from scans that are unadjusted for body weight, and in theory children should be undergoing CT with reduced radiation exposure parameters. Whether they actually are, particularly at nonpediatric facilities, is unknown.

"We hope that at all facilities, whether they are pediatric-focused or not, the dose is being tailored to the patient's size," Larson says, "but we don't know. We know that it has [improved] at children's hospitals; that study just hasn't been done at non-children's hospitals. I think the concern is that right now, it's actually rather difficult to monitor that."

At Graykoski's facility, which is not pediatric-focused, the staff is "acutely aware of this issue." Consultations with the radiologist prior to the ordering of scans are common, protocols are in place to limit the amount of radiation exposure in CT scans, and the newest-generation equipment, which has built-in capabilities to limit exposure, is available. "We're trying to do everything we can to make sure that the risks associated with imaging are offset by the benefits to be realized from it," Graykoski says.

The National Cancer Institute stresses that "the individual cancer risks associated with CT scans are small," with lifetime risks estimated at less than 1 in 1,000. However, as the data indicate, children are increasingly being exposed to those risks, and they may be particularly vulnerable. "From age 0 to 14 especially, the DNA is rapidly replicating, and that's when it is most vulnerable to insult from radiation," Graykoski explains.

Furthermore, "the risk of radiation is a cumulative lifetime risk. It's not the case that you just take a picture and in 24 hours, the side effects are gone," he adds. Young children have the rest of their lives to accumulate radiation exposure from additional imaging tests and from natural circumstances. (The average effective dose of natural background radiation is 3 mSv per year in the United States.)

"It's not that we have the crisis right now—this is a problem that will be growing into the future," Graykoski says, especially if the boom in the use of this imaging modality does not abate. "And of course, our concern is for safety—we don't want to be responsible for causing harm to any patient, especially a youngster."

First, Do No Harm
Any clinician who is considering ordering CT for a pediatric patient may want to paraphrase a classic World War II adage. Instead of asking, "Is this trip really necessary?" the question should be, "Is this test really necessary?"

As with any type of test, the decision to order CT should be made after careful consideration of the risks and benefits, as well as how the specific test will change the clinical management of the patient. Will the child be able to go home? Will he/she require an operation? Will the child need to be admitted?

Health care providers "need to be absolutely sure that the results of that test are actually going to help them make a decision or a diagnosis," Poirier says. "And if time will help you make a diagnosis and does not put the patient at risk, then sometimes you don't do the test. You talk to the family, and maybe you admit the patient or maybe you have them follow up the next day."

A classic example is a child who has experienced head trauma; perhaps he or she was stunned at the time of the event or had an episode or two of vomiting. "It used to be pretty routine that all of those kids would get CT evaluations," Poirier says. "The recent studies have shown that those CT scans don't change the management of those patients. It's just unnecessary radiation."

Instead, it may be more appropriate to watch the patient in the ED until it is clear his/her condition is not going to deteriorate, ensure the family has adequate follow-up, or even keep the child in the ED or admit him/her for overnight observation. Of course, there are geographic factors to consider as well.

"A lot has to do with the comfort level of the parents—are they comfortable waiting and watching? Is it convenient?" says Graykoski, whose facility is in west-central Wisconsin. "We have patients who are two hours away from the hospital, so it's not the easiest thing to say, 'Well, go home; if it gets worse, bring him back.' A couple of hours can certainly be very serious."

Communication is key so that parents have a full understanding of why an imaging study may or may not be in their child's best interest. Despite reports in the mainstream media about the radiation risk of CT, none of the clinicians interviewed has yet encountered parents who refused CT because of that risk. Graykoski says he is usually the one to broach the subject with parents.

"Most parents, I think, want to hear that discussion," he says, "but I would say the majority want the reassurance of having some of these tests done and frequently will err on the side of getting that information and ruling something out, as opposed to thinking about the future effect of radiation accumulation."

In the pediatric emergency setting, Poirier says it is more likely that the clinicians will utilize the available information to talk families out of getting an unnecessary test. "They may come with preconceived expectations," he says. "Maybe they were sent from the adult facility or from another provider because they 'need' this head CT or they 'need' that abdominal CT—and in fact, they don't. We very frequently explain to them that we don't want to expose the child to any unnecessary radiation, and therefore, we don't think this test is necessary."

How significant a role "defensive medicine" plays in the decision-making process is unclear, although studies have shown that the fear of litigation increases utilization of all imaging, not just CT. The fear of being sued for missing a diagnosis could someday be countered by the fear of being sued for exposing a child to radiation unnecessarily—a rock/hard place debate if ever there was one.

"All you can do is apply the best information you have with your best clinical judgment and try to do what's right for the patient," Graykoski says, "and hope that in 20 years some lawyer doesn't come knocking on your door, saying 'pay up.' But I think for all of us, our motivation and training is 'first, do no harm,' and we all take that very seriously."

Will CT one day be a diagnostic modality for which informed consent is universally required? Or will advances in technology continue to occur, producing safer scanners? Larson, for one, defends the judicious use of CT, saying, "It keeps getting better and better, and the manufacturers are continuing to decrease the radiation dose. So I expect it's going to continue to be important for a long time."

As technology improves, other modalities may emerge as more valuable diagnostic tools in certain situations, providing alternatives to CT. "I think in the next 10 to 15 years, we're probably going to be shifting to high-speed MRIs, which don't have the radiation exposure," Poirier says. "And we're going to look back at this time, in the '80s and '90s, when the use of CT scans basically just exploded, and we're going to be dealing with the consequences."

Graykoski also points out that ultrasound "is becoming a viable alternative to CT in the case of appendicitis. The key now is training the ultrasonographers and having the quality in place to ensure that the accuracy is at a point where it should be."

Clinicians should also remember that the radiologist is another partner and a valuable human asset in patient care. He or she should be reviewing the orders, particularly the indication for the request, and may follow up if the order doesn't make sense.

"Try to avoid becoming defensive and understand that the radiologist usually views himself/herself as a last stand in confirming that this is an appropriate examination," Larson advises. "Often, the radiologist can offer alternative imaging or talk the clinician through a case that is on the margin in terms of whether CT is indicated."

Deciding whether to order CT in a child is about striking an appropriate balance. "On the one hand, we might say, 'If you don't need the CT, don't get it,' or 'If there is a reasonable alternative, then go with that reasonable alternative,'" Larson says. "On the other hand, if there is a serious or life-threatening illness or injury, or a case where you really need that information, then the parent and the clinician should absolutely just get the CT and not give it a second thought."

Poirier thinks there is a place for observation and for ruling out life-threatening and dangerous diagnoses, "but there's also a place for having an unknown and letting time help you decide, with close follow-up and appropriate observation. And therefore, sometimes you are able to avoid performing one of these tests. You're going to get the same information; you're just going to get it a little later. That's the art of medicine—knowing when to order it and knowing when not to."

"The bottom line is that medical science is a human science, and there are no absolutes," Graykoski says. "You can do your best, but you cannot predict the future. We graduate and get a stethoscope; we don't get a crystal ball."

Between 1995 and 2008, the number of pediatric visits to an emergency department (ED) that included computed tomography (CT) increased fivefold, according to study results published online ahead of print by the journal Radiology. The researchers, led by David B. Larson, MD, MBA, Director of Quality Improvement in the Department of Radiology at Cincinnati Children's Hospital Medical Center in Ohio, say the substantial growth in CT use "is explained by increasing frequency of use, not by an increase in the number of pediatric visits to the ED."

Larson and colleagues also reported that about 90% of the visits associated with CT in children were made to nonpediatric-focused EDs (ie, those in which the average patient was older than 10). Given what is understood about the increased risks of radiation exposure in children, this finding raises additional questions and concerns about whether children received a radiation dose that was scaled to their body size or an adult dose. (The study was not designed to assess that.)

Whether to order CT in a child may be a daunting proposition for a clinician, particularly if he or she does not have subspecialty training in pediatrics. Ordering an unnecessary test may needlessly expose the patient to radiation, but missing a diagnosis that results in a negative outcome is also fraught with peril.

"This is the fine line that we walk in this conversation: On the one hand, CT uses radiation, so we should use it cautiously," Larson says. "On the other hand, the risk is very low, and we don't want to scare people out of getting CT."

Boom Years for CT Use
The National Cancer Institute reports that four to seven million CT exams are performed in children annually in the US, and that the use of CT (in both adults and children) has increased significantly since 1980, growing at an estimated rate of 10% per year. Larson attributes much of the increase observed in his study—an annual growth rate of about 13%—to the fact that the technology "improved significantly" during the time period examined.

"This is a time when the technology moved from basically axial scanning to helical scanning, and also from single detector to multichannel detectors," he says. "So, that translates into a much faster scan and a much higher-resolution scan. This is especially important in children, because it means less sedation, and in the ED, it means you can come to a decision very quickly."

Another factor driving the increased use of CT has been the ready availability of the equipment. A decade ago, major hospitals might have had a scanner, but it was not necessarily located adjacent to, let alone within, the ED. Smaller facilities may not have had a scanner, period.

"The availability of CT has increased exponentially over the past 10 years, and it has been a very reliable diagnostic tool," says John J. Graykoski, MPAS, PA-C, President of the Society of Emergency Medicine PAs and ER PA Supervisor at Luther Midelfort Mayo Health System in Colfax, Wisconsin. "It has tremendously enhanced our ability to identify problems much earlier and with much greater accuracy than our old plain films could do."

Speed and accuracy are particularly valuable in the emergency department, where, in the words of Michael P. Poirier, MD, Associate Professor of Pediatrics, Eastern Virginia Medical School, and Fellowship Director, Division of Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, Virginia, "you have one chance to get it right."

That time pressure to make an accurate diagnosis, coupled with the ever-present fear of litigation if the wrong decision is made or a negative outcome occurs despite the clinician's best efforts, may lead to the ordering of a CT scan that is not truly necessary. The prevailing wisdom might be "It's better to rule out the worst-case scenario and have that reassurance than to take the chance of missing something."

The drawback to that philosophy is that CT uses radiation—more of it than the average x-ray. The effective dose of radiation in the average CT scan of the head is equivalent to approximately 100 x-rays and in the average abdominal CT scan, 400 x-rays. Granted, these doses are from scans that are unadjusted for body weight, and in theory children should be undergoing CT with reduced radiation exposure parameters. Whether they actually are, particularly at nonpediatric facilities, is unknown.

"We hope that at all facilities, whether they are pediatric-focused or not, the dose is being tailored to the patient's size," Larson says, "but we don't know. We know that it has [improved] at children's hospitals; that study just hasn't been done at non-children's hospitals. I think the concern is that right now, it's actually rather difficult to monitor that."

At Graykoski's facility, which is not pediatric-focused, the staff is "acutely aware of this issue." Consultations with the radiologist prior to the ordering of scans are common, protocols are in place to limit the amount of radiation exposure in CT scans, and the newest-generation equipment, which has built-in capabilities to limit exposure, is available. "We're trying to do everything we can to make sure that the risks associated with imaging are offset by the benefits to be realized from it," Graykoski says.

The National Cancer Institute stresses that "the individual cancer risks associated with CT scans are small," with lifetime risks estimated at less than 1 in 1,000. However, as the data indicate, children are increasingly being exposed to those risks, and they may be particularly vulnerable. "From age 0 to 14 especially, the DNA is rapidly replicating, and that's when it is most vulnerable to insult from radiation," Graykoski explains.

Furthermore, "the risk of radiation is a cumulative lifetime risk. It's not the case that you just take a picture and in 24 hours, the side effects are gone," he adds. Young children have the rest of their lives to accumulate radiation exposure from additional imaging tests and from natural circumstances. (The average effective dose of natural background radiation is 3 mSv per year in the United States.)

"It's not that we have the crisis right now—this is a problem that will be growing into the future," Graykoski says, especially if the boom in the use of this imaging modality does not abate. "And of course, our concern is for safety—we don't want to be responsible for causing harm to any patient, especially a youngster."

First, Do No Harm
Any clinician who is considering ordering CT for a pediatric patient may want to paraphrase a classic World War II adage. Instead of asking, "Is this trip really necessary?" the question should be, "Is this test really necessary?"

As with any type of test, the decision to order CT should be made after careful consideration of the risks and benefits, as well as how the specific test will change the clinical management of the patient. Will the child be able to go home? Will he/she require an operation? Will the child need to be admitted?

Health care providers "need to be absolutely sure that the results of that test are actually going to help them make a decision or a diagnosis," Poirier says. "And if time will help you make a diagnosis and does not put the patient at risk, then sometimes you don't do the test. You talk to the family, and maybe you admit the patient or maybe you have them follow up the next day."

A classic example is a child who has experienced head trauma; perhaps he or she was stunned at the time of the event or had an episode or two of vomiting. "It used to be pretty routine that all of those kids would get CT evaluations," Poirier says. "The recent studies have shown that those CT scans don't change the management of those patients. It's just unnecessary radiation."

Instead, it may be more appropriate to watch the patient in the ED until it is clear his/her condition is not going to deteriorate, ensure the family has adequate follow-up, or even keep the child in the ED or admit him/her for overnight observation. Of course, there are geographic factors to consider as well.

"A lot has to do with the comfort level of the parents—are they comfortable waiting and watching? Is it convenient?" says Graykoski, whose facility is in west-central Wisconsin. "We have patients who are two hours away from the hospital, so it's not the easiest thing to say, 'Well, go home; if it gets worse, bring him back.' A couple of hours can certainly be very serious."

Communication is key so that parents have a full understanding of why an imaging study may or may not be in their child's best interest. Despite reports in the mainstream media about the radiation risk of CT, none of the clinicians interviewed has yet encountered parents who refused CT because of that risk. Graykoski says he is usually the one to broach the subject with parents.

"Most parents, I think, want to hear that discussion," he says, "but I would say the majority want the reassurance of having some of these tests done and frequently will err on the side of getting that information and ruling something out, as opposed to thinking about the future effect of radiation accumulation."

In the pediatric emergency setting, Poirier says it is more likely that the clinicians will utilize the available information to talk families out of getting an unnecessary test. "They may come with preconceived expectations," he says. "Maybe they were sent from the adult facility or from another provider because they 'need' this head CT or they 'need' that abdominal CT—and in fact, they don't. We very frequently explain to them that we don't want to expose the child to any unnecessary radiation, and therefore, we don't think this test is necessary."

How significant a role "defensive medicine" plays in the decision-making process is unclear, although studies have shown that the fear of litigation increases utilization of all imaging, not just CT. The fear of being sued for missing a diagnosis could someday be countered by the fear of being sued for exposing a child to radiation unnecessarily—a rock/hard place debate if ever there was one.

"All you can do is apply the best information you have with your best clinical judgment and try to do what's right for the patient," Graykoski says, "and hope that in 20 years some lawyer doesn't come knocking on your door, saying 'pay up.' But I think for all of us, our motivation and training is 'first, do no harm,' and we all take that very seriously."

Will CT one day be a diagnostic modality for which informed consent is universally required? Or will advances in technology continue to occur, producing safer scanners? Larson, for one, defends the judicious use of CT, saying, "It keeps getting better and better, and the manufacturers are continuing to decrease the radiation dose. So I expect it's going to continue to be important for a long time."

As technology improves, other modalities may emerge as more valuable diagnostic tools in certain situations, providing alternatives to CT. "I think in the next 10 to 15 years, we're probably going to be shifting to high-speed MRIs, which don't have the radiation exposure," Poirier says. "And we're going to look back at this time, in the '80s and '90s, when the use of CT scans basically just exploded, and we're going to be dealing with the consequences."

Graykoski also points out that ultrasound "is becoming a viable alternative to CT in the case of appendicitis. The key now is training the ultrasonographers and having the quality in place to ensure that the accuracy is at a point where it should be."

Clinicians should also remember that the radiologist is another partner and a valuable human asset in patient care. He or she should be reviewing the orders, particularly the indication for the request, and may follow up if the order doesn't make sense.

"Try to avoid becoming defensive and understand that the radiologist usually views himself/herself as a last stand in confirming that this is an appropriate examination," Larson advises. "Often, the radiologist can offer alternative imaging or talk the clinician through a case that is on the margin in terms of whether CT is indicated."

Deciding whether to order CT in a child is about striking an appropriate balance. "On the one hand, we might say, 'If you don't need the CT, don't get it,' or 'If there is a reasonable alternative, then go with that reasonable alternative,'" Larson says. "On the other hand, if there is a serious or life-threatening illness or injury, or a case where you really need that information, then the parent and the clinician should absolutely just get the CT and not give it a second thought."

Poirier thinks there is a place for observation and for ruling out life-threatening and dangerous diagnoses, "but there's also a place for having an unknown and letting time help you decide, with close follow-up and appropriate observation. And therefore, sometimes you are able to avoid performing one of these tests. You're going to get the same information; you're just going to get it a little later. That's the art of medicine—knowing when to order it and knowing when not to."

"The bottom line is that medical science is a human science, and there are no absolutes," Graykoski says. "You can do your best, but you cannot predict the future. We graduate and get a stethoscope; we don't get a crystal ball."

Between 1995 and 2008, the number of pediatric visits to an emergency department (ED) that included computed tomography (CT) increased fivefold, according to study results published online ahead of print by the journal Radiology. The researchers, led by David B. Larson, MD, MBA, Director of Quality Improvement in the Department of Radiology at Cincinnati Children's Hospital Medical Center in Ohio, say the substantial growth in CT use "is explained by increasing frequency of use, not by an increase in the number of pediatric visits to the ED."

Larson and colleagues also reported that about 90% of the visits associated with CT in children were made to nonpediatric-focused EDs (ie, those in which the average patient was older than 10). Given what is understood about the increased risks of radiation exposure in children, this finding raises additional questions and concerns about whether children received a radiation dose that was scaled to their body size or an adult dose. (The study was not designed to assess that.)

Whether to order CT in a child may be a daunting proposition for a clinician, particularly if he or she does not have subspecialty training in pediatrics. Ordering an unnecessary test may needlessly expose the patient to radiation, but missing a diagnosis that results in a negative outcome is also fraught with peril.

"This is the fine line that we walk in this conversation: On the one hand, CT uses radiation, so we should use it cautiously," Larson says. "On the other hand, the risk is very low, and we don't want to scare people out of getting CT."

Boom Years for CT Use
The National Cancer Institute reports that four to seven million CT exams are performed in children annually in the US, and that the use of CT (in both adults and children) has increased significantly since 1980, growing at an estimated rate of 10% per year. Larson attributes much of the increase observed in his study—an annual growth rate of about 13%—to the fact that the technology "improved significantly" during the time period examined.

"This is a time when the technology moved from basically axial scanning to helical scanning, and also from single detector to multichannel detectors," he says. "So, that translates into a much faster scan and a much higher-resolution scan. This is especially important in children, because it means less sedation, and in the ED, it means you can come to a decision very quickly."

Another factor driving the increased use of CT has been the ready availability of the equipment. A decade ago, major hospitals might have had a scanner, but it was not necessarily located adjacent to, let alone within, the ED. Smaller facilities may not have had a scanner, period.

"The availability of CT has increased exponentially over the past 10 years, and it has been a very reliable diagnostic tool," says John J. Graykoski, MPAS, PA-C, President of the Society of Emergency Medicine PAs and ER PA Supervisor at Luther Midelfort Mayo Health System in Colfax, Wisconsin. "It has tremendously enhanced our ability to identify problems much earlier and with much greater accuracy than our old plain films could do."

Speed and accuracy are particularly valuable in the emergency department, where, in the words of Michael P. Poirier, MD, Associate Professor of Pediatrics, Eastern Virginia Medical School, and Fellowship Director, Division of Emergency Medicine, Children's Hospital of the King's Daughters, Norfolk, Virginia, "you have one chance to get it right."

That time pressure to make an accurate diagnosis, coupled with the ever-present fear of litigation if the wrong decision is made or a negative outcome occurs despite the clinician's best efforts, may lead to the ordering of a CT scan that is not truly necessary. The prevailing wisdom might be "It's better to rule out the worst-case scenario and have that reassurance than to take the chance of missing something."

The drawback to that philosophy is that CT uses radiation—more of it than the average x-ray. The effective dose of radiation in the average CT scan of the head is equivalent to approximately 100 x-rays and in the average abdominal CT scan, 400 x-rays. Granted, these doses are from scans that are unadjusted for body weight, and in theory children should be undergoing CT with reduced radiation exposure parameters. Whether they actually are, particularly at nonpediatric facilities, is unknown.

"We hope that at all facilities, whether they are pediatric-focused or not, the dose is being tailored to the patient's size," Larson says, "but we don't know. We know that it has [improved] at children's hospitals; that study just hasn't been done at non-children's hospitals. I think the concern is that right now, it's actually rather difficult to monitor that."

At Graykoski's facility, which is not pediatric-focused, the staff is "acutely aware of this issue." Consultations with the radiologist prior to the ordering of scans are common, protocols are in place to limit the amount of radiation exposure in CT scans, and the newest-generation equipment, which has built-in capabilities to limit exposure, is available. "We're trying to do everything we can to make sure that the risks associated with imaging are offset by the benefits to be realized from it," Graykoski says.

The National Cancer Institute stresses that "the individual cancer risks associated with CT scans are small," with lifetime risks estimated at less than 1 in 1,000. However, as the data indicate, children are increasingly being exposed to those risks, and they may be particularly vulnerable. "From age 0 to 14 especially, the DNA is rapidly replicating, and that's when it is most vulnerable to insult from radiation," Graykoski explains.

Furthermore, "the risk of radiation is a cumulative lifetime risk. It's not the case that you just take a picture and in 24 hours, the side effects are gone," he adds. Young children have the rest of their lives to accumulate radiation exposure from additional imaging tests and from natural circumstances. (The average effective dose of natural background radiation is 3 mSv per year in the United States.)

"It's not that we have the crisis right now—this is a problem that will be growing into the future," Graykoski says, especially if the boom in the use of this imaging modality does not abate. "And of course, our concern is for safety—we don't want to be responsible for causing harm to any patient, especially a youngster."

First, Do No Harm
Any clinician who is considering ordering CT for a pediatric patient may want to paraphrase a classic World War II adage. Instead of asking, "Is this trip really necessary?" the question should be, "Is this test really necessary?"

As with any type of test, the decision to order CT should be made after careful consideration of the risks and benefits, as well as how the specific test will change the clinical management of the patient. Will the child be able to go home? Will he/she require an operation? Will the child need to be admitted?

Health care providers "need to be absolutely sure that the results of that test are actually going to help them make a decision or a diagnosis," Poirier says. "And if time will help you make a diagnosis and does not put the patient at risk, then sometimes you don't do the test. You talk to the family, and maybe you admit the patient or maybe you have them follow up the next day."

A classic example is a child who has experienced head trauma; perhaps he or she was stunned at the time of the event or had an episode or two of vomiting. "It used to be pretty routine that all of those kids would get CT evaluations," Poirier says. "The recent studies have shown that those CT scans don't change the management of those patients. It's just unnecessary radiation."

Instead, it may be more appropriate to watch the patient in the ED until it is clear his/her condition is not going to deteriorate, ensure the family has adequate follow-up, or even keep the child in the ED or admit him/her for overnight observation. Of course, there are geographic factors to consider as well.

"A lot has to do with the comfort level of the parents—are they comfortable waiting and watching? Is it convenient?" says Graykoski, whose facility is in west-central Wisconsin. "We have patients who are two hours away from the hospital, so it's not the easiest thing to say, 'Well, go home; if it gets worse, bring him back.' A couple of hours can certainly be very serious."

Communication is key so that parents have a full understanding of why an imaging study may or may not be in their child's best interest. Despite reports in the mainstream media about the radiation risk of CT, none of the clinicians interviewed has yet encountered parents who refused CT because of that risk. Graykoski says he is usually the one to broach the subject with parents.

"Most parents, I think, want to hear that discussion," he says, "but I would say the majority want the reassurance of having some of these tests done and frequently will err on the side of getting that information and ruling something out, as opposed to thinking about the future effect of radiation accumulation."

In the pediatric emergency setting, Poirier says it is more likely that the clinicians will utilize the available information to talk families out of getting an unnecessary test. "They may come with preconceived expectations," he says. "Maybe they were sent from the adult facility or from another provider because they 'need' this head CT or they 'need' that abdominal CT—and in fact, they don't. We very frequently explain to them that we don't want to expose the child to any unnecessary radiation, and therefore, we don't think this test is necessary."

How significant a role "defensive medicine" plays in the decision-making process is unclear, although studies have shown that the fear of litigation increases utilization of all imaging, not just CT. The fear of being sued for missing a diagnosis could someday be countered by the fear of being sued for exposing a child to radiation unnecessarily—a rock/hard place debate if ever there was one.

"All you can do is apply the best information you have with your best clinical judgment and try to do what's right for the patient," Graykoski says, "and hope that in 20 years some lawyer doesn't come knocking on your door, saying 'pay up.' But I think for all of us, our motivation and training is 'first, do no harm,' and we all take that very seriously."

Will CT one day be a diagnostic modality for which informed consent is universally required? Or will advances in technology continue to occur, producing safer scanners? Larson, for one, defends the judicious use of CT, saying, "It keeps getting better and better, and the manufacturers are continuing to decrease the radiation dose. So I expect it's going to continue to be important for a long time."

As technology improves, other modalities may emerge as more valuable diagnostic tools in certain situations, providing alternatives to CT. "I think in the next 10 to 15 years, we're probably going to be shifting to high-speed MRIs, which don't have the radiation exposure," Poirier says. "And we're going to look back at this time, in the '80s and '90s, when the use of CT scans basically just exploded, and we're going to be dealing with the consequences."

Graykoski also points out that ultrasound "is becoming a viable alternative to CT in the case of appendicitis. The key now is training the ultrasonographers and having the quality in place to ensure that the accuracy is at a point where it should be."

Clinicians should also remember that the radiologist is another partner and a valuable human asset in patient care. He or she should be reviewing the orders, particularly the indication for the request, and may follow up if the order doesn't make sense.

"Try to avoid becoming defensive and understand that the radiologist usually views himself/herself as a last stand in confirming that this is an appropriate examination," Larson advises. "Often, the radiologist can offer alternative imaging or talk the clinician through a case that is on the margin in terms of whether CT is indicated."

Deciding whether to order CT in a child is about striking an appropriate balance. "On the one hand, we might say, 'If you don't need the CT, don't get it,' or 'If there is a reasonable alternative, then go with that reasonable alternative,'" Larson says. "On the other hand, if there is a serious or life-threatening illness or injury, or a case where you really need that information, then the parent and the clinician should absolutely just get the CT and not give it a second thought."

Poirier thinks there is a place for observation and for ruling out life-threatening and dangerous diagnoses, "but there's also a place for having an unknown and letting time help you decide, with close follow-up and appropriate observation. And therefore, sometimes you are able to avoid performing one of these tests. You're going to get the same information; you're just going to get it a little later. That's the art of medicine—knowing when to order it and knowing when not to."

"The bottom line is that medical science is a human science, and there are no absolutes," Graykoski says. "You can do your best, but you cannot predict the future. We graduate and get a stethoscope; we don't get a crystal ball."

By now, you have most likely heard about the United Network for Organ Sharing’s Concepts for Kidney Allocation, which outlines potential changes to the way deceased-donor kidneys are, so to speak, “distributed” to any of the 85,000 people currently waiting for one. Depending on your source, however, what you have heard about the concept document probably varies from “It is an effort to make the best use of a limited resource” (true) to “No one over the age of 60 will get a kidney!” (erroneous and also, frankly, outrageous).

The simple fact is that there are not enough available kidneys in the United States to make a dent in the waiting list. UNOS’s concept document does not address the issue of how to increase donations (one manufactured controversy is sufficient for a single document). What it does is provide a rationale for ensuring that each available kidney finds its best possible match.

“We’re not going to create any new kidneys with this, unfortunately,” says John J. Friedewald, MD, Vice Chair of UNOS’s Kidney Transplantation Committee and Assistant Professor in Medicine–Nephrology and Surgery at Northwestern University. “What we are going to do, the idea of this, is to give the right kidney to the right person.”

Tremendous Shift in Transplant Recipients
Just who is the right person for each kidney? And why, after years of the traditionally accepted “first come, first served” method, would the US even need a change in plan?

For one thing, statistics from the US Renal Data System paint a picture of a changing kidney transplantation system. In 1991, three in 10 patients were older than 50; by 2008, that proportion had doubled to six in 10, and one in six was older than 65. Since 2000, the transplantation rate has decreased 30% for persons ages 29 to 50 and increased 49% for those older than 65.

“All of a sudden, we’ve had this tremendous shift, which has only just begun, to transplanting an elderly population,” says Barbara Weis Malone, CFNP, Senior Instructor in the Division of Renal Disease and Hypertension at the University of Colorado Health Sciences Center. “I remember when I started in the transplant community nine years ago, we would barely look at a 60-year-old, and now, regularly, we are transplanting 64-year-olds and occasionally even putting people at 70 on the transplant list.”

At the same time, the average deceased donor is still from among the younger portion of the population, which can lead to serious disparities between graft longevity and recipient longevity. No one is saying older persons don’t deserve a kidney as much as younger persons—but, realistically, does a 68-year-old man need a 6-year-old’s kidney?

“Currently, our system can give a very long-lived kidney to a person who is not expected to live very long,” Friedewald points out. “And vice versa, which is sometimes worse—give a short-lived kidney to someone who is expected to live really long. What that means is that person, usually a younger person, may need a second or even third transplant in his or her lifetime.”

Almost 15% of the waiting list represents people waiting for their second, third, fourth, or even fifth transplant, Friedewald says. Part of the return on investment if the concept document becomes policy could be a reduction in that number. “If we give organs to younger people who are going to live a long time with them, then eventually—not tomorrow; maybe in five, 10, or 15 years—there will be fewer people returning to the wait list,” according to Friedewald. (But we’re getting ahead of ourselves, because the document cannot even be accurately termed a proposal at this point.)

For clinicians in nephrology, seeing the current allocation system in action can be distressing, even though they want to provide the best care to all patients. A sweet, 66-year-old grandmother may end up with an 11-year-old’s kidney, while a 20-year-old, otherwise healthy man with glomerular nephritis may spend years waiting and not get the kidney he ideally needs, one that will last 30 years or longer.

“When I first came into kidney transplant, I thought, ‘It’s just the first person in line; that’s wonderful,’” says Weis Malone. “But now it kind of breaks my heart. As a medical professional, it’s hard to see your younger population who could really use a kidney tomorrow.”

In essence, along with the disparities comes a sense of wasted opportunity. “One in three people dies with a functioning kidney,” says Kim Zuber, PA-C, MSPS, DFAAPA, Chair of the National Kidney Foundation Council of Advanced Practitioners, who practices at Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland. “As far as I’m concerned, that’s a waste, because the kidney should fail before you die; then you’ve used it all up.”

And for those who insist that “first come, first served” is fair, Friedewald has a different opinion, calling it “a complete fallacy. The first come aren’t the first served. Some people won’t live long enough to wait for a kidney, if the line is too long. Everyone believes that a line is ‘first come, first served,’ because we’re used to delis and things like that, where you actually get served. But a lot of people aren’t getting served.”

That may never change, but the concepts outlined in the UNOS document aim to achieve an additional 15,223 life-years lived with a transplanted kidney for every year’s worth of deceased-donor transplants. How? Let’s explore.

How the System Would Change
Early on, Concepts for Kidney Allocation (available at optn.transplant.hrsa.gov/SharedContentDocuments/KidneyConceptDocument.pdf) outlines the flaws of the current system: “[I]t does not strive to minimize death on the waiting list nor maximize survival following transplant. It does not recognize that all candidates do not have the same ability to survive the wait. It does not attempt to match the characteristics of a donor’s kidney to the candidate’s characteristics to promote a long and healthy survival post-transplant. The system can be better, and it can be designed to achieve more in the way of health and longevity than it currently does.”

Aware of the problems, and with input from hundreds of individuals—including transplant professionals, recipients, and candidates, as well as donor families, living donors, and the general public—UNOS’s Kidney Transplantation Committee has spent six years (so far) developing goals for a new allocation system. The concept document delineates three key factors in achieving those goals:

• Utilizing a kidney donor profile index (KDPI), a continuous measure used to estimate the potential function of a donated kidney if it were transplanted into the average recipient, to better characterize donor kidneys.

• Allocating some kidneys (20%) by a combination of the KDPI and a candidate’s estimated post-transplant survival (EPTS).

• Allocating the majority of organs (80%) by age-matching so that candidates within 15 years older or younger than the donor are prioritized.

The KDPI is based on the characteristics of the donor, including age, race/ethnicity, height, and weight, and whether he/she had any of the following factors: hypertension, diabetes, hepatitis C, elevated creatinine level, a cerebrovascular cause of death, or cardiac death. It is important to remember that a score below 20% indicates a kidney with the predicted longest function; it’s like being in the top 20% of your graduating class.

A candidate’s EPTS is based on age, length of time on dialysis, diabetes status, and history of prior organ transplant. “While no calculation will be able to predict life expectancy with 100% certainty, these four factors provide a reasonable estimate for identifying those candidates who have the longest possible EPTS,” the committee writes.

Once a KDPI has been established, there are two scenarios for how a candidate might be selected. Kidneys with a KDPI of 20% or lower are allocated based on EPTS. Those with a KDPI of more than 20% are allocated based on age-matching within 15 years (older or younger) of the recipient’s age.

To use the examples given in the report: Let’s say there are three candidates for a kidney. Mary is 30, Sophia is 21, and David is 60. Along comes a kidney with a KDPI of 10%. Since Mary and Sophia have better estimated survival than David (EPTS, 19%, 12%, and 75% respectively; again, it’s the percentile, so lower is better), they would have priority for that kidney.

However, if the available kidney has a KDPI of, say, 40%, age becomes a bigger factor. If the donor is 34, Mary and Sophia continue to have priority over David, since recipients ages 19 to 49 would be considered first. If the donor is 55, however, David would have precedence over Mary and Sophia, since the age range for that kidney recipient would be 40 to 70.

All of this can be confusing, and it leads one to suspect that some of the news entities who misspoke either did not understand what they were reading or perhaps did not even finish reading the report. But these components do not even tell the entire story; they are exactly that, components. The final proposal, which will be written only when all the feedback from a public comment period has been compiled and analyzed, “will include all the details of who gets the kidney,” as Friedewald says.

What is important to know now is that “waiting time will continue to be a major part of who gets a kidney” if the revised allocation concepts become policy, Friedewald emphasizes. “What this document says is that we’re generally going to group people based on the quality of the donor kidney. But once we do that—let’s say it’s a top 20% kidney—well, then the top 20% of candidates who are expected to live the longest will be up for that kidney. But that may be 10,000 people. Which of the 10,000 people gets the kidney? The person who waits the longest.”

Besides making better use of the available kidneys, the revised allocation system would also make use of more kidneys, by eliminating the previous designation of “expanded criteria donor,” or ECD, kidneys. Some patients turn down ECD kidneys when they are offered, because they may consider the designation a kind of stigma.

“People think ‘expanded criteria’ is this horrible kidney that came from someone who was very old or who probably drank his whole life or had HIV and hepatitis B,” Weis Malone says. “But it could be a 55-year-old person who was taking one blood pressure medication. Right now, there is something like a 12% waste of kidneys that are just being thrown away. As the transplant list grows, it would be nice to utilize those kidneys.”

Obviously, no one would object to someone turning down a kidney from, say, a known IV drug user who was testing negative at the time of death. But does it make sense for a 70-year-old man to turn down an ECD kidney with a creatine level of 1.3, indicative of slight kidney damage? “When you’re talking about someone who has all kidney damage,” Zuber says, “you want to say, ‘What are you thinking? You don’t need a perfect kidney; you need a kidney.’”

Two other provisos: The revised allocation criteria do not affect persons waiting for a multiple-organ transplant (such as kidney/pancreas, kidney/heart, or kidney/liver). They also would apply to the adult (18 and older) population; pediatric candidates would continue to have priority, because as Zuber says, “If you don’t transplant a child, they will lose growth. It makes a huge difference when you’re a child, whereas when you’re an adult, it doesn’t matter if you’re 20 or 50.”

Focus on Prevention, Solutions
As indicated above, Concepts for Kidney Allocation is the latest step in the process of revising how kidneys are allocated. The Kidney Transplantation Committee will assess the feedback it receives, determine if there is a consensus, then issue a final proposal. UNOS and the Health Resources and Services Administration will be the groups that vote on whether to adopt the recommendations as policy.

In the meantime, other aspects of kidney allocation and transplantation will continue to be discussed and debated, whether officially or among the general public. Among the questions: How can the pool of living donors be increased? Should the US adopt a “presumed consent” policy that would require people to expressly opt out of organ donation? What other methods might increase donations—better education, payment of funeral expenses for the deceased donor, or something as yet undetermined?

For nephrology clinicians, the goal remains keeping people alive while they await transplantation. “Even when I’m doing a perfect job—that’s a perfect job, and at few times in my life am I perfect—I am no better than 15% of a kidney,” Zuber says of her dialysis work. At the same time, it must be accepted that even transplantation is “not a cure,” as Weis Malone points out. “It’s a treatment, just like dialysis is a treatment. Not everyone does well with it.”

For Weis Malone, “the focus always needs to be on the prevention of kidney disease, especially as diabetes continues to grow massively in this country. Probably 30% to 40% of people who start dialysis had no idea they had kidney disease. So that’s where it has to start, with the education of the medical community that the only way you can tell kidney function is through a blood test or a urine dip.”

And the search for solutions to the growing problem of kidney disease, and subsequent kidney failure, will continue. “This is what the public debate is about: what is acceptable,” Friedewald says. “There is no right or wrong here. But what is acceptable, and what kind of trade-offs are we willing to make to get more out of a scarce resource?”

By now, you have most likely heard about the United Network for Organ Sharing’s Concepts for Kidney Allocation, which outlines potential changes to the way deceased-donor kidneys are, so to speak, “distributed” to any of the 85,000 people currently waiting for one. Depending on your source, however, what you have heard about the concept document probably varies from “It is an effort to make the best use of a limited resource” (true) to “No one over the age of 60 will get a kidney!” (erroneous and also, frankly, outrageous).

The simple fact is that there are not enough available kidneys in the United States to make a dent in the waiting list. UNOS’s concept document does not address the issue of how to increase donations (one manufactured controversy is sufficient for a single document). What it does is provide a rationale for ensuring that each available kidney finds its best possible match.

“We’re not going to create any new kidneys with this, unfortunately,” says John J. Friedewald, MD, Vice Chair of UNOS’s Kidney Transplantation Committee and Assistant Professor in Medicine–Nephrology and Surgery at Northwestern University. “What we are going to do, the idea of this, is to give the right kidney to the right person.”

Tremendous Shift in Transplant Recipients
Just who is the right person for each kidney? And why, after years of the traditionally accepted “first come, first served” method, would the US even need a change in plan?

For one thing, statistics from the US Renal Data System paint a picture of a changing kidney transplantation system. In 1991, three in 10 patients were older than 50; by 2008, that proportion had doubled to six in 10, and one in six was older than 65. Since 2000, the transplantation rate has decreased 30% for persons ages 29 to 50 and increased 49% for those older than 65.

“All of a sudden, we’ve had this tremendous shift, which has only just begun, to transplanting an elderly population,” says Barbara Weis Malone, CFNP, Senior Instructor in the Division of Renal Disease and Hypertension at the University of Colorado Health Sciences Center. “I remember when I started in the transplant community nine years ago, we would barely look at a 60-year-old, and now, regularly, we are transplanting 64-year-olds and occasionally even putting people at 70 on the transplant list.”

At the same time, the average deceased donor is still from among the younger portion of the population, which can lead to serious disparities between graft longevity and recipient longevity. No one is saying older persons don’t deserve a kidney as much as younger persons—but, realistically, does a 68-year-old man need a 6-year-old’s kidney?

“Currently, our system can give a very long-lived kidney to a person who is not expected to live very long,” Friedewald points out. “And vice versa, which is sometimes worse—give a short-lived kidney to someone who is expected to live really long. What that means is that person, usually a younger person, may need a second or even third transplant in his or her lifetime.”

Almost 15% of the waiting list represents people waiting for their second, third, fourth, or even fifth transplant, Friedewald says. Part of the return on investment if the concept document becomes policy could be a reduction in that number. “If we give organs to younger people who are going to live a long time with them, then eventually—not tomorrow; maybe in five, 10, or 15 years—there will be fewer people returning to the wait list,” according to Friedewald. (But we’re getting ahead of ourselves, because the document cannot even be accurately termed a proposal at this point.)

For clinicians in nephrology, seeing the current allocation system in action can be distressing, even though they want to provide the best care to all patients. A sweet, 66-year-old grandmother may end up with an 11-year-old’s kidney, while a 20-year-old, otherwise healthy man with glomerular nephritis may spend years waiting and not get the kidney he ideally needs, one that will last 30 years or longer.

“When I first came into kidney transplant, I thought, ‘It’s just the first person in line; that’s wonderful,’” says Weis Malone. “But now it kind of breaks my heart. As a medical professional, it’s hard to see your younger population who could really use a kidney tomorrow.”

In essence, along with the disparities comes a sense of wasted opportunity. “One in three people dies with a functioning kidney,” says Kim Zuber, PA-C, MSPS, DFAAPA, Chair of the National Kidney Foundation Council of Advanced Practitioners, who practices at Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland. “As far as I’m concerned, that’s a waste, because the kidney should fail before you die; then you’ve used it all up.”

And for those who insist that “first come, first served” is fair, Friedewald has a different opinion, calling it “a complete fallacy. The first come aren’t the first served. Some people won’t live long enough to wait for a kidney, if the line is too long. Everyone believes that a line is ‘first come, first served,’ because we’re used to delis and things like that, where you actually get served. But a lot of people aren’t getting served.”

That may never change, but the concepts outlined in the UNOS document aim to achieve an additional 15,223 life-years lived with a transplanted kidney for every year’s worth of deceased-donor transplants. How? Let’s explore.

How the System Would Change
Early on, Concepts for Kidney Allocation (available at optn.transplant.hrsa.gov/SharedContentDocuments/KidneyConceptDocument.pdf) outlines the flaws of the current system: “[I]t does not strive to minimize death on the waiting list nor maximize survival following transplant. It does not recognize that all candidates do not have the same ability to survive the wait. It does not attempt to match the characteristics of a donor’s kidney to the candidate’s characteristics to promote a long and healthy survival post-transplant. The system can be better, and it can be designed to achieve more in the way of health and longevity than it currently does.”

Aware of the problems, and with input from hundreds of individuals—including transplant professionals, recipients, and candidates, as well as donor families, living donors, and the general public—UNOS’s Kidney Transplantation Committee has spent six years (so far) developing goals for a new allocation system. The concept document delineates three key factors in achieving those goals:

• Utilizing a kidney donor profile index (KDPI), a continuous measure used to estimate the potential function of a donated kidney if it were transplanted into the average recipient, to better characterize donor kidneys.

• Allocating some kidneys (20%) by a combination of the KDPI and a candidate’s estimated post-transplant survival (EPTS).

• Allocating the majority of organs (80%) by age-matching so that candidates within 15 years older or younger than the donor are prioritized.

The KDPI is based on the characteristics of the donor, including age, race/ethnicity, height, and weight, and whether he/she had any of the following factors: hypertension, diabetes, hepatitis C, elevated creatinine level, a cerebrovascular cause of death, or cardiac death. It is important to remember that a score below 20% indicates a kidney with the predicted longest function; it’s like being in the top 20% of your graduating class.

A candidate’s EPTS is based on age, length of time on dialysis, diabetes status, and history of prior organ transplant. “While no calculation will be able to predict life expectancy with 100% certainty, these four factors provide a reasonable estimate for identifying those candidates who have the longest possible EPTS,” the committee writes.

Once a KDPI has been established, there are two scenarios for how a candidate might be selected. Kidneys with a KDPI of 20% or lower are allocated based on EPTS. Those with a KDPI of more than 20% are allocated based on age-matching within 15 years (older or younger) of the recipient’s age.

To use the examples given in the report: Let’s say there are three candidates for a kidney. Mary is 30, Sophia is 21, and David is 60. Along comes a kidney with a KDPI of 10%. Since Mary and Sophia have better estimated survival than David (EPTS, 19%, 12%, and 75% respectively; again, it’s the percentile, so lower is better), they would have priority for that kidney.

However, if the available kidney has a KDPI of, say, 40%, age becomes a bigger factor. If the donor is 34, Mary and Sophia continue to have priority over David, since recipients ages 19 to 49 would be considered first. If the donor is 55, however, David would have precedence over Mary and Sophia, since the age range for that kidney recipient would be 40 to 70.

All of this can be confusing, and it leads one to suspect that some of the news entities who misspoke either did not understand what they were reading or perhaps did not even finish reading the report. But these components do not even tell the entire story; they are exactly that, components. The final proposal, which will be written only when all the feedback from a public comment period has been compiled and analyzed, “will include all the details of who gets the kidney,” as Friedewald says.

What is important to know now is that “waiting time will continue to be a major part of who gets a kidney” if the revised allocation concepts become policy, Friedewald emphasizes. “What this document says is that we’re generally going to group people based on the quality of the donor kidney. But once we do that—let’s say it’s a top 20% kidney—well, then the top 20% of candidates who are expected to live the longest will be up for that kidney. But that may be 10,000 people. Which of the 10,000 people gets the kidney? The person who waits the longest.”

Besides making better use of the available kidneys, the revised allocation system would also make use of more kidneys, by eliminating the previous designation of “expanded criteria donor,” or ECD, kidneys. Some patients turn down ECD kidneys when they are offered, because they may consider the designation a kind of stigma.

“People think ‘expanded criteria’ is this horrible kidney that came from someone who was very old or who probably drank his whole life or had HIV and hepatitis B,” Weis Malone says. “But it could be a 55-year-old person who was taking one blood pressure medication. Right now, there is something like a 12% waste of kidneys that are just being thrown away. As the transplant list grows, it would be nice to utilize those kidneys.”

Obviously, no one would object to someone turning down a kidney from, say, a known IV drug user who was testing negative at the time of death. But does it make sense for a 70-year-old man to turn down an ECD kidney with a creatine level of 1.3, indicative of slight kidney damage? “When you’re talking about someone who has all kidney damage,” Zuber says, “you want to say, ‘What are you thinking? You don’t need a perfect kidney; you need a kidney.’”

Two other provisos: The revised allocation criteria do not affect persons waiting for a multiple-organ transplant (such as kidney/pancreas, kidney/heart, or kidney/liver). They also would apply to the adult (18 and older) population; pediatric candidates would continue to have priority, because as Zuber says, “If you don’t transplant a child, they will lose growth. It makes a huge difference when you’re a child, whereas when you’re an adult, it doesn’t matter if you’re 20 or 50.”

Focus on Prevention, Solutions
As indicated above, Concepts for Kidney Allocation is the latest step in the process of revising how kidneys are allocated. The Kidney Transplantation Committee will assess the feedback it receives, determine if there is a consensus, then issue a final proposal. UNOS and the Health Resources and Services Administration will be the groups that vote on whether to adopt the recommendations as policy.

In the meantime, other aspects of kidney allocation and transplantation will continue to be discussed and debated, whether officially or among the general public. Among the questions: How can the pool of living donors be increased? Should the US adopt a “presumed consent” policy that would require people to expressly opt out of organ donation? What other methods might increase donations—better education, payment of funeral expenses for the deceased donor, or something as yet undetermined?

For nephrology clinicians, the goal remains keeping people alive while they await transplantation. “Even when I’m doing a perfect job—that’s a perfect job, and at few times in my life am I perfect—I am no better than 15% of a kidney,” Zuber says of her dialysis work. At the same time, it must be accepted that even transplantation is “not a cure,” as Weis Malone points out. “It’s a treatment, just like dialysis is a treatment. Not everyone does well with it.”

For Weis Malone, “the focus always needs to be on the prevention of kidney disease, especially as diabetes continues to grow massively in this country. Probably 30% to 40% of people who start dialysis had no idea they had kidney disease. So that’s where it has to start, with the education of the medical community that the only way you can tell kidney function is through a blood test or a urine dip.”

And the search for solutions to the growing problem of kidney disease, and subsequent kidney failure, will continue. “This is what the public debate is about: what is acceptable,” Friedewald says. “There is no right or wrong here. But what is acceptable, and what kind of trade-offs are we willing to make to get more out of a scarce resource?”

By now, you have most likely heard about the United Network for Organ Sharing’s Concepts for Kidney Allocation, which outlines potential changes to the way deceased-donor kidneys are, so to speak, “distributed” to any of the 85,000 people currently waiting for one. Depending on your source, however, what you have heard about the concept document probably varies from “It is an effort to make the best use of a limited resource” (true) to “No one over the age of 60 will get a kidney!” (erroneous and also, frankly, outrageous).

The simple fact is that there are not enough available kidneys in the United States to make a dent in the waiting list. UNOS’s concept document does not address the issue of how to increase donations (one manufactured controversy is sufficient for a single document). What it does is provide a rationale for ensuring that each available kidney finds its best possible match.

“We’re not going to create any new kidneys with this, unfortunately,” says John J. Friedewald, MD, Vice Chair of UNOS’s Kidney Transplantation Committee and Assistant Professor in Medicine–Nephrology and Surgery at Northwestern University. “What we are going to do, the idea of this, is to give the right kidney to the right person.”

Tremendous Shift in Transplant Recipients
Just who is the right person for each kidney? And why, after years of the traditionally accepted “first come, first served” method, would the US even need a change in plan?

For one thing, statistics from the US Renal Data System paint a picture of a changing kidney transplantation system. In 1991, three in 10 patients were older than 50; by 2008, that proportion had doubled to six in 10, and one in six was older than 65. Since 2000, the transplantation rate has decreased 30% for persons ages 29 to 50 and increased 49% for those older than 65.

“All of a sudden, we’ve had this tremendous shift, which has only just begun, to transplanting an elderly population,” says Barbara Weis Malone, CFNP, Senior Instructor in the Division of Renal Disease and Hypertension at the University of Colorado Health Sciences Center. “I remember when I started in the transplant community nine years ago, we would barely look at a 60-year-old, and now, regularly, we are transplanting 64-year-olds and occasionally even putting people at 70 on the transplant list.”

At the same time, the average deceased donor is still from among the younger portion of the population, which can lead to serious disparities between graft longevity and recipient longevity. No one is saying older persons don’t deserve a kidney as much as younger persons—but, realistically, does a 68-year-old man need a 6-year-old’s kidney?

“Currently, our system can give a very long-lived kidney to a person who is not expected to live very long,” Friedewald points out. “And vice versa, which is sometimes worse—give a short-lived kidney to someone who is expected to live really long. What that means is that person, usually a younger person, may need a second or even third transplant in his or her lifetime.”

Almost 15% of the waiting list represents people waiting for their second, third, fourth, or even fifth transplant, Friedewald says. Part of the return on investment if the concept document becomes policy could be a reduction in that number. “If we give organs to younger people who are going to live a long time with them, then eventually—not tomorrow; maybe in five, 10, or 15 years—there will be fewer people returning to the wait list,” according to Friedewald. (But we’re getting ahead of ourselves, because the document cannot even be accurately termed a proposal at this point.)

For clinicians in nephrology, seeing the current allocation system in action can be distressing, even though they want to provide the best care to all patients. A sweet, 66-year-old grandmother may end up with an 11-year-old’s kidney, while a 20-year-old, otherwise healthy man with glomerular nephritis may spend years waiting and not get the kidney he ideally needs, one that will last 30 years or longer.

“When I first came into kidney transplant, I thought, ‘It’s just the first person in line; that’s wonderful,’” says Weis Malone. “But now it kind of breaks my heart. As a medical professional, it’s hard to see your younger population who could really use a kidney tomorrow.”

In essence, along with the disparities comes a sense of wasted opportunity. “One in three people dies with a functioning kidney,” says Kim Zuber, PA-C, MSPS, DFAAPA, Chair of the National Kidney Foundation Council of Advanced Practitioners, who practices at Metropolitan Nephrology in Alexandria, Virginia, and Clinton, Maryland. “As far as I’m concerned, that’s a waste, because the kidney should fail before you die; then you’ve used it all up.”

And for those who insist that “first come, first served” is fair, Friedewald has a different opinion, calling it “a complete fallacy. The first come aren’t the first served. Some people won’t live long enough to wait for a kidney, if the line is too long. Everyone believes that a line is ‘first come, first served,’ because we’re used to delis and things like that, where you actually get served. But a lot of people aren’t getting served.”

That may never change, but the concepts outlined in the UNOS document aim to achieve an additional 15,223 life-years lived with a transplanted kidney for every year’s worth of deceased-donor transplants. How? Let’s explore.

How the System Would Change
Early on, Concepts for Kidney Allocation (available at optn.transplant.hrsa.gov/SharedContentDocuments/KidneyConceptDocument.pdf) outlines the flaws of the current system: “[I]t does not strive to minimize death on the waiting list nor maximize survival following transplant. It does not recognize that all candidates do not have the same ability to survive the wait. It does not attempt to match the characteristics of a donor’s kidney to the candidate’s characteristics to promote a long and healthy survival post-transplant. The system can be better, and it can be designed to achieve more in the way of health and longevity than it currently does.”

Aware of the problems, and with input from hundreds of individuals—including transplant professionals, recipients, and candidates, as well as donor families, living donors, and the general public—UNOS’s Kidney Transplantation Committee has spent six years (so far) developing goals for a new allocation system. The concept document delineates three key factors in achieving those goals:

• Utilizing a kidney donor profile index (KDPI), a continuous measure used to estimate the potential function of a donated kidney if it were transplanted into the average recipient, to better characterize donor kidneys.

• Allocating some kidneys (20%) by a combination of the KDPI and a candidate’s estimated post-transplant survival (EPTS).

• Allocating the majority of organs (80%) by age-matching so that candidates within 15 years older or younger than the donor are prioritized.

The KDPI is based on the characteristics of the donor, including age, race/ethnicity, height, and weight, and whether he/she had any of the following factors: hypertension, diabetes, hepatitis C, elevated creatinine level, a cerebrovascular cause of death, or cardiac death. It is important to remember that a score below 20% indicates a kidney with the predicted longest function; it’s like being in the top 20% of your graduating class.

A candidate’s EPTS is based on age, length of time on dialysis, diabetes status, and history of prior organ transplant. “While no calculation will be able to predict life expectancy with 100% certainty, these four factors provide a reasonable estimate for identifying those candidates who have the longest possible EPTS,” the committee writes.

Once a KDPI has been established, there are two scenarios for how a candidate might be selected. Kidneys with a KDPI of 20% or lower are allocated based on EPTS. Those with a KDPI of more than 20% are allocated based on age-matching within 15 years (older or younger) of the recipient’s age.

To use the examples given in the report: Let’s say there are three candidates for a kidney. Mary is 30, Sophia is 21, and David is 60. Along comes a kidney with a KDPI of 10%. Since Mary and Sophia have better estimated survival than David (EPTS, 19%, 12%, and 75% respectively; again, it’s the percentile, so lower is better), they would have priority for that kidney.

However, if the available kidney has a KDPI of, say, 40%, age becomes a bigger factor. If the donor is 34, Mary and Sophia continue to have priority over David, since recipients ages 19 to 49 would be considered first. If the donor is 55, however, David would have precedence over Mary and Sophia, since the age range for that kidney recipient would be 40 to 70.

All of this can be confusing, and it leads one to suspect that some of the news entities who misspoke either did not understand what they were reading or perhaps did not even finish reading the report. But these components do not even tell the entire story; they are exactly that, components. The final proposal, which will be written only when all the feedback from a public comment period has been compiled and analyzed, “will include all the details of who gets the kidney,” as Friedewald says.

What is important to know now is that “waiting time will continue to be a major part of who gets a kidney” if the revised allocation concepts become policy, Friedewald emphasizes. “What this document says is that we’re generally going to group people based on the quality of the donor kidney. But once we do that—let’s say it’s a top 20% kidney—well, then the top 20% of candidates who are expected to live the longest will be up for that kidney. But that may be 10,000 people. Which of the 10,000 people gets the kidney? The person who waits the longest.”

Besides making better use of the available kidneys, the revised allocation system would also make use of more kidneys, by eliminating the previous designation of “expanded criteria donor,” or ECD, kidneys. Some patients turn down ECD kidneys when they are offered, because they may consider the designation a kind of stigma.

“People think ‘expanded criteria’ is this horrible kidney that came from someone who was very old or who probably drank his whole life or had HIV and hepatitis B,” Weis Malone says. “But it could be a 55-year-old person who was taking one blood pressure medication. Right now, there is something like a 12% waste of kidneys that are just being thrown away. As the transplant list grows, it would be nice to utilize those kidneys.”

Obviously, no one would object to someone turning down a kidney from, say, a known IV drug user who was testing negative at the time of death. But does it make sense for a 70-year-old man to turn down an ECD kidney with a creatine level of 1.3, indicative of slight kidney damage? “When you’re talking about someone who has all kidney damage,” Zuber says, “you want to say, ‘What are you thinking? You don’t need a perfect kidney; you need a kidney.’”

Two other provisos: The revised allocation criteria do not affect persons waiting for a multiple-organ transplant (such as kidney/pancreas, kidney/heart, or kidney/liver). They also would apply to the adult (18 and older) population; pediatric candidates would continue to have priority, because as Zuber says, “If you don’t transplant a child, they will lose growth. It makes a huge difference when you’re a child, whereas when you’re an adult, it doesn’t matter if you’re 20 or 50.”

Focus on Prevention, Solutions
As indicated above, Concepts for Kidney Allocation is the latest step in the process of revising how kidneys are allocated. The Kidney Transplantation Committee will assess the feedback it receives, determine if there is a consensus, then issue a final proposal. UNOS and the Health Resources and Services Administration will be the groups that vote on whether to adopt the recommendations as policy.

In the meantime, other aspects of kidney allocation and transplantation will continue to be discussed and debated, whether officially or among the general public. Among the questions: How can the pool of living donors be increased? Should the US adopt a “presumed consent” policy that would require people to expressly opt out of organ donation? What other methods might increase donations—better education, payment of funeral expenses for the deceased donor, or something as yet undetermined?

For nephrology clinicians, the goal remains keeping people alive while they await transplantation. “Even when I’m doing a perfect job—that’s a perfect job, and at few times in my life am I perfect—I am no better than 15% of a kidney,” Zuber says of her dialysis work. At the same time, it must be accepted that even transplantation is “not a cure,” as Weis Malone points out. “It’s a treatment, just like dialysis is a treatment. Not everyone does well with it.”

For Weis Malone, “the focus always needs to be on the prevention of kidney disease, especially as diabetes continues to grow massively in this country. Probably 30% to 40% of people who start dialysis had no idea they had kidney disease. So that’s where it has to start, with the education of the medical community that the only way you can tell kidney function is through a blood test or a urine dip.”

And the search for solutions to the growing problem of kidney disease, and subsequent kidney failure, will continue. “This is what the public debate is about: what is acceptable,” Friedewald says. “There is no right or wrong here. But what is acceptable, and what kind of trade-offs are we willing to make to get more out of a scarce resource?”

Ah, spring! When many a young (and old) person’s fancy turns to baseball, and Americans shake off their post-holiday slumber. Unfortunately, in recent years, there has been an additional rite of passage, as economically strapped states look to trim their budgets and set their sights, in part, on Medicaid programs.

Gone are the glory days when reimbursement rates for health care providers were gradually increasing. In fiscal year (FY) 2010, 39 states froze or reduced payments to providers. Some states are now beginning to restrict benefits or require a utilization review before patients can access care—and the proposals seem to get more extreme with each announcement.

In California, Governor Jerry Brown has proposed about $1.7 billion in cuts to Medicaid, which would be accomplished in part by restricting beneficiaries to 10 “doctor” visits per year and six prescriptions per month. (The state’s Medicaid director told the New York Times the cuts would “affect only 10% of Medicaid recipients.”) In New York, Governor Andrew Cuomo’s proposed budget would reduce Medicaid spending by almost $3 billion (yes, billion) in FY 2011-2012 and by more than $4 billion in FY 2012-2013. Combined with the loss of matching federal funds, New York’s state Medicaid program would lose $15 billion in funding over two years.

States are currently limited in how they can cut Medicaid funding. They can reduce payments to clinicians and medical facilities (eg, hospitals and nursing homes), raise taxes on those providers, or cut benefits that are not expressly required by the federal government.

“Any time you start to reduce provider payments, the incentive for anyone—any health care professional—to take on a larger role or more patients under Medicaid becomes a difficult proposition,” says Michael L. Powe, Vice President of Reimbursement and Professional Advocacy for the American Academy of Physician Assistants (AAPA). “They can’t afford to lose money on every patient they see, either.”

Whatever form state cuts to Medicaid encompass, this is an issue all health care providers should take an active interest in—because it will affect patient care, which should always be Priority #1.

The Path to Optimal Utilization
Representatives of AAPA and the American Academy of Nurse Practitioners (AANP) say they are “sensitive” and “sympathetic” to the plight of states that are considering budget cuts. “State budgets are hemorrhaging in many ways, and clearly Medicaid is the fastest-growing facet of a state budget, followed closely by education,” Powe observes. “So we understand they have to do something to control costs.”

His viewpoint is shared by Tay Kopanos, DNP, NP, AANP’s Director of Health Policy, State Government Affairs. “Legislators are being asked to make some hard choices, and we believe NPs can help inform them,” she says. “What we’re looking at is both short- and long-term solutions that we can offer legislators.”

Florida is one state where legislators appear to be getting the message that NPs and PAs can be part of the solution to Medicaid and other health care woes. On December 30, 2010, the state’s Office of Program Policy Analysis and Government Accountability (OPPAGA) released a research memorandum called “Expanding Scope of Practice for Advanced Registered Nurse Practitioners, Physician Assistants, Optometrists, and Dental Hygienists.” In the paper, the OPPAGA estimates the “potential cost-savings from expanding ARNP and PA scope of practice” in the state at $339 million across Florida’s health care system. This includes savings of $7 million to $44 million annually for Medicaid, and of $744,000 to $2.2 million for state employee health insurance.

The OPPAGA’s memorandum does not provide recommendations but does outline factors that impact utilization of NPs and PAs in Florida. Florida, for example, is one of two states that do not allow ARNPs and PAs to prescribe controlled substances (Alabama is the other for NPs and Kentucky for PAs). The report also includes the observation that “Florida law neither prohibits nor requires insurance companies and managed care companies to allow ARNPs and PAs to bill them directly.”

Whether this report translates into political action remains to be seen, but it is an illustration of a general principle. “If we could utilize clinicians to the highest level of their education and skill, we would save the system money by reducing some redundancies that are occurring,” Kopanos says, “and glitches that patients face in their care because we are not utilizing people effectively.”

At the federal and state levels, AAPA and AANP are continually working to improve the recognition of PAs and NPs and their inclusion in various programs. For AAPA, having PAs added to the category of mandated (as opposed to “optional”) providers through the Centers for Medicare and Medicaid Services (CMS) is “an ongoing legislative agenda item,” Powe says.

“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”

Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”

Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.

“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”

Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”

One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)

In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.

Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.

“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”

In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.

In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.

“Initially, the state had thought they would save $600,000 if they paid that 10%-reduced rate to all NP and PA providers,” Kopanos says. “But after hearing the cost shift that would occur, the decreased number of primary care access points patients would have, and the lack of transparency, the legislature decided it was not going to get the state where it needed to go.”

Solutions Welcome
All of this serves to illustrate the oft-repeated but important point that PAs and NPs can make a difference by speaking up and sharing their expertise. This is not limited to Medicaid cutbacks; as Powe points out, a number of provisions in the health care reform legislation are beginning to take form at the state level—accountable care organizations, patient-centered medical homes, and insurance exchanges.

“PAs cannot afford to sit on the sidelines and let other people carry the water for them. They have to come up to the plate and be involved in the commissions, the councils, the meetings—any opportunity they have to get involved,” Powe says. “We think it’s essential for PAs to, whenever possible, take leadership roles and tell their stories about what impact—positive or negative—these issues will have on their ability to provide care to patients. That really is what it’s all about.”

Kopanos echoes those sentiments: “Talk to a legislator. Let them know, ‘on the ground, this is what that cut would look like.’ Or, ‘on the ground, if we could tweak this part of the system, I could be more effective in meeting those care needs.’ Our legislators need that input.”

Connecting with a state professional organization (which probably already has relationships with the relevant parties—policymakers, the governor’s office, and the state Medicaid office) and reading the budget and the related recommendations, which are publicly available, will also help. Most of all, have a constructive alternative to suggest.

“The legislators already know that they’re going to have to make cuts and it’s going to make people unhappy,” Kopanos points out. “They would very much appreciate it if you could bring solutions to the table.”

In Colorado last year, for example, the Colorado Nurses Association made some calculations and discovered that if the across-the-board reimbursement cut was increased to 1.1%—just one-tenth of a percent—the state could save $900,000 (more than its original proposal, without the negative consequences to access and transparency).

“It’s tough times and tough decisions,” Kopanos says. “If you can provide some traction for good ideas, they’re listening.”

Ah, spring! When many a young (and old) person’s fancy turns to baseball, and Americans shake off their post-holiday slumber. Unfortunately, in recent years, there has been an additional rite of passage, as economically strapped states look to trim their budgets and set their sights, in part, on Medicaid programs.

Gone are the glory days when reimbursement rates for health care providers were gradually increasing. In fiscal year (FY) 2010, 39 states froze or reduced payments to providers. Some states are now beginning to restrict benefits or require a utilization review before patients can access care—and the proposals seem to get more extreme with each announcement.

In California, Governor Jerry Brown has proposed about $1.7 billion in cuts to Medicaid, which would be accomplished in part by restricting beneficiaries to 10 “doctor” visits per year and six prescriptions per month. (The state’s Medicaid director told the New York Times the cuts would “affect only 10% of Medicaid recipients.”) In New York, Governor Andrew Cuomo’s proposed budget would reduce Medicaid spending by almost $3 billion (yes, billion) in FY 2011-2012 and by more than $4 billion in FY 2012-2013. Combined with the loss of matching federal funds, New York’s state Medicaid program would lose $15 billion in funding over two years.

States are currently limited in how they can cut Medicaid funding. They can reduce payments to clinicians and medical facilities (eg, hospitals and nursing homes), raise taxes on those providers, or cut benefits that are not expressly required by the federal government.

“Any time you start to reduce provider payments, the incentive for anyone—any health care professional—to take on a larger role or more patients under Medicaid becomes a difficult proposition,” says Michael L. Powe, Vice President of Reimbursement and Professional Advocacy for the American Academy of Physician Assistants (AAPA). “They can’t afford to lose money on every patient they see, either.”

Whatever form state cuts to Medicaid encompass, this is an issue all health care providers should take an active interest in—because it will affect patient care, which should always be Priority #1.

The Path to Optimal Utilization
Representatives of AAPA and the American Academy of Nurse Practitioners (AANP) say they are “sensitive” and “sympathetic” to the plight of states that are considering budget cuts. “State budgets are hemorrhaging in many ways, and clearly Medicaid is the fastest-growing facet of a state budget, followed closely by education,” Powe observes. “So we understand they have to do something to control costs.”

His viewpoint is shared by Tay Kopanos, DNP, NP, AANP’s Director of Health Policy, State Government Affairs. “Legislators are being asked to make some hard choices, and we believe NPs can help inform them,” she says. “What we’re looking at is both short- and long-term solutions that we can offer legislators.”

Florida is one state where legislators appear to be getting the message that NPs and PAs can be part of the solution to Medicaid and other health care woes. On December 30, 2010, the state’s Office of Program Policy Analysis and Government Accountability (OPPAGA) released a research memorandum called “Expanding Scope of Practice for Advanced Registered Nurse Practitioners, Physician Assistants, Optometrists, and Dental Hygienists.” In the paper, the OPPAGA estimates the “potential cost-savings from expanding ARNP and PA scope of practice” in the state at $339 million across Florida’s health care system. This includes savings of $7 million to $44 million annually for Medicaid, and of $744,000 to $2.2 million for state employee health insurance.

The OPPAGA’s memorandum does not provide recommendations but does outline factors that impact utilization of NPs and PAs in Florida. Florida, for example, is one of two states that do not allow ARNPs and PAs to prescribe controlled substances (Alabama is the other for NPs and Kentucky for PAs). The report also includes the observation that “Florida law neither prohibits nor requires insurance companies and managed care companies to allow ARNPs and PAs to bill them directly.”

Whether this report translates into political action remains to be seen, but it is an illustration of a general principle. “If we could utilize clinicians to the highest level of their education and skill, we would save the system money by reducing some redundancies that are occurring,” Kopanos says, “and glitches that patients face in their care because we are not utilizing people effectively.”

At the federal and state levels, AAPA and AANP are continually working to improve the recognition of PAs and NPs and their inclusion in various programs. For AAPA, having PAs added to the category of mandated (as opposed to “optional”) providers through the Centers for Medicare and Medicaid Services (CMS) is “an ongoing legislative agenda item,” Powe says.

“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”

Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”

Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.

“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”

Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”

One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)

In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.

Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.

“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”

In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.

In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.

“Initially, the state had thought they would save $600,000 if they paid that 10%-reduced rate to all NP and PA providers,” Kopanos says. “But after hearing the cost shift that would occur, the decreased number of primary care access points patients would have, and the lack of transparency, the legislature decided it was not going to get the state where it needed to go.”

Solutions Welcome
All of this serves to illustrate the oft-repeated but important point that PAs and NPs can make a difference by speaking up and sharing their expertise. This is not limited to Medicaid cutbacks; as Powe points out, a number of provisions in the health care reform legislation are beginning to take form at the state level—accountable care organizations, patient-centered medical homes, and insurance exchanges.

“PAs cannot afford to sit on the sidelines and let other people carry the water for them. They have to come up to the plate and be involved in the commissions, the councils, the meetings—any opportunity they have to get involved,” Powe says. “We think it’s essential for PAs to, whenever possible, take leadership roles and tell their stories about what impact—positive or negative—these issues will have on their ability to provide care to patients. That really is what it’s all about.”

Kopanos echoes those sentiments: “Talk to a legislator. Let them know, ‘on the ground, this is what that cut would look like.’ Or, ‘on the ground, if we could tweak this part of the system, I could be more effective in meeting those care needs.’ Our legislators need that input.”

Connecting with a state professional organization (which probably already has relationships with the relevant parties—policymakers, the governor’s office, and the state Medicaid office) and reading the budget and the related recommendations, which are publicly available, will also help. Most of all, have a constructive alternative to suggest.

“The legislators already know that they’re going to have to make cuts and it’s going to make people unhappy,” Kopanos points out. “They would very much appreciate it if you could bring solutions to the table.”

In Colorado last year, for example, the Colorado Nurses Association made some calculations and discovered that if the across-the-board reimbursement cut was increased to 1.1%—just one-tenth of a percent—the state could save $900,000 (more than its original proposal, without the negative consequences to access and transparency).

“It’s tough times and tough decisions,” Kopanos says. “If you can provide some traction for good ideas, they’re listening.”

Ah, spring! When many a young (and old) person’s fancy turns to baseball, and Americans shake off their post-holiday slumber. Unfortunately, in recent years, there has been an additional rite of passage, as economically strapped states look to trim their budgets and set their sights, in part, on Medicaid programs.

Gone are the glory days when reimbursement rates for health care providers were gradually increasing. In fiscal year (FY) 2010, 39 states froze or reduced payments to providers. Some states are now beginning to restrict benefits or require a utilization review before patients can access care—and the proposals seem to get more extreme with each announcement.

In California, Governor Jerry Brown has proposed about $1.7 billion in cuts to Medicaid, which would be accomplished in part by restricting beneficiaries to 10 “doctor” visits per year and six prescriptions per month. (The state’s Medicaid director told the New York Times the cuts would “affect only 10% of Medicaid recipients.”) In New York, Governor Andrew Cuomo’s proposed budget would reduce Medicaid spending by almost $3 billion (yes, billion) in FY 2011-2012 and by more than $4 billion in FY 2012-2013. Combined with the loss of matching federal funds, New York’s state Medicaid program would lose $15 billion in funding over two years.

States are currently limited in how they can cut Medicaid funding. They can reduce payments to clinicians and medical facilities (eg, hospitals and nursing homes), raise taxes on those providers, or cut benefits that are not expressly required by the federal government.

“Any time you start to reduce provider payments, the incentive for anyone—any health care professional—to take on a larger role or more patients under Medicaid becomes a difficult proposition,” says Michael L. Powe, Vice President of Reimbursement and Professional Advocacy for the American Academy of Physician Assistants (AAPA). “They can’t afford to lose money on every patient they see, either.”

Whatever form state cuts to Medicaid encompass, this is an issue all health care providers should take an active interest in—because it will affect patient care, which should always be Priority #1.

The Path to Optimal Utilization
Representatives of AAPA and the American Academy of Nurse Practitioners (AANP) say they are “sensitive” and “sympathetic” to the plight of states that are considering budget cuts. “State budgets are hemorrhaging in many ways, and clearly Medicaid is the fastest-growing facet of a state budget, followed closely by education,” Powe observes. “So we understand they have to do something to control costs.”

His viewpoint is shared by Tay Kopanos, DNP, NP, AANP’s Director of Health Policy, State Government Affairs. “Legislators are being asked to make some hard choices, and we believe NPs can help inform them,” she says. “What we’re looking at is both short- and long-term solutions that we can offer legislators.”

Florida is one state where legislators appear to be getting the message that NPs and PAs can be part of the solution to Medicaid and other health care woes. On December 30, 2010, the state’s Office of Program Policy Analysis and Government Accountability (OPPAGA) released a research memorandum called “Expanding Scope of Practice for Advanced Registered Nurse Practitioners, Physician Assistants, Optometrists, and Dental Hygienists.” In the paper, the OPPAGA estimates the “potential cost-savings from expanding ARNP and PA scope of practice” in the state at $339 million across Florida’s health care system. This includes savings of $7 million to $44 million annually for Medicaid, and of $744,000 to $2.2 million for state employee health insurance.

The OPPAGA’s memorandum does not provide recommendations but does outline factors that impact utilization of NPs and PAs in Florida. Florida, for example, is one of two states that do not allow ARNPs and PAs to prescribe controlled substances (Alabama is the other for NPs and Kentucky for PAs). The report also includes the observation that “Florida law neither prohibits nor requires insurance companies and managed care companies to allow ARNPs and PAs to bill them directly.”

Whether this report translates into political action remains to be seen, but it is an illustration of a general principle. “If we could utilize clinicians to the highest level of their education and skill, we would save the system money by reducing some redundancies that are occurring,” Kopanos says, “and glitches that patients face in their care because we are not utilizing people effectively.”

At the federal and state levels, AAPA and AANP are continually working to improve the recognition of PAs and NPs and their inclusion in various programs. For AAPA, having PAs added to the category of mandated (as opposed to “optional”) providers through the Centers for Medicare and Medicaid Services (CMS) is “an ongoing legislative agenda item,” Powe says.

“We believe there are no such things as ‘PA services,’” he explains. “These are medical services that otherwise would be provided by physicians, and we see no reason for PAs to be separated from physicians when it comes to determining the range of services that can be offered.”

Another area of interest is the patient-centered medical homes, which, if their full potential is reached, could improve the quality of care and patient outcomes while effectively reducing costs. “We’re really working to make sure that in all states, NPs and our colleagues PAs are able to be recognized as primary care providers in the Medicaid programs and within the medical homes,” Kopanos says, pointing out that there are states that recognize only family and pediatric NPs, not all NPs, as mandatory providers. “In part, this is to ensure that we have an adequate provider pool for Medicaid patients. But it’s also to make sure we can utilize those resources effectively.”

Some Cases in Point
Issues of access—never ideal—become exacerbated in a tough economic climate. The choices people are often forced to make have repercussions throughout the health care system, which is why every clinician should care about what happens to the Medicaid program in his or her state—even if his/her practice does not accept Medicaid patients.

“When patients don’t have reasonable access to care, they will either delay care or get it in the most unusual places—often in an urgent care environment,” Powe points out. “That trip to the ED is going to cost seven times what an office visit might have cost. So the idea of saving money by perhaps cutting out or closing down a rural clinic becomes, really, a loss to the state budget, when you start looking at other ways patients will access care.”

Like most practitioners, Kopanos has witnessed this firsthand, in her days as a family NP in a Colorado ED fast-track. “We would have individuals who would come in to the ED and get funneled into the urgent care fast-track for things like refills on their albuterol inhalers,” she recalls. “They weren’t in crisis, they weren’t having an asthma attack or flare. They just couldn’t find a primary care provider to give them a refill.”

One state where access to care is already an issue—and which Powe calls “a unique problem for PAs” in the current Medicaid cutback plans—is Tennessee. In an effort to reduce costs in Tenn Care, the state’s Medicaid program, the state submitted a proposal to CMS “that would eliminate the ability of PAs to treat adult Medicaid patients,” Powe says. “It would allow them to treat children and pregnant women, but other adult Medicaid patients could not be treated by a PA.” (The cutbacks also extend to podiatrists, physical therapists, and occupational therapists.)

In fairness, Powe says the state of Tennessee did try to submit a proposal that included PAs in the physician (ie, mandated) category, but CMS ruled that optional and mandated providers could not be combined in this way. (Hence the AAPA’s ongoing efforts to have PAs recognized in the mandatory category.) Tennessee’s plans are still under negotiation, and Powe is hopeful that the Hospital Association of Tennessee will step in to avert the crisis, as they did last year, by assessing itself a fee that would offset the cuts. But if the proposed cuts go through, patients would find themselves with fewer access points into the health care system—and might choose to delay care or find it in a less appropriate, more costly venue.

Access to care was part of a rationale used successfully to prevent steep cuts in Medicaid reimbursement in Colorado last year. In 2010, the Colorado budget included a 1% across-the-board decrease in reimbursement to all health care providers and an additional 10% reduction to all nonphysician providers. Aside from the inequitable sacrifice involved, the impact such a cut would have on patient care was significant.

“We found that those practices where NPs were employed were going to make the decision that no Medicaid patient would see an NP,” Kopanos reports. “They would be shunted to the physician, where the practice would still get the maximum reimbursement.”

In addition to disrupting long-standing relationships between NPs and patients, this decision would also increase wait times for appointments and perhaps contribute to patients’ seeking care from the ED for a nonemergent problem.

In other instances, practices were planning to employ incident-to billing, so that the practice would get the maximum reimbursement by billing under the physician’s number. But incident-to billing limits access to care since “all care provided by any provider other than a physician must directly relate back to a plan of care initiated by the physician”—no new complaints, even if they are within the NP’s or PA’s scope of practice—and also impedes transparency. With multiple providers billing under a single number, it is impossible to track who is providing the care, what care is being provided, and what the quality of the care is.

“Initially, the state had thought they would save $600,000 if they paid that 10%-reduced rate to all NP and PA providers,” Kopanos says. “But after hearing the cost shift that would occur, the decreased number of primary care access points patients would have, and the lack of transparency, the legislature decided it was not going to get the state where it needed to go.”

Solutions Welcome
All of this serves to illustrate the oft-repeated but important point that PAs and NPs can make a difference by speaking up and sharing their expertise. This is not limited to Medicaid cutbacks; as Powe points out, a number of provisions in the health care reform legislation are beginning to take form at the state level—accountable care organizations, patient-centered medical homes, and insurance exchanges.

“PAs cannot afford to sit on the sidelines and let other people carry the water for them. They have to come up to the plate and be involved in the commissions, the councils, the meetings—any opportunity they have to get involved,” Powe says. “We think it’s essential for PAs to, whenever possible, take leadership roles and tell their stories about what impact—positive or negative—these issues will have on their ability to provide care to patients. That really is what it’s all about.”

Kopanos echoes those sentiments: “Talk to a legislator. Let them know, ‘on the ground, this is what that cut would look like.’ Or, ‘on the ground, if we could tweak this part of the system, I could be more effective in meeting those care needs.’ Our legislators need that input.”

Connecting with a state professional organization (which probably already has relationships with the relevant parties—policymakers, the governor’s office, and the state Medicaid office) and reading the budget and the related recommendations, which are publicly available, will also help. Most of all, have a constructive alternative to suggest.

“The legislators already know that they’re going to have to make cuts and it’s going to make people unhappy,” Kopanos points out. “They would very much appreciate it if you could bring solutions to the table.”

In Colorado last year, for example, the Colorado Nurses Association made some calculations and discovered that if the across-the-board reimbursement cut was increased to 1.1%—just one-tenth of a percent—the state could save $900,000 (more than its original proposal, without the negative consequences to access and transparency).

“It’s tough times and tough decisions,” Kopanos says. “If you can provide some traction for good ideas, they’re listening.”

If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”

Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.

Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?

Dismal Rates of Coverage

The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.

In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)

“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”

There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”

Underestimating the Disease

Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.

“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”

Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”

Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.

Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.

“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”

Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”

Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”

A Matter of Patient Safety

Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”

However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”

“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”

The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.

The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–­associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–­associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.

In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”

But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”

That’s why the organizations have resorted to what some may see as a hard line on the subject (SHEA recommends that only medical contraindications should be acceptable exemption criteria; AAP, on the other hand, recommends that exemptions for medical and religious reasons be permitted on an individual basis). Fishman points out that vaccine mandates aren’t even unprecedented: Most institutions require vaccination against measles-mumps-rubella, varicella, and hepatitis B, for example, as a condition of employment.

Other arguments aside, Fishman says, there is one compelling reason why health care providers should get their annual flu vaccination. “Health care providers assume an ethical responsibility to prevent disease in our patients when we enter the profession,” he says. “That ethical obligation overrides other beliefs.”

Bottom Line: Get Vaccinated!

How far the push for mandatory influenza vaccination of health care personnel will go remains to be seen, as does what impact the movement will have on NPs and PAs. For the foreseeable future, it may depend on the practice setting. As of now, neither AAPA nor the American Academy of Nurse Practitioners (AANP) has taken a position on the mandate issue. (The American Nurses Association has, stating in a press release that it “does not support such policies” unless they adhere to specific guidelines. The organization does emphasize that it strongly encourages nurses to be vaccinated against influenza, however.)

Could this someday become a regulatory issue or a national health policy? “Initially, I’d be happy—we’d be happy—if more institutions around the country begin to adopt mandatory vaccination policies,” Fishman says. “If that happens, that will create a force around the country, and it will become the standard. If that doesn’t happen, I think we’ll have to see about pursuing more of a regulatory standard.”

Poland is a believer in the idea of a tipping point, and he thinks it’s drawing nearer: “I truly believe that within a decade, we will look back and say, ‘It is really unconscionable that we allowed this to happen,’ given the data that we have.”

Whatever else is accomplished in the immediate aftermath of the release of the SHEA and AAP papers, one thing is clear: It will hopefully encourage discussion about flu vaccine among health care providers, and perhaps encourage many of them to seek vaccination of their own volition. That is something both AAPA and AANP encourage. And perhaps too it will create opportunities for education.

AANP Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, says that hospitals, clinics, and group practices can provide more education to their employees, showing data to indicate that not getting vaccinated is causing a problem. “Most people are conscientious providers,” she says, “and even though they may never get the flu—or they think they’ll never get it—if they are creating an environment that makes it easier for patients to get it, then showing that data and educating them would certainly be the way to go.”

Towers encourages NPs to receive flu vaccine—and to encourage their patients to get it as well (barring contraindications, of course). “One of the things that I think NPs do better than some other providers is make sure that people are getting their flu shots and that the vaccine is available to them,” she says. “I think that’s important. If you don’t bring it up with some of your patients, they’ll never think to get it. So we have a big responsibility to make sure our patients are aware of the need to get flu vaccine.”

Killeen has a twofold mission for his colleagues. “We really need to challenge our Ob-Gyn practitioners to vaccinate pregnant women,” he says. “Out of all the populations that I see, the one that refuses the vaccine is that population. Again, it’s the safety issues: ‘How will this affect my pregnancy and my unborn child?’ That’s a huge stretch for women.”

The second piece of Killeen’s request to PAs is not to rest on the laurels, so to speak, of that 67% coverage rate reported in 2008: “I would like to see that number significantly increase.”

It is important to remember that the entire concept of vaccination is that it protects you and helps to protect everyone else as well. “[The SHEA position paper] is saying that as a health care provider, you’re responsible to protect yourself and your patients,” Killeen says. “I think that’s the best thing to come out of it.”

If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”

Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.

Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?

Dismal Rates of Coverage

The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.

In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)

“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”

There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”

Underestimating the Disease

Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.

“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”

Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”

Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.

Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.

“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”

Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”

Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”

A Matter of Patient Safety

Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”

However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”

“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”

The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.

The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–­associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–­associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.

In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”

But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”

That’s why the organizations have resorted to what some may see as a hard line on the subject (SHEA recommends that only medical contraindications should be acceptable exemption criteria; AAP, on the other hand, recommends that exemptions for medical and religious reasons be permitted on an individual basis). Fishman points out that vaccine mandates aren’t even unprecedented: Most institutions require vaccination against measles-mumps-rubella, varicella, and hepatitis B, for example, as a condition of employment.

Other arguments aside, Fishman says, there is one compelling reason why health care providers should get their annual flu vaccination. “Health care providers assume an ethical responsibility to prevent disease in our patients when we enter the profession,” he says. “That ethical obligation overrides other beliefs.”

Bottom Line: Get Vaccinated!

How far the push for mandatory influenza vaccination of health care personnel will go remains to be seen, as does what impact the movement will have on NPs and PAs. For the foreseeable future, it may depend on the practice setting. As of now, neither AAPA nor the American Academy of Nurse Practitioners (AANP) has taken a position on the mandate issue. (The American Nurses Association has, stating in a press release that it “does not support such policies” unless they adhere to specific guidelines. The organization does emphasize that it strongly encourages nurses to be vaccinated against influenza, however.)

Could this someday become a regulatory issue or a national health policy? “Initially, I’d be happy—we’d be happy—if more institutions around the country begin to adopt mandatory vaccination policies,” Fishman says. “If that happens, that will create a force around the country, and it will become the standard. If that doesn’t happen, I think we’ll have to see about pursuing more of a regulatory standard.”

Poland is a believer in the idea of a tipping point, and he thinks it’s drawing nearer: “I truly believe that within a decade, we will look back and say, ‘It is really unconscionable that we allowed this to happen,’ given the data that we have.”

Whatever else is accomplished in the immediate aftermath of the release of the SHEA and AAP papers, one thing is clear: It will hopefully encourage discussion about flu vaccine among health care providers, and perhaps encourage many of them to seek vaccination of their own volition. That is something both AAPA and AANP encourage. And perhaps too it will create opportunities for education.

AANP Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, says that hospitals, clinics, and group practices can provide more education to their employees, showing data to indicate that not getting vaccinated is causing a problem. “Most people are conscientious providers,” she says, “and even though they may never get the flu—or they think they’ll never get it—if they are creating an environment that makes it easier for patients to get it, then showing that data and educating them would certainly be the way to go.”

Towers encourages NPs to receive flu vaccine—and to encourage their patients to get it as well (barring contraindications, of course). “One of the things that I think NPs do better than some other providers is make sure that people are getting their flu shots and that the vaccine is available to them,” she says. “I think that’s important. If you don’t bring it up with some of your patients, they’ll never think to get it. So we have a big responsibility to make sure our patients are aware of the need to get flu vaccine.”

Killeen has a twofold mission for his colleagues. “We really need to challenge our Ob-Gyn practitioners to vaccinate pregnant women,” he says. “Out of all the populations that I see, the one that refuses the vaccine is that population. Again, it’s the safety issues: ‘How will this affect my pregnancy and my unborn child?’ That’s a huge stretch for women.”

The second piece of Killeen’s request to PAs is not to rest on the laurels, so to speak, of that 67% coverage rate reported in 2008: “I would like to see that number significantly increase.”

It is important to remember that the entire concept of vaccination is that it protects you and helps to protect everyone else as well. “[The SHEA position paper] is saying that as a health care provider, you’re responsible to protect yourself and your patients,” Killeen says. “I think that’s the best thing to come out of it.”

If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”

Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.

Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?

Dismal Rates of Coverage

The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.

In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)

“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”

There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”

Underestimating the Disease

Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.

“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”

Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”

Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.

Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.

“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”

Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”

Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”

A Matter of Patient Safety

Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”

However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”

“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”

The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.

The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–­associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–­associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.

In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”

But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”

That’s why the organizations have resorted to what some may see as a hard line on the subject (SHEA recommends that only medical contraindications should be acceptable exemption criteria; AAP, on the other hand, recommends that exemptions for medical and religious reasons be permitted on an individual basis). Fishman points out that vaccine mandates aren’t even unprecedented: Most institutions require vaccination against measles-mumps-rubella, varicella, and hepatitis B, for example, as a condition of employment.

Other arguments aside, Fishman says, there is one compelling reason why health care providers should get their annual flu vaccination. “Health care providers assume an ethical responsibility to prevent disease in our patients when we enter the profession,” he says. “That ethical obligation overrides other beliefs.”

Bottom Line: Get Vaccinated!

How far the push for mandatory influenza vaccination of health care personnel will go remains to be seen, as does what impact the movement will have on NPs and PAs. For the foreseeable future, it may depend on the practice setting. As of now, neither AAPA nor the American Academy of Nurse Practitioners (AANP) has taken a position on the mandate issue. (The American Nurses Association has, stating in a press release that it “does not support such policies” unless they adhere to specific guidelines. The organization does emphasize that it strongly encourages nurses to be vaccinated against influenza, however.)

Could this someday become a regulatory issue or a national health policy? “Initially, I’d be happy—we’d be happy—if more institutions around the country begin to adopt mandatory vaccination policies,” Fishman says. “If that happens, that will create a force around the country, and it will become the standard. If that doesn’t happen, I think we’ll have to see about pursuing more of a regulatory standard.”

Poland is a believer in the idea of a tipping point, and he thinks it’s drawing nearer: “I truly believe that within a decade, we will look back and say, ‘It is really unconscionable that we allowed this to happen,’ given the data that we have.”

Whatever else is accomplished in the immediate aftermath of the release of the SHEA and AAP papers, one thing is clear: It will hopefully encourage discussion about flu vaccine among health care providers, and perhaps encourage many of them to seek vaccination of their own volition. That is something both AAPA and AANP encourage. And perhaps too it will create opportunities for education.

AANP Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, says that hospitals, clinics, and group practices can provide more education to their employees, showing data to indicate that not getting vaccinated is causing a problem. “Most people are conscientious providers,” she says, “and even though they may never get the flu—or they think they’ll never get it—if they are creating an environment that makes it easier for patients to get it, then showing that data and educating them would certainly be the way to go.”

Towers encourages NPs to receive flu vaccine—and to encourage their patients to get it as well (barring contraindications, of course). “One of the things that I think NPs do better than some other providers is make sure that people are getting their flu shots and that the vaccine is available to them,” she says. “I think that’s important. If you don’t bring it up with some of your patients, they’ll never think to get it. So we have a big responsibility to make sure our patients are aware of the need to get flu vaccine.”

Killeen has a twofold mission for his colleagues. “We really need to challenge our Ob-Gyn practitioners to vaccinate pregnant women,” he says. “Out of all the populations that I see, the one that refuses the vaccine is that population. Again, it’s the safety issues: ‘How will this affect my pregnancy and my unborn child?’ That’s a huge stretch for women.”

The second piece of Killeen’s request to PAs is not to rest on the laurels, so to speak, of that 67% coverage rate reported in 2008: “I would like to see that number significantly increase.”

It is important to remember that the entire concept of vaccination is that it protects you and helps to protect everyone else as well. “[The SHEA position paper] is saying that as a health care provider, you’re responsible to protect yourself and your patients,” Killeen says. “I think that’s the best thing to come out of it.”

Editor’s Note: Part 1, featuring American Academy of Physician Assistants President Patrick Killeen, MS, PA-C, appeared in the July issue.

Penny Kaye ­Jensen, DNP, APRN, FNP, FAANP, has a wealth of experience at the state and national levels. She has practiced at the VA Medical Center in Salt Lake City for 16 years, was in the first cohort of DNP students at the University of Utah, and was one of seven NPs to staff a medical clinic during the 2002 Olympic Winter Games, held in Salt Lake City.

On the national front, she was recently appointed to the Joint Commission Ambulatory Professional and Technical Advisory Committee (2010-2012) and to the Veterans Affairs’ Office of Academic Affiliations Primary Care Medical Home Academic Subcommittee (2010-2012). She also became President of the American Academy of Nurse Practitioners (AANP), for which she had previously served as a state and a regional director.

Despite an undoubtedly jam-packed schedule, Jensen answered a few probing questions for Clinician Reviews.

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency? 

Jensen: I have been an integral part of AANP’s leadership for the past year, witnessing the tremendous amount of work that goes on behind the scenes. I have had the opportunity to be President-Elect at one of the most exciting times in the organization’s history. I call it the “perfect storm.” Health care reform has been at the forefront, which has resulted in increased visibility for NPs. [My predecessor as President] Dee Swanson was featured on Fox News, with an estimated two million viewers tuning in to hear about NPs and our role in health care reform.

I have received invitations to present to various nursing and medical organizations and was able to participate in a Senate briefing focusing on health care reform. AANP was invited to President Obama’s press conference on health care reform in March 2010, and I was able to attend and shake hands with our president.

I also have had the opportunity to attend many national and regional meetings throughout the United States, and to give interviews and craft position statements regarding NP practice and our contributions to health care.

I have had the best mentor in the world; Dee Swanson has been remarkable and will be a tough act to follow. 

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Jensen: It is my goal to continue to increase the public awareness of NP practice and to advocate for the profession. There are major misconceptions by the public, legislators, media, and even other health care providers regarding NP practice. These issues should be addressed through consistent and accurate messaging. NPs need to continue to speak with a unified voice.

There is strength in numbers, and AANP’s membership continues to increase. We are building coalitions with other NP organizations and other health care providers and stakeholders. It is my hope that these coalitions will continue to grow and strengthen under my leadership.

I will continue to advocate for licensed independent practice for NPs in each of our states. Many states have been able to accomplish this by developing alliances with other regions within our country. It is important to promote consistent access to quality advanced practice nursing care within states and across state lines. This is critical for the advancement of our profession and would increase access to qualified NPs. 

The issue of increasing membership is integral to AANP’s effort to influence national policy; better laws would mean more NPs in the US and better access to quality care. Each year, US nursing schools prepare 7,000 to 8,000 NPs but must turn away approximately 6,000 qualified applicants due to faculty shortages and lack of funding.

Improved funding for nursing faculty, loan repayment programs, and nurse-managed centers, and the initiation of graduate nursing education funding, if passed, would increase the number of highly qualified NPs available to provide care and to educate future NPs.

CR: What impact do you foresee health care reform having on your profession? How might NP practice change as a result of these changes?

Jensen: Because health care is at the top of the national agenda, as well as on the minds of most Americans, it is in the best interest of consumers that they receive all the facts available about health care professionals so that they can make intelligent and informed decisions when selecting the provider of their care.

The nation is currently experiencing a shortage of primary care providers. As recently as 2008, less than 10% of graduating medical students chose careers in primary care, while 70% of NPs practice in the primary care setting. These numbers suggest that changes in the health care system are inevitable—and that in whatever system emerges from the current reform efforts, NPs will play a dominant role in improving Americans’ access to primary care.

One of the concepts being discussed is the medical home, which promotes whole-patient wellness and disease prevention by developing partnerships between patients and a team of health care providers. Since the inception of the NP role, we have followed this type of practice model. NPs are uniquely positioned to absorb the increasing demand for primary care, and AANP is actively promoting NPs as a natural choice to assume leadership of medical home teams.

The inclusion of NPs in medical home legislation is critical. This model strives to deliver coordinated primary care directed by a single health care provider. NPs are not a threat, as some of our medical colleagues believe. We too are trying to answer the challenge of keeping pace with the demands for quality health care for everyone.

CR: How would you rate the current level of recognition your profession has with the public? How can we increase public awareness of NPs?

Jensen: Public awareness has grown over the past five years due to the expansion of retail clinics, which have been a very successful venue to showcase NP practice. However, this has also affected the perception of some consumers, who feel NPs can only treat acute illness and work within a narrow scope of practice. This is simply not true.

In addition to diagnosing and managing acute episodic illnesses, NPs have been managing patients with chronic illness successfully for many years. A large body of research has established that NPs provide high-quality, cost-effective, comprehensive, personalized, patient-centered health care with excellent patient outcomes. NPs place a strong emphasis on health promotion and disease prevention, which is imperative to reduce the relentless increase in spending on medical care.

We are always trying to get the message out. Under the leadership of our new CEO, Tim Knettler, and the Board of Directors, AANP recently hired a public relations firm. In our 25 years we have never had a national PR firm represent our organization. The company, Weber Shandwick, launched a very successful campaign for the Susan G. Komen Foundation. As Dee Swanson often says, “Everybody knows what a pink ribbon means.” It is my hope that during my term, NPs’ visibility will improve dramatically.

The early results of the consumer surveys undertaken by our PR firm have confirmed a frustrating truth long known to NPs: 50% of those surveyed did not know that NPs can prescribe medications, diagnose, or treat patients without a supervising physician.

Confusion over the role of NPs has led to state laws and regulations governing our work. Although many of the barriers to independent practice have been removed, many still remain. While many states grant full independence to NPs, some still require NPs to work under the direct supervision of a physician.

On a daily basis, NPs have an opportunity to impact the public’s perception about NPs, our abilities, and those we serve. NPs are constantly challenged with countering misinformation or verifying the positive outcome data that are published, but unfortunately we spend a large amount of time correcting misleading or erroneous information reported by the media. 

This year, National NP Week will take place from November 7 to 13. NPs in individual states are encouraged to request proclamations from their governors or mayors to improve NP visibility locally. AANP supplies the materials needed, including a resource guide, press release, and radio spots (PSAs) that we can give to local radio stations.

CR: How can we increase collaboration between NPs and PAs at all levels (national, state, individual practice setting)?

Jensen: As with all other health care providers, our patient population should be our utmost concern. We both have separate issues as related to licensure and supervision, but we do have many issues that we work closely together on.

I think it is critical to build coalitions with PAs for addressing areas of common concern: for example, access to affordable medications for our patient population and access to quality health care.

We share common concerns that affect our practice and ability to provide high-quality care for our patients. It is very important to recognize the value of our PA colleagues; on a daily basis, we often consult with one another and welcome the opportunity to work together on many issues, such as professional practice and health policy. NPs collaborate with health care providers at all levels and certainly work with PAs on those issues. Our training is different, but we work well together as part of the health care team.

Editor’s Note: Part 1, featuring American Academy of Physician Assistants President Patrick Killeen, MS, PA-C, appeared in the July issue.

Penny Kaye ­Jensen, DNP, APRN, FNP, FAANP, has a wealth of experience at the state and national levels. She has practiced at the VA Medical Center in Salt Lake City for 16 years, was in the first cohort of DNP students at the University of Utah, and was one of seven NPs to staff a medical clinic during the 2002 Olympic Winter Games, held in Salt Lake City.

On the national front, she was recently appointed to the Joint Commission Ambulatory Professional and Technical Advisory Committee (2010-2012) and to the Veterans Affairs’ Office of Academic Affiliations Primary Care Medical Home Academic Subcommittee (2010-2012). She also became President of the American Academy of Nurse Practitioners (AANP), for which she had previously served as a state and a regional director.

Despite an undoubtedly jam-packed schedule, Jensen answered a few probing questions for Clinician Reviews.

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency? 

Jensen: I have been an integral part of AANP’s leadership for the past year, witnessing the tremendous amount of work that goes on behind the scenes. I have had the opportunity to be President-Elect at one of the most exciting times in the organization’s history. I call it the “perfect storm.” Health care reform has been at the forefront, which has resulted in increased visibility for NPs. [My predecessor as President] Dee Swanson was featured on Fox News, with an estimated two million viewers tuning in to hear about NPs and our role in health care reform.

I have received invitations to present to various nursing and medical organizations and was able to participate in a Senate briefing focusing on health care reform. AANP was invited to President Obama’s press conference on health care reform in March 2010, and I was able to attend and shake hands with our president.

I also have had the opportunity to attend many national and regional meetings throughout the United States, and to give interviews and craft position statements regarding NP practice and our contributions to health care.

I have had the best mentor in the world; Dee Swanson has been remarkable and will be a tough act to follow. 

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Jensen: It is my goal to continue to increase the public awareness of NP practice and to advocate for the profession. There are major misconceptions by the public, legislators, media, and even other health care providers regarding NP practice. These issues should be addressed through consistent and accurate messaging. NPs need to continue to speak with a unified voice.

There is strength in numbers, and AANP’s membership continues to increase. We are building coalitions with other NP organizations and other health care providers and stakeholders. It is my hope that these coalitions will continue to grow and strengthen under my leadership.

I will continue to advocate for licensed independent practice for NPs in each of our states. Many states have been able to accomplish this by developing alliances with other regions within our country. It is important to promote consistent access to quality advanced practice nursing care within states and across state lines. This is critical for the advancement of our profession and would increase access to qualified NPs. 

The issue of increasing membership is integral to AANP’s effort to influence national policy; better laws would mean more NPs in the US and better access to quality care. Each year, US nursing schools prepare 7,000 to 8,000 NPs but must turn away approximately 6,000 qualified applicants due to faculty shortages and lack of funding.

Improved funding for nursing faculty, loan repayment programs, and nurse-managed centers, and the initiation of graduate nursing education funding, if passed, would increase the number of highly qualified NPs available to provide care and to educate future NPs.

CR: What impact do you foresee health care reform having on your profession? How might NP practice change as a result of these changes?

Jensen: Because health care is at the top of the national agenda, as well as on the minds of most Americans, it is in the best interest of consumers that they receive all the facts available about health care professionals so that they can make intelligent and informed decisions when selecting the provider of their care.

The nation is currently experiencing a shortage of primary care providers. As recently as 2008, less than 10% of graduating medical students chose careers in primary care, while 70% of NPs practice in the primary care setting. These numbers suggest that changes in the health care system are inevitable—and that in whatever system emerges from the current reform efforts, NPs will play a dominant role in improving Americans’ access to primary care.

One of the concepts being discussed is the medical home, which promotes whole-patient wellness and disease prevention by developing partnerships between patients and a team of health care providers. Since the inception of the NP role, we have followed this type of practice model. NPs are uniquely positioned to absorb the increasing demand for primary care, and AANP is actively promoting NPs as a natural choice to assume leadership of medical home teams.

The inclusion of NPs in medical home legislation is critical. This model strives to deliver coordinated primary care directed by a single health care provider. NPs are not a threat, as some of our medical colleagues believe. We too are trying to answer the challenge of keeping pace with the demands for quality health care for everyone.

CR: How would you rate the current level of recognition your profession has with the public? How can we increase public awareness of NPs?

Jensen: Public awareness has grown over the past five years due to the expansion of retail clinics, which have been a very successful venue to showcase NP practice. However, this has also affected the perception of some consumers, who feel NPs can only treat acute illness and work within a narrow scope of practice. This is simply not true.

In addition to diagnosing and managing acute episodic illnesses, NPs have been managing patients with chronic illness successfully for many years. A large body of research has established that NPs provide high-quality, cost-effective, comprehensive, personalized, patient-centered health care with excellent patient outcomes. NPs place a strong emphasis on health promotion and disease prevention, which is imperative to reduce the relentless increase in spending on medical care.

We are always trying to get the message out. Under the leadership of our new CEO, Tim Knettler, and the Board of Directors, AANP recently hired a public relations firm. In our 25 years we have never had a national PR firm represent our organization. The company, Weber Shandwick, launched a very successful campaign for the Susan G. Komen Foundation. As Dee Swanson often says, “Everybody knows what a pink ribbon means.” It is my hope that during my term, NPs’ visibility will improve dramatically.

The early results of the consumer surveys undertaken by our PR firm have confirmed a frustrating truth long known to NPs: 50% of those surveyed did not know that NPs can prescribe medications, diagnose, or treat patients without a supervising physician.

Confusion over the role of NPs has led to state laws and regulations governing our work. Although many of the barriers to independent practice have been removed, many still remain. While many states grant full independence to NPs, some still require NPs to work under the direct supervision of a physician.

On a daily basis, NPs have an opportunity to impact the public’s perception about NPs, our abilities, and those we serve. NPs are constantly challenged with countering misinformation or verifying the positive outcome data that are published, but unfortunately we spend a large amount of time correcting misleading or erroneous information reported by the media. 

This year, National NP Week will take place from November 7 to 13. NPs in individual states are encouraged to request proclamations from their governors or mayors to improve NP visibility locally. AANP supplies the materials needed, including a resource guide, press release, and radio spots (PSAs) that we can give to local radio stations.

CR: How can we increase collaboration between NPs and PAs at all levels (national, state, individual practice setting)?

Jensen: As with all other health care providers, our patient population should be our utmost concern. We both have separate issues as related to licensure and supervision, but we do have many issues that we work closely together on.

I think it is critical to build coalitions with PAs for addressing areas of common concern: for example, access to affordable medications for our patient population and access to quality health care.

We share common concerns that affect our practice and ability to provide high-quality care for our patients. It is very important to recognize the value of our PA colleagues; on a daily basis, we often consult with one another and welcome the opportunity to work together on many issues, such as professional practice and health policy. NPs collaborate with health care providers at all levels and certainly work with PAs on those issues. Our training is different, but we work well together as part of the health care team.

Editor’s Note: Part 1, featuring American Academy of Physician Assistants President Patrick Killeen, MS, PA-C, appeared in the July issue.

Penny Kaye ­Jensen, DNP, APRN, FNP, FAANP, has a wealth of experience at the state and national levels. She has practiced at the VA Medical Center in Salt Lake City for 16 years, was in the first cohort of DNP students at the University of Utah, and was one of seven NPs to staff a medical clinic during the 2002 Olympic Winter Games, held in Salt Lake City.

On the national front, she was recently appointed to the Joint Commission Ambulatory Professional and Technical Advisory Committee (2010-2012) and to the Veterans Affairs’ Office of Academic Affiliations Primary Care Medical Home Academic Subcommittee (2010-2012). She also became President of the American Academy of Nurse Practitioners (AANP), for which she had previously served as a state and a regional director.

Despite an undoubtedly jam-packed schedule, Jensen answered a few probing questions for Clinician Reviews.

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency? 

Jensen: I have been an integral part of AANP’s leadership for the past year, witnessing the tremendous amount of work that goes on behind the scenes. I have had the opportunity to be President-Elect at one of the most exciting times in the organization’s history. I call it the “perfect storm.” Health care reform has been at the forefront, which has resulted in increased visibility for NPs. [My predecessor as President] Dee Swanson was featured on Fox News, with an estimated two million viewers tuning in to hear about NPs and our role in health care reform.

I have received invitations to present to various nursing and medical organizations and was able to participate in a Senate briefing focusing on health care reform. AANP was invited to President Obama’s press conference on health care reform in March 2010, and I was able to attend and shake hands with our president.

I also have had the opportunity to attend many national and regional meetings throughout the United States, and to give interviews and craft position statements regarding NP practice and our contributions to health care.

I have had the best mentor in the world; Dee Swanson has been remarkable and will be a tough act to follow. 

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Jensen: It is my goal to continue to increase the public awareness of NP practice and to advocate for the profession. There are major misconceptions by the public, legislators, media, and even other health care providers regarding NP practice. These issues should be addressed through consistent and accurate messaging. NPs need to continue to speak with a unified voice.

There is strength in numbers, and AANP’s membership continues to increase. We are building coalitions with other NP organizations and other health care providers and stakeholders. It is my hope that these coalitions will continue to grow and strengthen under my leadership.

I will continue to advocate for licensed independent practice for NPs in each of our states. Many states have been able to accomplish this by developing alliances with other regions within our country. It is important to promote consistent access to quality advanced practice nursing care within states and across state lines. This is critical for the advancement of our profession and would increase access to qualified NPs. 

The issue of increasing membership is integral to AANP’s effort to influence national policy; better laws would mean more NPs in the US and better access to quality care. Each year, US nursing schools prepare 7,000 to 8,000 NPs but must turn away approximately 6,000 qualified applicants due to faculty shortages and lack of funding.

Improved funding for nursing faculty, loan repayment programs, and nurse-managed centers, and the initiation of graduate nursing education funding, if passed, would increase the number of highly qualified NPs available to provide care and to educate future NPs.

CR: What impact do you foresee health care reform having on your profession? How might NP practice change as a result of these changes?

Jensen: Because health care is at the top of the national agenda, as well as on the minds of most Americans, it is in the best interest of consumers that they receive all the facts available about health care professionals so that they can make intelligent and informed decisions when selecting the provider of their care.

The nation is currently experiencing a shortage of primary care providers. As recently as 2008, less than 10% of graduating medical students chose careers in primary care, while 70% of NPs practice in the primary care setting. These numbers suggest that changes in the health care system are inevitable—and that in whatever system emerges from the current reform efforts, NPs will play a dominant role in improving Americans’ access to primary care.

One of the concepts being discussed is the medical home, which promotes whole-patient wellness and disease prevention by developing partnerships between patients and a team of health care providers. Since the inception of the NP role, we have followed this type of practice model. NPs are uniquely positioned to absorb the increasing demand for primary care, and AANP is actively promoting NPs as a natural choice to assume leadership of medical home teams.

The inclusion of NPs in medical home legislation is critical. This model strives to deliver coordinated primary care directed by a single health care provider. NPs are not a threat, as some of our medical colleagues believe. We too are trying to answer the challenge of keeping pace with the demands for quality health care for everyone.

CR: How would you rate the current level of recognition your profession has with the public? How can we increase public awareness of NPs?

Jensen: Public awareness has grown over the past five years due to the expansion of retail clinics, which have been a very successful venue to showcase NP practice. However, this has also affected the perception of some consumers, who feel NPs can only treat acute illness and work within a narrow scope of practice. This is simply not true.

In addition to diagnosing and managing acute episodic illnesses, NPs have been managing patients with chronic illness successfully for many years. A large body of research has established that NPs provide high-quality, cost-effective, comprehensive, personalized, patient-centered health care with excellent patient outcomes. NPs place a strong emphasis on health promotion and disease prevention, which is imperative to reduce the relentless increase in spending on medical care.

We are always trying to get the message out. Under the leadership of our new CEO, Tim Knettler, and the Board of Directors, AANP recently hired a public relations firm. In our 25 years we have never had a national PR firm represent our organization. The company, Weber Shandwick, launched a very successful campaign for the Susan G. Komen Foundation. As Dee Swanson often says, “Everybody knows what a pink ribbon means.” It is my hope that during my term, NPs’ visibility will improve dramatically.

The early results of the consumer surveys undertaken by our PR firm have confirmed a frustrating truth long known to NPs: 50% of those surveyed did not know that NPs can prescribe medications, diagnose, or treat patients without a supervising physician.

Confusion over the role of NPs has led to state laws and regulations governing our work. Although many of the barriers to independent practice have been removed, many still remain. While many states grant full independence to NPs, some still require NPs to work under the direct supervision of a physician.

On a daily basis, NPs have an opportunity to impact the public’s perception about NPs, our abilities, and those we serve. NPs are constantly challenged with countering misinformation or verifying the positive outcome data that are published, but unfortunately we spend a large amount of time correcting misleading or erroneous information reported by the media. 

This year, National NP Week will take place from November 7 to 13. NPs in individual states are encouraged to request proclamations from their governors or mayors to improve NP visibility locally. AANP supplies the materials needed, including a resource guide, press release, and radio spots (PSAs) that we can give to local radio stations.

CR: How can we increase collaboration between NPs and PAs at all levels (national, state, individual practice setting)?

Jensen: As with all other health care providers, our patient population should be our utmost concern. We both have separate issues as related to licensure and supervision, but we do have many issues that we work closely together on.

I think it is critical to build coalitions with PAs for addressing areas of common concern: for example, access to affordable medications for our patient population and access to quality health care.

We share common concerns that affect our practice and ability to provide high-quality care for our patients. It is very important to recognize the value of our PA colleagues; on a daily basis, we often consult with one another and welcome the opportunity to work together on many issues, such as professional practice and health policy. NPs collaborate with health care providers at all levels and certainly work with PAs on those issues. Our training is different, but we work well together as part of the health care team.

Patrick Killeen, MS, PA-C, may have just taken the reins as President of the American Academy of Physician Assistants (AAPA), but he is no stranger to leadership roles. His extensive resume includes tenures as President of the Society for PAs in Pediatrics and as the AAPA Liaison to the American Academy of Pediatrics. But for Killeen, one of the significant highlights was serving as President of the Student Academy of AAPA (in 1986-1987): “Without that,” he says, “I don’t think I would have continued in the track that I did.”

As he commences his newest role, Killeen found time to answer a few questions for Clinician Reviews.  

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency?

Killeen: The past year was all about health care reform. Like no other year previously, that was the hot issue. So what I learned is that we have to be very, very organized as a profession, in order to be at the table and not “on the table,” as people say. If you’re not sitting there talking about your profession, then your profession may not be noted. In the past year, in my opinion at least, the Academy has done a great job promoting what the PA profession should be doing within health care reform, without talking about the Democratic or Republican side, but rather in reference to how PAs should practice.

[On a more personal note,] Steve Hanson, the current Immediate Past President, gave me some great advice in reference to looking at the future. It was “Do everything you need to do in the moment, because the big picture is overwhelming.” And it’s really true. When you look at everything you have to do as a profession, oh my gosh, it’s so much work to be done. But if you live in the moment to get done what you need to do right now or be at the table you need to be sitting at today, you’re going to make great progress. That’s probably the best advice he gave me.

CR: What impact do you foresee health care reform having on your profession? How might PA practice change as a result?

Killeen: It’s going to be about primary care. The Obama administration just announced that about $250 million will be going to health care reform in the primary care workforce. And we know that 15%, or about $32 million, of that is going to go to PA education, and that’s going to focus on primary care.

To me, it’s amazing that PAs are already recognized, with other providers such as nurse practitioners, as being primary care providers in a medical home or chronic care management model. Those are things that weren’t acknowledged at the federal level prior to health care reform. For the PA profession, it’s placed us with a great opportunity to make an impact in primary care.

When you talk about throwing 32 million [previously uninsured] people into the primary care pool and looking at where they are getting their care—no longer, hopefully, in emergency rooms—I think PAs, NPs, MDs, and DOs are really going to have to look at their patient mix—and reimbursement has to be appropriate for that patient mix…. So for right now, I think the focus is going to be on looking at increasing the patient load and looking at appropriate reimbursement.

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Killeen: For me there are two things, the first being the implementation of health care reform and all the different venues we have to look at. That’s probably our biggest thing, because again, if we’re not at the table, we’re not going to be the people who are able to implement changes.

And the second thing is research on the PA profession. I’m excited about working to develop extensive research on how PAs impact patient care, patient care outcomes, compliance to medications, compliance to smoking cessation and obesity interventions. Those are the types of things that we really need to look at. The PA profession has some of that information. But if you were to ask, “Is there one study that tells everything you need to know, or one great study that’s kind of the blueprint [for the profession]?” that would be a hard one to pick. I think this research agenda will allow the profession to really target some areas of clinical expertise, in addition to how they affect patient outcomes.

Patients need to understand that they’re receiving quality care and that it’s effective and safe; those same issues can be noted by other health care providers, insurers, and people who are doing appropriate reimbursement for physician services [provided] by a PA—because you’re in a team. As always, PAs have talked about a team approach, an interdisciplinary approach, to care. And I think that component needs to really be pushed out there, how the team approach improves patient care. In reality, the PA profession, and NPs and other groups, talk about it, but is there one really great sentinel study? That would be a difficult thing for PAs or NPs, to promote one study or one topic area that made a big impact.

CR: How would you rate the current level of recognition the PA profession has with the public? How can we increase public awareness of PAs?

Killeen: We need to do more. But overall, when you look at the profession and its marketing and public relations component, with regard to patients, I would say that the profession has slowly increased that knowledge base within the past five years. And, partly because of health care reform, we have groups like Money magazine listing the PA profession as the second-best career and Forbes.com listing ours as the best master’s degree to receive. Those media pieces are huge for the profession. And it’s really exciting to see that finally come to fruition, so the public can see that information out there.

But it doesn’t mean that every patient you see has a full understanding about your profession and its all-encompassing components. We do have a way to go, but I think as a profession we’ve made some significant strides. When you look at the future of the profession, it’s very bright. We talk about PAs’ numbers increasing and about being noted by all these different organizations—I think that says a lot.

Now, we have to take all that information and bring it down to a patient care level. I think the Academy is great at creating coalitions with other health care organizations—like the American Med­ical Association, the American Academy of Family Practitioners, the American Academy of Pediatrics—and at getting the message out to legislators. But we need to take all that information and then filter that through to the general public as well.

CR: How can we increase collaboration between PAs and NPs at all levels (national, state, individual practice settings)?

Killeen: I think there are some great opportunities there. We know that PAs and NPs work very well together clinically. But I think we do have to reach across the aisle at the state and national levels, when we talk about how we can work in teams, when we talk about the team approach to medicine or the interprofessionalism of medicine for patient care.

I think that’s something that we need to improve on, because we’re all talking about the same thing: How do we approach patient care within a medical home? How are we going to get preventive care and information out there?…. There are some great areas regarding patient care and patient advocacy that we can partner on—obesity being one of them. What kind of programs on obesity are the NP state and national organizations working on? That affects so many other aspects of life, such as hypertension, cholesterol, etc. And those are the types of partnerships that I think our profession and the NP profession should be really looking at, some of those clinical practice issues where we really make a great impact on patient care.

CR: What other message(s) do you have for your colleagues?

Killeen: I think the biggest, and the most difficult, thing is to volunteer. It doesn’t matter if you’re an NP or a PA, you need to have some component of your life to volunteer. I don’t care if it’s with the United Way or a gay and lesbian medical association—some type of group that you work with, because as a PA or an NP you’ll make a huge impact with any type of volunteer [activity]. If it’s an hour a week, that’s a huge impact for some individuals—and the more you can give, the better impact you can make. And that can be at the state level, professional level, or national level.

That’s something I’ve always done; I sort of grew up with the thought that you volunteer, you help out at church, you do your activities, because it’s the right thing to do. I would like to see more people do what they think is the right thing, by volunteering in something that they’re really passionate about. It doesn’t have to be medicine. It could be hockey or some other sport or something. But volunteering for it, being the parent who does that, makes a big impact, in comparison to the parent who is unfortunately too busy or is overwhelmed with life and activities as well.

Patrick Killeen, MS, PA-C, may have just taken the reins as President of the American Academy of Physician Assistants (AAPA), but he is no stranger to leadership roles. His extensive resume includes tenures as President of the Society for PAs in Pediatrics and as the AAPA Liaison to the American Academy of Pediatrics. But for Killeen, one of the significant highlights was serving as President of the Student Academy of AAPA (in 1986-1987): “Without that,” he says, “I don’t think I would have continued in the track that I did.”

As he commences his newest role, Killeen found time to answer a few questions for Clinician Reviews.  

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency?

Killeen: The past year was all about health care reform. Like no other year previously, that was the hot issue. So what I learned is that we have to be very, very organized as a profession, in order to be at the table and not “on the table,” as people say. If you’re not sitting there talking about your profession, then your profession may not be noted. In the past year, in my opinion at least, the Academy has done a great job promoting what the PA profession should be doing within health care reform, without talking about the Democratic or Republican side, but rather in reference to how PAs should practice.

[On a more personal note,] Steve Hanson, the current Immediate Past President, gave me some great advice in reference to looking at the future. It was “Do everything you need to do in the moment, because the big picture is overwhelming.” And it’s really true. When you look at everything you have to do as a profession, oh my gosh, it’s so much work to be done. But if you live in the moment to get done what you need to do right now or be at the table you need to be sitting at today, you’re going to make great progress. That’s probably the best advice he gave me.

CR: What impact do you foresee health care reform having on your profession? How might PA practice change as a result?

Killeen: It’s going to be about primary care. The Obama administration just announced that about $250 million will be going to health care reform in the primary care workforce. And we know that 15%, or about $32 million, of that is going to go to PA education, and that’s going to focus on primary care.

To me, it’s amazing that PAs are already recognized, with other providers such as nurse practitioners, as being primary care providers in a medical home or chronic care management model. Those are things that weren’t acknowledged at the federal level prior to health care reform. For the PA profession, it’s placed us with a great opportunity to make an impact in primary care.

When you talk about throwing 32 million [previously uninsured] people into the primary care pool and looking at where they are getting their care—no longer, hopefully, in emergency rooms—I think PAs, NPs, MDs, and DOs are really going to have to look at their patient mix—and reimbursement has to be appropriate for that patient mix…. So for right now, I think the focus is going to be on looking at increasing the patient load and looking at appropriate reimbursement.

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Killeen: For me there are two things, the first being the implementation of health care reform and all the different venues we have to look at. That’s probably our biggest thing, because again, if we’re not at the table, we’re not going to be the people who are able to implement changes.

And the second thing is research on the PA profession. I’m excited about working to develop extensive research on how PAs impact patient care, patient care outcomes, compliance to medications, compliance to smoking cessation and obesity interventions. Those are the types of things that we really need to look at. The PA profession has some of that information. But if you were to ask, “Is there one study that tells everything you need to know, or one great study that’s kind of the blueprint [for the profession]?” that would be a hard one to pick. I think this research agenda will allow the profession to really target some areas of clinical expertise, in addition to how they affect patient outcomes.

Patients need to understand that they’re receiving quality care and that it’s effective and safe; those same issues can be noted by other health care providers, insurers, and people who are doing appropriate reimbursement for physician services [provided] by a PA—because you’re in a team. As always, PAs have talked about a team approach, an interdisciplinary approach, to care. And I think that component needs to really be pushed out there, how the team approach improves patient care. In reality, the PA profession, and NPs and other groups, talk about it, but is there one really great sentinel study? That would be a difficult thing for PAs or NPs, to promote one study or one topic area that made a big impact.

CR: How would you rate the current level of recognition the PA profession has with the public? How can we increase public awareness of PAs?

Killeen: We need to do more. But overall, when you look at the profession and its marketing and public relations component, with regard to patients, I would say that the profession has slowly increased that knowledge base within the past five years. And, partly because of health care reform, we have groups like Money magazine listing the PA profession as the second-best career and Forbes.com listing ours as the best master’s degree to receive. Those media pieces are huge for the profession. And it’s really exciting to see that finally come to fruition, so the public can see that information out there.

But it doesn’t mean that every patient you see has a full understanding about your profession and its all-encompassing components. We do have a way to go, but I think as a profession we’ve made some significant strides. When you look at the future of the profession, it’s very bright. We talk about PAs’ numbers increasing and about being noted by all these different organizations—I think that says a lot.

Now, we have to take all that information and bring it down to a patient care level. I think the Academy is great at creating coalitions with other health care organizations—like the American Med­ical Association, the American Academy of Family Practitioners, the American Academy of Pediatrics—and at getting the message out to legislators. But we need to take all that information and then filter that through to the general public as well.

CR: How can we increase collaboration between PAs and NPs at all levels (national, state, individual practice settings)?

Killeen: I think there are some great opportunities there. We know that PAs and NPs work very well together clinically. But I think we do have to reach across the aisle at the state and national levels, when we talk about how we can work in teams, when we talk about the team approach to medicine or the interprofessionalism of medicine for patient care.

I think that’s something that we need to improve on, because we’re all talking about the same thing: How do we approach patient care within a medical home? How are we going to get preventive care and information out there?…. There are some great areas regarding patient care and patient advocacy that we can partner on—obesity being one of them. What kind of programs on obesity are the NP state and national organizations working on? That affects so many other aspects of life, such as hypertension, cholesterol, etc. And those are the types of partnerships that I think our profession and the NP profession should be really looking at, some of those clinical practice issues where we really make a great impact on patient care.

CR: What other message(s) do you have for your colleagues?

Killeen: I think the biggest, and the most difficult, thing is to volunteer. It doesn’t matter if you’re an NP or a PA, you need to have some component of your life to volunteer. I don’t care if it’s with the United Way or a gay and lesbian medical association—some type of group that you work with, because as a PA or an NP you’ll make a huge impact with any type of volunteer [activity]. If it’s an hour a week, that’s a huge impact for some individuals—and the more you can give, the better impact you can make. And that can be at the state level, professional level, or national level.

That’s something I’ve always done; I sort of grew up with the thought that you volunteer, you help out at church, you do your activities, because it’s the right thing to do. I would like to see more people do what they think is the right thing, by volunteering in something that they’re really passionate about. It doesn’t have to be medicine. It could be hockey or some other sport or something. But volunteering for it, being the parent who does that, makes a big impact, in comparison to the parent who is unfortunately too busy or is overwhelmed with life and activities as well.

Patrick Killeen, MS, PA-C, may have just taken the reins as President of the American Academy of Physician Assistants (AAPA), but he is no stranger to leadership roles. His extensive resume includes tenures as President of the Society for PAs in Pediatrics and as the AAPA Liaison to the American Academy of Pediatrics. But for Killeen, one of the significant highlights was serving as President of the Student Academy of AAPA (in 1986-1987): “Without that,” he says, “I don’t think I would have continued in the track that I did.”

As he commences his newest role, Killeen found time to answer a few questions for Clinician Reviews.  

CR: What have you learned during your tenure as President-Elect that will shape or inform your presidency?

Killeen: The past year was all about health care reform. Like no other year previously, that was the hot issue. So what I learned is that we have to be very, very organized as a profession, in order to be at the table and not “on the table,” as people say. If you’re not sitting there talking about your profession, then your profession may not be noted. In the past year, in my opinion at least, the Academy has done a great job promoting what the PA profession should be doing within health care reform, without talking about the Democratic or Republican side, but rather in reference to how PAs should practice.

[On a more personal note,] Steve Hanson, the current Immediate Past President, gave me some great advice in reference to looking at the future. It was “Do everything you need to do in the moment, because the big picture is overwhelming.” And it’s really true. When you look at everything you have to do as a profession, oh my gosh, it’s so much work to be done. But if you live in the moment to get done what you need to do right now or be at the table you need to be sitting at today, you’re going to make great progress. That’s probably the best advice he gave me.

CR: What impact do you foresee health care reform having on your profession? How might PA practice change as a result?

Killeen: It’s going to be about primary care. The Obama administration just announced that about $250 million will be going to health care reform in the primary care workforce. And we know that 15%, or about $32 million, of that is going to go to PA education, and that’s going to focus on primary care.

To me, it’s amazing that PAs are already recognized, with other providers such as nurse practitioners, as being primary care providers in a medical home or chronic care management model. Those are things that weren’t acknowledged at the federal level prior to health care reform. For the PA profession, it’s placed us with a great opportunity to make an impact in primary care.

When you talk about throwing 32 million [previously uninsured] people into the primary care pool and looking at where they are getting their care—no longer, hopefully, in emergency rooms—I think PAs, NPs, MDs, and DOs are really going to have to look at their patient mix—and reimbursement has to be appropriate for that patient mix…. So for right now, I think the focus is going to be on looking at increasing the patient load and looking at appropriate reimbursement.

CR: Personally, which initiatives are you most excited about working on during your time in office? What are your own goals for your presidency?

Killeen: For me there are two things, the first being the implementation of health care reform and all the different venues we have to look at. That’s probably our biggest thing, because again, if we’re not at the table, we’re not going to be the people who are able to implement changes.

And the second thing is research on the PA profession. I’m excited about working to develop extensive research on how PAs impact patient care, patient care outcomes, compliance to medications, compliance to smoking cessation and obesity interventions. Those are the types of things that we really need to look at. The PA profession has some of that information. But if you were to ask, “Is there one study that tells everything you need to know, or one great study that’s kind of the blueprint [for the profession]?” that would be a hard one to pick. I think this research agenda will allow the profession to really target some areas of clinical expertise, in addition to how they affect patient outcomes.

Patients need to understand that they’re receiving quality care and that it’s effective and safe; those same issues can be noted by other health care providers, insurers, and people who are doing appropriate reimbursement for physician services [provided] by a PA—because you’re in a team. As always, PAs have talked about a team approach, an interdisciplinary approach, to care. And I think that component needs to really be pushed out there, how the team approach improves patient care. In reality, the PA profession, and NPs and other groups, talk about it, but is there one really great sentinel study? That would be a difficult thing for PAs or NPs, to promote one study or one topic area that made a big impact.

CR: How would you rate the current level of recognition the PA profession has with the public? How can we increase public awareness of PAs?

Killeen: We need to do more. But overall, when you look at the profession and its marketing and public relations component, with regard to patients, I would say that the profession has slowly increased that knowledge base within the past five years. And, partly because of health care reform, we have groups like Money magazine listing the PA profession as the second-best career and Forbes.com listing ours as the best master’s degree to receive. Those media pieces are huge for the profession. And it’s really exciting to see that finally come to fruition, so the public can see that information out there.

But it doesn’t mean that every patient you see has a full understanding about your profession and its all-encompassing components. We do have a way to go, but I think as a profession we’ve made some significant strides. When you look at the future of the profession, it’s very bright. We talk about PAs’ numbers increasing and about being noted by all these different organizations—I think that says a lot.

Now, we have to take all that information and bring it down to a patient care level. I think the Academy is great at creating coalitions with other health care organizations—like the American Med­ical Association, the American Academy of Family Practitioners, the American Academy of Pediatrics—and at getting the message out to legislators. But we need to take all that information and then filter that through to the general public as well.

CR: How can we increase collaboration between PAs and NPs at all levels (national, state, individual practice settings)?

Killeen: I think there are some great opportunities there. We know that PAs and NPs work very well together clinically. But I think we do have to reach across the aisle at the state and national levels, when we talk about how we can work in teams, when we talk about the team approach to medicine or the interprofessionalism of medicine for patient care.

I think that’s something that we need to improve on, because we’re all talking about the same thing: How do we approach patient care within a medical home? How are we going to get preventive care and information out there?…. There are some great areas regarding patient care and patient advocacy that we can partner on—obesity being one of them. What kind of programs on obesity are the NP state and national organizations working on? That affects so many other aspects of life, such as hypertension, cholesterol, etc. And those are the types of partnerships that I think our profession and the NP profession should be really looking at, some of those clinical practice issues where we really make a great impact on patient care.

CR: What other message(s) do you have for your colleagues?

Killeen: I think the biggest, and the most difficult, thing is to volunteer. It doesn’t matter if you’re an NP or a PA, you need to have some component of your life to volunteer. I don’t care if it’s with the United Way or a gay and lesbian medical association—some type of group that you work with, because as a PA or an NP you’ll make a huge impact with any type of volunteer [activity]. If it’s an hour a week, that’s a huge impact for some individuals—and the more you can give, the better impact you can make. And that can be at the state level, professional level, or national level.

That’s something I’ve always done; I sort of grew up with the thought that you volunteer, you help out at church, you do your activities, because it’s the right thing to do. I would like to see more people do what they think is the right thing, by volunteering in something that they’re really passionate about. It doesn’t have to be medicine. It could be hockey or some other sport or something. But volunteering for it, being the parent who does that, makes a big impact, in comparison to the parent who is unfortunately too busy or is overwhelmed with life and activities as well.

Picture it: Kansas City, 1984. At a meeting sponsored by the American Nurses Association (ANA), conversation among the NP attendees from across the United States focuses on the widely perceived need for “common representation” of their distinct interests. Who among the existing nursing organizations has the time, money, and/or inclination to serve as the voice of all NPs, providing a conduit for communication and leadership in legislative efforts to remove barriers to practice?

As it will turn out, the answer is no one—at least, not in the way these NPs envision. So they ­decide to do something about that … and since the result of their collaborative vision is the American Academy of Nurse Practitioners (AANP), you have a pretty good idea how it worked out.

AANP is celebrating its 25th anniversary this year—a milestone its founders probably never doubted would be reached, although others initially questioned the viability of such an organization.

“The feeling was that if it was needed, it would grow, and if it wasn’t needed, it wouldn’t grow,” recalls Jan Towers, PhD, NP-C, CRNP, FAANP, a founding member and past president who continues to serve AANP as Director of Health Policy. “And indeed it grew—so I think we know what our answer was!”

A SEPARATE BUT EQUAL NEED
Of course, creating a new professional organization was not as simple as a group of individuals putting their heads together. And yet, in a certain sense, it was that easy.

Shortly after those initial discussions in Kansas City, there was another conference in Washington, DC. During a panel discussion with executives from the insurance and advertising industries, it became evident that the biggest issue for NPs was “no one knew who we were,” says Clinician Reviews NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP, also a founder and past president of AANP. Clearly, that situation needed to be remedied—but how?

At that time, many NPs were members of ANA (and, it should be noted, many still are). However, since ANA represents all of nursing, the bulk of its resources could not be devoted to NPs. The organization had created a Council of Primary Care NPs in 1974, but the “renegade” NPs of 1984 felt that structure didn’t provide the latitude they wanted in their representation.

“We needed a way to really work together and have our ­undivided attention focused on NP issues,” Towers says. Onieal adds, “We weren’t abandoning our ‘nursing-ness,’ but clearly we had separate and distinctly different issues at hand than did the general populace of the nursing profession.”

The fact that NPs from across the country—remember, this is pre-Internet—shared this viewpoint added strength to the argument. If dozens of people who didn’t really know one another could see the same need, it must be real—and therefore, it had to be addressed.

“The [NP] role had been around since 1965, but nursing faculty were just beginning to define what NP education ought to look like,” says Carole Kain, DNS, ARNP, PNP-BC, a founding member and the first president of AANP. (She was Carole Kerwin then.) “A lot of things were changing in the profession, and we all wanted to be part of defining what that change meant. It was everybody coming together with a skill set that set us on this course.”

The time was certainly ripe. In her files, Kain still has a copy of a document discussing a referendum the American Medical Association passed in 1984, in which “they said they were actually going to try to inhibit the practice of NPs, PAs, nurse-midwives, and pharmacists, as to prescribing and taking care of patients.”

In addition to that restrictive attitude—a cause to rally around for NPs nationwide—the NP profession had reached a tipping point in terms of growth. “Enough of us had been prepared, but we were still small enough to be spread out [across the country],” Towers says. “We needed some way to connect.”

By the time they left Washington, DC, a steering committee had been formed to explore the need for an organization representing the nation’s approximately 24,000 NPs. They were expected to report back to the ANA one year later, at a meeting in Chicago. And so, the hard work began.

SO, YOU WANT TO START AN ORGANIZATION?
For a group of virtual strangers who had never started an organization before, they went about their business in a methodical and logical way. Different task forces were created, including one to look into how to do articles of incorporation and other “legalese” pieces, and another to develop a list of reasons why a separate organization was needed.

Onieal recalls a good deal of traveling that she and some other NPs did “to every NP meeting, every NP gathering, across the US for a year. We had a petition, and I’d say, ‘All I want to know is whether you think we should start an NP organization.’” The list grew over the course of the year.

In the meantime, contact was made with the handful of existing NP organizations, to see if any of them could meet the needs of the profession at large: the National Association of Pediatric NPs (1973), the National Association of NPs in Reproductive Health (which became the National Association of NPs in Women’s Health; 1980), and the National Conference of Gerontological NPs (1981). But obviously, since these groups had been tasked by their members with representing the interests of NPs in specific fields, their responses boiled down to “We can’t help you—but we wish you well.”

By the time the Chicago meeting rolled around in May 1985, about the only thing left to do was announce the new organization’s formation. Bylaws had already been drafted, and Onieal’s (now former) address in Lowell, Massachusetts, had been chosen as the original headquarters of the organization. (Trivia: AANP was originally incorporated in Lowell, before relocating to Austin, Texas.)

During a panel session in Chicago, Kain and Onieal told the assembled crowd, “This is what we need: We need to be heard as independent providers. We need to have some say in how our practice is regulated. We need … an organization that will allow us to learn from each other across the country,” as Kain recalls.

The official press release announcing AANP’s creation reads: “The overall purpose of the AANP is to promote high standards of health care as delivered by nurse practitioners and to act as a forum to enhance the identity and continuity of nurse practitioners. It is nationwide in scope and welcomes all nurse practitioners, regardless of specialty. The first year’s focus will be on networking and communications.”

AANP’s first elected officers were Kain (President), Towers (President-Elect), Onieal (Treasurer), Madeline D. Wiley, MSN, ARNP (Recording Secretary), and Robert T. Smithing, MSN, ARNP (Communications Secretary). Annual membership dues were $60.

25 YEARS OF PROGRESS
The leaders and members of the newly formed AANP wasted little time in setting out to accomplish their organizational goals. As Onieal says, “When we started, we had a five-year plan and a 10-year plan. And in five years, we got through all of that.”

With the initial focus on networking and communications, 10 geographical regions were established, based on the National Health Service Corps regions, and regional directors were found. So were individual reps from every state, each of whom then “started talking to people within their state,” Kain says.

For Towers, the focus was on legislative and regulatory issues, just as it is today. “One of the first things we started doing was finding ways to influence policy, both in Washington and in our states,” she says. “Early on, we started working on reimbursement.”

An early victory was getting NPs reimbursement through the Federal Employees Health Benefits Program (1986-1987). On the Medicare front, AANP had a significant impact in securing reimbursement for NPs working in rural areas and in long-term care facilities (1989-1990). Additional milestones include mandated Medicare payment for family and pediatric NPs regardless of supervision status (the early ’90s) and direct Medicare reimbursement for NPs regardless of setting (1997).

Seeing all that has been accomplished in 25 years is still a little amazing, even to the people who set the wheels in motion. “We’re funding research, and we have a foundation that gives scholarships,” Kain says. “Those are things we talked about as ‘someday’ dreams, but now they’re actualizations.”

She’s greeted every day by signs of how much has changed since 1985. “I can remember the initial discussions about having a certification program, talking to the psychometricians about how we’d start up the exam and which criteria we’d use,” she reflects. “And now, the NPs that I’m teaching are using that certification exam to get their licensure!”

As much as Onieal appreciates all the services that AANP has grown to offer its members, she also recognizes the core value of the organization. “One of our primary purposes was to let people know what NPs are all about—to clarify that we’re not LPNs, we’re not students, we’re not people who couldn’t go to medical school and decided to do this instead; this was our chosen profession,” she says. “I think we’ve been successful in doing that.”

THE ULTIMATE COLLABORATION
The founders of AANP never doubted that forming the organization was the right thing to do, which probably confirms that they were the best people to do the job. Instead of expending energy on doubts or infighting, they figured out what needed to be done and moved forward. 

Kain still has a “vivid mental picture” of the early days in Kansas City and Washington, DC, when there was no organization and therefore no budget, so meetings were held in someone’s hotel room. “There would be people sitting on the bed, on the floor, standing up; we’re all crammed into the room,” she remembers with a laugh. “And people are talking, and we’re polite to one another, we’re respectful of one another. We’re passionate. We’re talking about the difficulties and why we need this. And if you could put that into a bottle, you could start a new organization right now!”

That spirit of collaboration is still a viable part of the organization, one that Onieal is proud of. “If anybody ever had an interest in doing something or being something within the organization, the doors were open,” she says. “Early on, a couple of students said, ‘But we have needs, too,’ so we said, ‘Fine, we’ll start a student special interest group. No problem.’” The point, after all, had always been to learn from one another.

If there is one lesson the AANP founders hope to pass along to future generations, it’s that great change can be brought about by a small group of (seemingly) ordinary people with extraordinary determination. They don’t want statues erected in their honor, but they do want others to be inspired to take an active role in the continuous evolution of the NP profession—especially since, as Towers observes, “There is still work to be done.”

“We need to get all the state practice acts on a level playing field,” she notes, “which we’re well on the way to doing now with our consensus document and the model rules and regulations. We need to have recognition within all the payment systems, and remove barriers within existing laws that prevent NPs from practicing to their fullest capability.”

The significant changes that have been brought about in the past 25 years can be difficult to fathom for those who did not witness them. In 2010, the NP profession is well established. (The same is true for PAs.) Students deciding their future choose these professions in part because of all they will be able to do and accomplish within their roles.

What they don’t always recognize is that it took hard work and continued vigilance on the part of those who have preceded them to achieve the privileges that today’s clinicians—and perhaps tomorrow’s—run the risk of taking for granted.

“We’re not done, and I don’t want anyone to think they can rest on the laurels of what has gone before or think that without their involvement it will continue,” says Kain. “It won’t. We need them. We need new blood, new thoughts, new ideas, to face the new challenges.”

When she reflects on how a group of near-strangers got together and made a mark on the history of their profession, she concludes, simply, “Others can do the same thing. They just have to want to, and see the need.”

Picture it: Kansas City, 1984. At a meeting sponsored by the American Nurses Association (ANA), conversation among the NP attendees from across the United States focuses on the widely perceived need for “common representation” of their distinct interests. Who among the existing nursing organizations has the time, money, and/or inclination to serve as the voice of all NPs, providing a conduit for communication and leadership in legislative efforts to remove barriers to practice?

As it will turn out, the answer is no one—at least, not in the way these NPs envision. So they ­decide to do something about that … and since the result of their collaborative vision is the American Academy of Nurse Practitioners (AANP), you have a pretty good idea how it worked out.

AANP is celebrating its 25th anniversary this year—a milestone its founders probably never doubted would be reached, although others initially questioned the viability of such an organization.

“The feeling was that if it was needed, it would grow, and if it wasn’t needed, it wouldn’t grow,” recalls Jan Towers, PhD, NP-C, CRNP, FAANP, a founding member and past president who continues to serve AANP as Director of Health Policy. “And indeed it grew—so I think we know what our answer was!”

A SEPARATE BUT EQUAL NEED
Of course, creating a new professional organization was not as simple as a group of individuals putting their heads together. And yet, in a certain sense, it was that easy.

Shortly after those initial discussions in Kansas City, there was another conference in Washington, DC. During a panel discussion with executives from the insurance and advertising industries, it became evident that the biggest issue for NPs was “no one knew who we were,” says Clinician Reviews NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP, also a founder and past president of AANP. Clearly, that situation needed to be remedied—but how?

At that time, many NPs were members of ANA (and, it should be noted, many still are). However, since ANA represents all of nursing, the bulk of its resources could not be devoted to NPs. The organization had created a Council of Primary Care NPs in 1974, but the “renegade” NPs of 1984 felt that structure didn’t provide the latitude they wanted in their representation.

“We needed a way to really work together and have our ­undivided attention focused on NP issues,” Towers says. Onieal adds, “We weren’t abandoning our ‘nursing-ness,’ but clearly we had separate and distinctly different issues at hand than did the general populace of the nursing profession.”

The fact that NPs from across the country—remember, this is pre-Internet—shared this viewpoint added strength to the argument. If dozens of people who didn’t really know one another could see the same need, it must be real—and therefore, it had to be addressed.

“The [NP] role had been around since 1965, but nursing faculty were just beginning to define what NP education ought to look like,” says Carole Kain, DNS, ARNP, PNP-BC, a founding member and the first president of AANP. (She was Carole Kerwin then.) “A lot of things were changing in the profession, and we all wanted to be part of defining what that change meant. It was everybody coming together with a skill set that set us on this course.”

The time was certainly ripe. In her files, Kain still has a copy of a document discussing a referendum the American Medical Association passed in 1984, in which “they said they were actually going to try to inhibit the practice of NPs, PAs, nurse-midwives, and pharmacists, as to prescribing and taking care of patients.”

In addition to that restrictive attitude—a cause to rally around for NPs nationwide—the NP profession had reached a tipping point in terms of growth. “Enough of us had been prepared, but we were still small enough to be spread out [across the country],” Towers says. “We needed some way to connect.”

By the time they left Washington, DC, a steering committee had been formed to explore the need for an organization representing the nation’s approximately 24,000 NPs. They were expected to report back to the ANA one year later, at a meeting in Chicago. And so, the hard work began.

SO, YOU WANT TO START AN ORGANIZATION?
For a group of virtual strangers who had never started an organization before, they went about their business in a methodical and logical way. Different task forces were created, including one to look into how to do articles of incorporation and other “legalese” pieces, and another to develop a list of reasons why a separate organization was needed.

Onieal recalls a good deal of traveling that she and some other NPs did “to every NP meeting, every NP gathering, across the US for a year. We had a petition, and I’d say, ‘All I want to know is whether you think we should start an NP organization.’” The list grew over the course of the year.

In the meantime, contact was made with the handful of existing NP organizations, to see if any of them could meet the needs of the profession at large: the National Association of Pediatric NPs (1973), the National Association of NPs in Reproductive Health (which became the National Association of NPs in Women’s Health; 1980), and the National Conference of Gerontological NPs (1981). But obviously, since these groups had been tasked by their members with representing the interests of NPs in specific fields, their responses boiled down to “We can’t help you—but we wish you well.”

By the time the Chicago meeting rolled around in May 1985, about the only thing left to do was announce the new organization’s formation. Bylaws had already been drafted, and Onieal’s (now former) address in Lowell, Massachusetts, had been chosen as the original headquarters of the organization. (Trivia: AANP was originally incorporated in Lowell, before relocating to Austin, Texas.)

During a panel session in Chicago, Kain and Onieal told the assembled crowd, “This is what we need: We need to be heard as independent providers. We need to have some say in how our practice is regulated. We need … an organization that will allow us to learn from each other across the country,” as Kain recalls.

The official press release announcing AANP’s creation reads: “The overall purpose of the AANP is to promote high standards of health care as delivered by nurse practitioners and to act as a forum to enhance the identity and continuity of nurse practitioners. It is nationwide in scope and welcomes all nurse practitioners, regardless of specialty. The first year’s focus will be on networking and communications.”

AANP’s first elected officers were Kain (President), Towers (President-Elect), Onieal (Treasurer), Madeline D. Wiley, MSN, ARNP (Recording Secretary), and Robert T. Smithing, MSN, ARNP (Communications Secretary). Annual membership dues were $60.

25 YEARS OF PROGRESS
The leaders and members of the newly formed AANP wasted little time in setting out to accomplish their organizational goals. As Onieal says, “When we started, we had a five-year plan and a 10-year plan. And in five years, we got through all of that.”

With the initial focus on networking and communications, 10 geographical regions were established, based on the National Health Service Corps regions, and regional directors were found. So were individual reps from every state, each of whom then “started talking to people within their state,” Kain says.

For Towers, the focus was on legislative and regulatory issues, just as it is today. “One of the first things we started doing was finding ways to influence policy, both in Washington and in our states,” she says. “Early on, we started working on reimbursement.”

An early victory was getting NPs reimbursement through the Federal Employees Health Benefits Program (1986-1987). On the Medicare front, AANP had a significant impact in securing reimbursement for NPs working in rural areas and in long-term care facilities (1989-1990). Additional milestones include mandated Medicare payment for family and pediatric NPs regardless of supervision status (the early ’90s) and direct Medicare reimbursement for NPs regardless of setting (1997).

Seeing all that has been accomplished in 25 years is still a little amazing, even to the people who set the wheels in motion. “We’re funding research, and we have a foundation that gives scholarships,” Kain says. “Those are things we talked about as ‘someday’ dreams, but now they’re actualizations.”

She’s greeted every day by signs of how much has changed since 1985. “I can remember the initial discussions about having a certification program, talking to the psychometricians about how we’d start up the exam and which criteria we’d use,” she reflects. “And now, the NPs that I’m teaching are using that certification exam to get their licensure!”

As much as Onieal appreciates all the services that AANP has grown to offer its members, she also recognizes the core value of the organization. “One of our primary purposes was to let people know what NPs are all about—to clarify that we’re not LPNs, we’re not students, we’re not people who couldn’t go to medical school and decided to do this instead; this was our chosen profession,” she says. “I think we’ve been successful in doing that.”

THE ULTIMATE COLLABORATION
The founders of AANP never doubted that forming the organization was the right thing to do, which probably confirms that they were the best people to do the job. Instead of expending energy on doubts or infighting, they figured out what needed to be done and moved forward. 

Kain still has a “vivid mental picture” of the early days in Kansas City and Washington, DC, when there was no organization and therefore no budget, so meetings were held in someone’s hotel room. “There would be people sitting on the bed, on the floor, standing up; we’re all crammed into the room,” she remembers with a laugh. “And people are talking, and we’re polite to one another, we’re respectful of one another. We’re passionate. We’re talking about the difficulties and why we need this. And if you could put that into a bottle, you could start a new organization right now!”

That spirit of collaboration is still a viable part of the organization, one that Onieal is proud of. “If anybody ever had an interest in doing something or being something within the organization, the doors were open,” she says. “Early on, a couple of students said, ‘But we have needs, too,’ so we said, ‘Fine, we’ll start a student special interest group. No problem.’” The point, after all, had always been to learn from one another.

If there is one lesson the AANP founders hope to pass along to future generations, it’s that great change can be brought about by a small group of (seemingly) ordinary people with extraordinary determination. They don’t want statues erected in their honor, but they do want others to be inspired to take an active role in the continuous evolution of the NP profession—especially since, as Towers observes, “There is still work to be done.”

“We need to get all the state practice acts on a level playing field,” she notes, “which we’re well on the way to doing now with our consensus document and the model rules and regulations. We need to have recognition within all the payment systems, and remove barriers within existing laws that prevent NPs from practicing to their fullest capability.”

The significant changes that have been brought about in the past 25 years can be difficult to fathom for those who did not witness them. In 2010, the NP profession is well established. (The same is true for PAs.) Students deciding their future choose these professions in part because of all they will be able to do and accomplish within their roles.

What they don’t always recognize is that it took hard work and continued vigilance on the part of those who have preceded them to achieve the privileges that today’s clinicians—and perhaps tomorrow’s—run the risk of taking for granted.

“We’re not done, and I don’t want anyone to think they can rest on the laurels of what has gone before or think that without their involvement it will continue,” says Kain. “It won’t. We need them. We need new blood, new thoughts, new ideas, to face the new challenges.”

When she reflects on how a group of near-strangers got together and made a mark on the history of their profession, she concludes, simply, “Others can do the same thing. They just have to want to, and see the need.”

Picture it: Kansas City, 1984. At a meeting sponsored by the American Nurses Association (ANA), conversation among the NP attendees from across the United States focuses on the widely perceived need for “common representation” of their distinct interests. Who among the existing nursing organizations has the time, money, and/or inclination to serve as the voice of all NPs, providing a conduit for communication and leadership in legislative efforts to remove barriers to practice?

As it will turn out, the answer is no one—at least, not in the way these NPs envision. So they ­decide to do something about that … and since the result of their collaborative vision is the American Academy of Nurse Practitioners (AANP), you have a pretty good idea how it worked out.

AANP is celebrating its 25th anniversary this year—a milestone its founders probably never doubted would be reached, although others initially questioned the viability of such an organization.

“The feeling was that if it was needed, it would grow, and if it wasn’t needed, it wouldn’t grow,” recalls Jan Towers, PhD, NP-C, CRNP, FAANP, a founding member and past president who continues to serve AANP as Director of Health Policy. “And indeed it grew—so I think we know what our answer was!”

A SEPARATE BUT EQUAL NEED
Of course, creating a new professional organization was not as simple as a group of individuals putting their heads together. And yet, in a certain sense, it was that easy.

Shortly after those initial discussions in Kansas City, there was another conference in Washington, DC. During a panel discussion with executives from the insurance and advertising industries, it became evident that the biggest issue for NPs was “no one knew who we were,” says Clinician Reviews NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP, also a founder and past president of AANP. Clearly, that situation needed to be remedied—but how?

At that time, many NPs were members of ANA (and, it should be noted, many still are). However, since ANA represents all of nursing, the bulk of its resources could not be devoted to NPs. The organization had created a Council of Primary Care NPs in 1974, but the “renegade” NPs of 1984 felt that structure didn’t provide the latitude they wanted in their representation.

“We needed a way to really work together and have our ­undivided attention focused on NP issues,” Towers says. Onieal adds, “We weren’t abandoning our ‘nursing-ness,’ but clearly we had separate and distinctly different issues at hand than did the general populace of the nursing profession.”

The fact that NPs from across the country—remember, this is pre-Internet—shared this viewpoint added strength to the argument. If dozens of people who didn’t really know one another could see the same need, it must be real—and therefore, it had to be addressed.

“The [NP] role had been around since 1965, but nursing faculty were just beginning to define what NP education ought to look like,” says Carole Kain, DNS, ARNP, PNP-BC, a founding member and the first president of AANP. (She was Carole Kerwin then.) “A lot of things were changing in the profession, and we all wanted to be part of defining what that change meant. It was everybody coming together with a skill set that set us on this course.”

The time was certainly ripe. In her files, Kain still has a copy of a document discussing a referendum the American Medical Association passed in 1984, in which “they said they were actually going to try to inhibit the practice of NPs, PAs, nurse-midwives, and pharmacists, as to prescribing and taking care of patients.”

In addition to that restrictive attitude—a cause to rally around for NPs nationwide—the NP profession had reached a tipping point in terms of growth. “Enough of us had been prepared, but we were still small enough to be spread out [across the country],” Towers says. “We needed some way to connect.”

By the time they left Washington, DC, a steering committee had been formed to explore the need for an organization representing the nation’s approximately 24,000 NPs. They were expected to report back to the ANA one year later, at a meeting in Chicago. And so, the hard work began.

SO, YOU WANT TO START AN ORGANIZATION?
For a group of virtual strangers who had never started an organization before, they went about their business in a methodical and logical way. Different task forces were created, including one to look into how to do articles of incorporation and other “legalese” pieces, and another to develop a list of reasons why a separate organization was needed.

Onieal recalls a good deal of traveling that she and some other NPs did “to every NP meeting, every NP gathering, across the US for a year. We had a petition, and I’d say, ‘All I want to know is whether you think we should start an NP organization.’” The list grew over the course of the year.

In the meantime, contact was made with the handful of existing NP organizations, to see if any of them could meet the needs of the profession at large: the National Association of Pediatric NPs (1973), the National Association of NPs in Reproductive Health (which became the National Association of NPs in Women’s Health; 1980), and the National Conference of Gerontological NPs (1981). But obviously, since these groups had been tasked by their members with representing the interests of NPs in specific fields, their responses boiled down to “We can’t help you—but we wish you well.”

By the time the Chicago meeting rolled around in May 1985, about the only thing left to do was announce the new organization’s formation. Bylaws had already been drafted, and Onieal’s (now former) address in Lowell, Massachusetts, had been chosen as the original headquarters of the organization. (Trivia: AANP was originally incorporated in Lowell, before relocating to Austin, Texas.)

During a panel session in Chicago, Kain and Onieal told the assembled crowd, “This is what we need: We need to be heard as independent providers. We need to have some say in how our practice is regulated. We need … an organization that will allow us to learn from each other across the country,” as Kain recalls.

The official press release announcing AANP’s creation reads: “The overall purpose of the AANP is to promote high standards of health care as delivered by nurse practitioners and to act as a forum to enhance the identity and continuity of nurse practitioners. It is nationwide in scope and welcomes all nurse practitioners, regardless of specialty. The first year’s focus will be on networking and communications.”

AANP’s first elected officers were Kain (President), Towers (President-Elect), Onieal (Treasurer), Madeline D. Wiley, MSN, ARNP (Recording Secretary), and Robert T. Smithing, MSN, ARNP (Communications Secretary). Annual membership dues were $60.

25 YEARS OF PROGRESS
The leaders and members of the newly formed AANP wasted little time in setting out to accomplish their organizational goals. As Onieal says, “When we started, we had a five-year plan and a 10-year plan. And in five years, we got through all of that.”

With the initial focus on networking and communications, 10 geographical regions were established, based on the National Health Service Corps regions, and regional directors were found. So were individual reps from every state, each of whom then “started talking to people within their state,” Kain says.

For Towers, the focus was on legislative and regulatory issues, just as it is today. “One of the first things we started doing was finding ways to influence policy, both in Washington and in our states,” she says. “Early on, we started working on reimbursement.”

An early victory was getting NPs reimbursement through the Federal Employees Health Benefits Program (1986-1987). On the Medicare front, AANP had a significant impact in securing reimbursement for NPs working in rural areas and in long-term care facilities (1989-1990). Additional milestones include mandated Medicare payment for family and pediatric NPs regardless of supervision status (the early ’90s) and direct Medicare reimbursement for NPs regardless of setting (1997).

Seeing all that has been accomplished in 25 years is still a little amazing, even to the people who set the wheels in motion. “We’re funding research, and we have a foundation that gives scholarships,” Kain says. “Those are things we talked about as ‘someday’ dreams, but now they’re actualizations.”

She’s greeted every day by signs of how much has changed since 1985. “I can remember the initial discussions about having a certification program, talking to the psychometricians about how we’d start up the exam and which criteria we’d use,” she reflects. “And now, the NPs that I’m teaching are using that certification exam to get their licensure!”

As much as Onieal appreciates all the services that AANP has grown to offer its members, she also recognizes the core value of the organization. “One of our primary purposes was to let people know what NPs are all about—to clarify that we’re not LPNs, we’re not students, we’re not people who couldn’t go to medical school and decided to do this instead; this was our chosen profession,” she says. “I think we’ve been successful in doing that.”

THE ULTIMATE COLLABORATION
The founders of AANP never doubted that forming the organization was the right thing to do, which probably confirms that they were the best people to do the job. Instead of expending energy on doubts or infighting, they figured out what needed to be done and moved forward. 

Kain still has a “vivid mental picture” of the early days in Kansas City and Washington, DC, when there was no organization and therefore no budget, so meetings were held in someone’s hotel room. “There would be people sitting on the bed, on the floor, standing up; we’re all crammed into the room,” she remembers with a laugh. “And people are talking, and we’re polite to one another, we’re respectful of one another. We’re passionate. We’re talking about the difficulties and why we need this. And if you could put that into a bottle, you could start a new organization right now!”

That spirit of collaboration is still a viable part of the organization, one that Onieal is proud of. “If anybody ever had an interest in doing something or being something within the organization, the doors were open,” she says. “Early on, a couple of students said, ‘But we have needs, too,’ so we said, ‘Fine, we’ll start a student special interest group. No problem.’” The point, after all, had always been to learn from one another.

If there is one lesson the AANP founders hope to pass along to future generations, it’s that great change can be brought about by a small group of (seemingly) ordinary people with extraordinary determination. They don’t want statues erected in their honor, but they do want others to be inspired to take an active role in the continuous evolution of the NP profession—especially since, as Towers observes, “There is still work to be done.”

“We need to get all the state practice acts on a level playing field,” she notes, “which we’re well on the way to doing now with our consensus document and the model rules and regulations. We need to have recognition within all the payment systems, and remove barriers within existing laws that prevent NPs from practicing to their fullest capability.”

The significant changes that have been brought about in the past 25 years can be difficult to fathom for those who did not witness them. In 2010, the NP profession is well established. (The same is true for PAs.) Students deciding their future choose these professions in part because of all they will be able to do and accomplish within their roles.

What they don’t always recognize is that it took hard work and continued vigilance on the part of those who have preceded them to achieve the privileges that today’s clinicians—and perhaps tomorrow’s—run the risk of taking for granted.

“We’re not done, and I don’t want anyone to think they can rest on the laurels of what has gone before or think that without their involvement it will continue,” says Kain. “It won’t. We need them. We need new blood, new thoughts, new ideas, to face the new challenges.”

When she reflects on how a group of near-strangers got together and made a mark on the history of their profession, she concludes, simply, “Others can do the same thing. They just have to want to, and see the need.”

Since joining the American Academy of Physician Assistants (AAPA) in February 2008 as Executive Vice President and CEO, Bill Leinweber has brought positive energy and a new focus to the organization. Despite his busy schedule, Leinweber recently found time to speak with Clinician Reviews about AAPA’s goals and priorities, the impact of health care reform on the direction of the profession, and efforts to raise PAs’ public profile.

Clinician Reviews: When you joined AAPA, what was your assessment of the profession’s needs?

Leinweber: My observation and experience was, from a PA perspective, a very high level of enthusiasm and commitment by PAs about the profession, and a strong desire for the profession to take its rightful, prominent place in health care. I really sensed a hunger, in those who make up the profession, for recognition, of wanting to be perceived as truly a player in the delivery of health care and the policy that accompanies that delivery.

CR: Of the changes implemented at AAPA in the past two years, which for you is the most significant and/or satisfying?

Leinweber: What jumps to mind is shifting the real focus and the work of the Board of Directors of the Academy from that of an operational board to a strategic board. What are the truly big issues and major priorities that the board needs to focus their time and attention on and allocate the organization’s resources to address? As we become more strategically focused, you’ll see continuity in terms of the goals that we’re working to achieve and the resources we’re putting behind achieving those goals.

We have also worked hard to shift—and this continues; I don’t want to suggest it’s completed—from a very process-driven organization to one that really wants to look at outcomes. You need some level of process, but if you have a lot of process but not the outcomes that really move the ball forward, then you’re not serving your members.

That said, there will be things that individuals or groups of individuals in the profession believe should be a priority that aren’t. I want to be clear that even in moving to a strategic focus and direction, everybody doesn’t get everything they want addressed all the time. That’s a challenge.

CR: What are your immediate and ongoing priorities for AAPA?

Leinweber: Our policymakers just passed historic health care reform legislation. There are clearly, even within our profession, varying points of view across the political spectrum in support for or opposition to health care reform.

The Academy had no position per se on any bill in its entirety. What we focused on was to ensure that as any and all legislation began to take shape, PAs were prominently and appropriately identified as key to the success of any reform effort.

I believe we made huge headway there. PAs are called out by name in the legislation, in terms of being critical to the success of the expansion of primary care and in a number of other ways.

That has implications in terms of priorities. The country will now move from a legislative process to the implementation of many of the provisions in the reform legislation over the next several years. That will have bearing on some of our work and some of our priorities. What will this mean for us as a profession? What does it mean for us as an Academy, and how do we respond?

Certainly the number of PAs in primary care today is not what it once was. We feel an obligation to really be looking for strategies to help grow, to the fullest degree possible, interest and commitment to primary care—and to do that in a way that doesn’t detract from the important contributions PAs in specialties are making.

I look at this as, how do we grow the whole “pie” of PAs exponentially, so that we can contribute larger numbers to the critical need in primary care, in addition to having PAs filling needs in surgery, surgical subspecialties, internal medicine, etc?

We continue to move forward with the development of a research agenda for the profession. In that regard, we hosted a research summit in early March, which was very well attended. We’ll be putting out a proceedings paper from that summit soon, which will outline the steps we will take to formulate a research agenda for the profession.

Also, we’re undertaking a lot of work on the governance front of the Academy. Over the next year, we’ll be looking at the relationship AAPA has with its state chapters and with its specialty organizations. The way those relationships have been chartered and have worked hasn’t really changed in 30 or 40 years, and I think the world in that time has changed dramatically.

The profession has grown dramatically, and it’s time for us to sit down with representatives of our constituent organizations and make sure that we’re working in the best model that we can to have the fullest impact at the local and the national level.

CR: How will AAPA address the increased movement by PAs from primary to specialty care?

Leinweber: If you step back and look at primary health care in its totality, the reality is that the demand for PAs continues to outstrip the supply. When you look at health care reform and the strong focus on primary care, I don’t think we’re necessarily going to see any immediate lessening of demand for PAs in specialty areas at the expense of growth in the primary care arena. So our challenge will be to grow that pie in totality.

We worked to have incentives built into the health care reform legislation that would encourage PA programs to participate in grant programs and other efforts that would really reward them for growing the number of PAs who choose primary care as their specialty, and to incentivize students who choose that path by increasing opportunities through the National Health Service Corps and loan forgiveness programs. Those things matter.

When you look at the primary care challenges of the country, the challenges that MDs or DOs face in terms of trying to grow the cadre of individuals going into primary care aren’t all that different from what we face. It comes down to quality of life, the compensation that’s tied to that particular kind of medicine, opportunities for advancement, flexibility.

Those are all issues that we’re going to have to address. We’ve begun to do that, but we’re going to have to work with organized medicine to continue to push for a shift in how the country rewards and positions primary care.

CR: How will AAPA provide support to PAs in specialties, while maintaining its commitment to primary care?

Leinweber: There are 24 specialty organizations that have a charter agreement with AAPA and are represented in our House of Delegates. We work closely with our specialty organizations; we collaborate with them, increasingly, on continuing medical education (CME) programs that they provide to their members.

The AAPA will work with the Society of PAs in Pediatrics, for example, and work to bring the American Academy of Pediatrics to the table so that we can contribute to shaping the delivery of programs that are of value to PAs in particular specialty fields. I certainly see us continuing to do that.

We completely recognize that the demographic has shifted. Our statistics now show that 35.7% of PAs identify themselves as practicing in primary care. So, that means almost 65% are in a specialized field. That’s a reality that we look at and we shape our services accordingly.

But considering how things are moving nationwide, relative to a reformed health care system, we very much feel the need, the pressure, and the obligation to do everything we can to grow those primary care numbers.

CR: What opportunities do you see for PAs to partner with NPs?

Leinweber: We are doing some partnering now in the form of joint CME programs that we’ve conducted in the past couple of years with the American Academy of Nurse Practitioners and various doctor specialty groups. For instance, there was a boot camp last August with the Society for Hospital Medicine. We will collaboratively put on programs that are designed to serve the CME needs of PAs and NPs primarily, although physicians can participate as well. Those have been tremendously successful. We certainly want to continue to do that.

On the legislative front, I think there is value in PAs and NPs working collaboratively wherever we can at the federal level. Wherever we have common messages that support our various legislative goals, we’re certainly open to that. I think when you start to look at the state level and where health care is delivered, on the front lines, things become a little more challenging because we don’t answer to the same regulatory body at that level.

But our philosophy is, the country has an enormous need in terms of individuals requiring care from qualified, competent providers. We need many more PAs, we need more NPs; there are very important and distinct roles that we play. And wherever we can work together to bring the wherewithal of our respective professions to improve health care and health care delivery, I think we need to be open to that and look for those opportunities.

CR: NPs have been touted for significantly raising their public profile, while many PAs feel their profession has lagged behind in this area. How is AAPA approaching the public perception and marketing of the profession?

Leinweber: First of all, I think it’s accurate to say that the NPs have been ahead of us from a policymaker and a public recognition/perception point of view. But I think we’ve made some significant strides over the past couple of years with the PA profession.

We have been very targeted in our approach. We made a conscious decision that it was critical to elevate the presence and the positioning of the profession first and foremost among policymakers and thought leaders who have the authority to impact how the profession is practiced. So, much of our work has focused on building understanding and awareness among members of Congress, among the administration, among state leaders, elected and appointed officials.

We have undertaken a variety of initiatives that we have not done before: briefings, roundtables, advertising that we’re doing in targeted publications, such as Congressional Daily, Politico, Roll Call. Some of these ads have really made a difference in terms of the role that we were invited to play in shaping health care reform. We were very much at the table. We were invited to the White House continually and invited to meetings with Congressional leaders throughout the drafting of health care reform legislation. So I think we’ve made some real strides there.

We’re not ignoring the public. But in an organization with limited resources, it’s been our feeling and our belief that the best service we can provide to our members and the best return we can put on their investment, in terms of their membership dues, is to make certain that policies are put in place that allow PAs to really practice to the full degree that they’re equipped to practice and to remove any barriers we can that prevent that.

We are beginning to make some inroads, from a public perception standpoint. Increasingly, as debate and understanding around health care reform begins to trickle across the country, we hear from and are engaging more and more folks from the mainstream media, such as MSNBC, Newsweek, the Wall Street Journal, and others.

They’re seeing, from a legislative point of view, multiple references to this profession called “physician assistants,” and they want to talk to us. They want to know about the profession so they can inform consumers on how to access and utilize PAs.

So I’m really proud of the work we’ve accomplished there. We have a long way to go—and really that work will never stop. But I think we have been on target in terms of how we have focused our resources, and we need to continue that very strongly in the future.

CR: What other messages do you have for PAs and their NP colleagues?

Leinweber: From a professional point of view, I can’t imagine a more well-positioned, exciting, and thriving profession at this point in history than the physician assistant profession. We are really poised to play the leadership role that some may argue we have played for decades quietly, but I think [now] much more visibly and with much more recognition. I just think there’s a level of relevance and consideration about the profession that hasn’t existed before. That’s very exciting, and it bodes very well for the future of the profession.

Relative to our work with our NP colleagues, there is an enormous amount of work needed by NPs and PAs across the country and across the health care spectrum. PAs and NPs work extremely well together and often seamlessly on the clinical level, and my hope would be to leverage every opportunity we can at the national level to make sure patients have access to the best quality of care, to the best providers, when they need it.

Since joining the American Academy of Physician Assistants (AAPA) in February 2008 as Executive Vice President and CEO, Bill Leinweber has brought positive energy and a new focus to the organization. Despite his busy schedule, Leinweber recently found time to speak with Clinician Reviews about AAPA’s goals and priorities, the impact of health care reform on the direction of the profession, and efforts to raise PAs’ public profile.

Clinician Reviews: When you joined AAPA, what was your assessment of the profession’s needs?

Leinweber: My observation and experience was, from a PA perspective, a very high level of enthusiasm and commitment by PAs about the profession, and a strong desire for the profession to take its rightful, prominent place in health care. I really sensed a hunger, in those who make up the profession, for recognition, of wanting to be perceived as truly a player in the delivery of health care and the policy that accompanies that delivery.

CR: Of the changes implemented at AAPA in the past two years, which for you is the most significant and/or satisfying?

Leinweber: What jumps to mind is shifting the real focus and the work of the Board of Directors of the Academy from that of an operational board to a strategic board. What are the truly big issues and major priorities that the board needs to focus their time and attention on and allocate the organization’s resources to address? As we become more strategically focused, you’ll see continuity in terms of the goals that we’re working to achieve and the resources we’re putting behind achieving those goals.

We have also worked hard to shift—and this continues; I don’t want to suggest it’s completed—from a very process-driven organization to one that really wants to look at outcomes. You need some level of process, but if you have a lot of process but not the outcomes that really move the ball forward, then you’re not serving your members.

That said, there will be things that individuals or groups of individuals in the profession believe should be a priority that aren’t. I want to be clear that even in moving to a strategic focus and direction, everybody doesn’t get everything they want addressed all the time. That’s a challenge.

CR: What are your immediate and ongoing priorities for AAPA?

Leinweber: Our policymakers just passed historic health care reform legislation. There are clearly, even within our profession, varying points of view across the political spectrum in support for or opposition to health care reform.

The Academy had no position per se on any bill in its entirety. What we focused on was to ensure that as any and all legislation began to take shape, PAs were prominently and appropriately identified as key to the success of any reform effort.

I believe we made huge headway there. PAs are called out by name in the legislation, in terms of being critical to the success of the expansion of primary care and in a number of other ways.

That has implications in terms of priorities. The country will now move from a legislative process to the implementation of many of the provisions in the reform legislation over the next several years. That will have bearing on some of our work and some of our priorities. What will this mean for us as a profession? What does it mean for us as an Academy, and how do we respond?

Certainly the number of PAs in primary care today is not what it once was. We feel an obligation to really be looking for strategies to help grow, to the fullest degree possible, interest and commitment to primary care—and to do that in a way that doesn’t detract from the important contributions PAs in specialties are making.

I look at this as, how do we grow the whole “pie” of PAs exponentially, so that we can contribute larger numbers to the critical need in primary care, in addition to having PAs filling needs in surgery, surgical subspecialties, internal medicine, etc?

We continue to move forward with the development of a research agenda for the profession. In that regard, we hosted a research summit in early March, which was very well attended. We’ll be putting out a proceedings paper from that summit soon, which will outline the steps we will take to formulate a research agenda for the profession.

Also, we’re undertaking a lot of work on the governance front of the Academy. Over the next year, we’ll be looking at the relationship AAPA has with its state chapters and with its specialty organizations. The way those relationships have been chartered and have worked hasn’t really changed in 30 or 40 years, and I think the world in that time has changed dramatically.

The profession has grown dramatically, and it’s time for us to sit down with representatives of our constituent organizations and make sure that we’re working in the best model that we can to have the fullest impact at the local and the national level.

CR: How will AAPA address the increased movement by PAs from primary to specialty care?

Leinweber: If you step back and look at primary health care in its totality, the reality is that the demand for PAs continues to outstrip the supply. When you look at health care reform and the strong focus on primary care, I don’t think we’re necessarily going to see any immediate lessening of demand for PAs in specialty areas at the expense of growth in the primary care arena. So our challenge will be to grow that pie in totality.

We worked to have incentives built into the health care reform legislation that would encourage PA programs to participate in grant programs and other efforts that would really reward them for growing the number of PAs who choose primary care as their specialty, and to incentivize students who choose that path by increasing opportunities through the National Health Service Corps and loan forgiveness programs. Those things matter.

When you look at the primary care challenges of the country, the challenges that MDs or DOs face in terms of trying to grow the cadre of individuals going into primary care aren’t all that different from what we face. It comes down to quality of life, the compensation that’s tied to that particular kind of medicine, opportunities for advancement, flexibility.

Those are all issues that we’re going to have to address. We’ve begun to do that, but we’re going to have to work with organized medicine to continue to push for a shift in how the country rewards and positions primary care.

CR: How will AAPA provide support to PAs in specialties, while maintaining its commitment to primary care?

Leinweber: There are 24 specialty organizations that have a charter agreement with AAPA and are represented in our House of Delegates. We work closely with our specialty organizations; we collaborate with them, increasingly, on continuing medical education (CME) programs that they provide to their members.

The AAPA will work with the Society of PAs in Pediatrics, for example, and work to bring the American Academy of Pediatrics to the table so that we can contribute to shaping the delivery of programs that are of value to PAs in particular specialty fields. I certainly see us continuing to do that.

We completely recognize that the demographic has shifted. Our statistics now show that 35.7% of PAs identify themselves as practicing in primary care. So, that means almost 65% are in a specialized field. That’s a reality that we look at and we shape our services accordingly.

But considering how things are moving nationwide, relative to a reformed health care system, we very much feel the need, the pressure, and the obligation to do everything we can to grow those primary care numbers.

CR: What opportunities do you see for PAs to partner with NPs?

Leinweber: We are doing some partnering now in the form of joint CME programs that we’ve conducted in the past couple of years with the American Academy of Nurse Practitioners and various doctor specialty groups. For instance, there was a boot camp last August with the Society for Hospital Medicine. We will collaboratively put on programs that are designed to serve the CME needs of PAs and NPs primarily, although physicians can participate as well. Those have been tremendously successful. We certainly want to continue to do that.

On the legislative front, I think there is value in PAs and NPs working collaboratively wherever we can at the federal level. Wherever we have common messages that support our various legislative goals, we’re certainly open to that. I think when you start to look at the state level and where health care is delivered, on the front lines, things become a little more challenging because we don’t answer to the same regulatory body at that level.

But our philosophy is, the country has an enormous need in terms of individuals requiring care from qualified, competent providers. We need many more PAs, we need more NPs; there are very important and distinct roles that we play. And wherever we can work together to bring the wherewithal of our respective professions to improve health care and health care delivery, I think we need to be open to that and look for those opportunities.

CR: NPs have been touted for significantly raising their public profile, while many PAs feel their profession has lagged behind in this area. How is AAPA approaching the public perception and marketing of the profession?

Leinweber: First of all, I think it’s accurate to say that the NPs have been ahead of us from a policymaker and a public recognition/perception point of view. But I think we’ve made some significant strides over the past couple of years with the PA profession.

We have been very targeted in our approach. We made a conscious decision that it was critical to elevate the presence and the positioning of the profession first and foremost among policymakers and thought leaders who have the authority to impact how the profession is practiced. So, much of our work has focused on building understanding and awareness among members of Congress, among the administration, among state leaders, elected and appointed officials.

We have undertaken a variety of initiatives that we have not done before: briefings, roundtables, advertising that we’re doing in targeted publications, such as Congressional Daily, Politico, Roll Call. Some of these ads have really made a difference in terms of the role that we were invited to play in shaping health care reform. We were very much at the table. We were invited to the White House continually and invited to meetings with Congressional leaders throughout the drafting of health care reform legislation. So I think we’ve made some real strides there.

We’re not ignoring the public. But in an organization with limited resources, it’s been our feeling and our belief that the best service we can provide to our members and the best return we can put on their investment, in terms of their membership dues, is to make certain that policies are put in place that allow PAs to really practice to the full degree that they’re equipped to practice and to remove any barriers we can that prevent that.

We are beginning to make some inroads, from a public perception standpoint. Increasingly, as debate and understanding around health care reform begins to trickle across the country, we hear from and are engaging more and more folks from the mainstream media, such as MSNBC, Newsweek, the Wall Street Journal, and others.

They’re seeing, from a legislative point of view, multiple references to this profession called “physician assistants,” and they want to talk to us. They want to know about the profession so they can inform consumers on how to access and utilize PAs.

So I’m really proud of the work we’ve accomplished there. We have a long way to go—and really that work will never stop. But I think we have been on target in terms of how we have focused our resources, and we need to continue that very strongly in the future.

CR: What other messages do you have for PAs and their NP colleagues?

Leinweber: From a professional point of view, I can’t imagine a more well-positioned, exciting, and thriving profession at this point in history than the physician assistant profession. We are really poised to play the leadership role that some may argue we have played for decades quietly, but I think [now] much more visibly and with much more recognition. I just think there’s a level of relevance and consideration about the profession that hasn’t existed before. That’s very exciting, and it bodes very well for the future of the profession.

Relative to our work with our NP colleagues, there is an enormous amount of work needed by NPs and PAs across the country and across the health care spectrum. PAs and NPs work extremely well together and often seamlessly on the clinical level, and my hope would be to leverage every opportunity we can at the national level to make sure patients have access to the best quality of care, to the best providers, when they need it.

Since joining the American Academy of Physician Assistants (AAPA) in February 2008 as Executive Vice President and CEO, Bill Leinweber has brought positive energy and a new focus to the organization. Despite his busy schedule, Leinweber recently found time to speak with Clinician Reviews about AAPA’s goals and priorities, the impact of health care reform on the direction of the profession, and efforts to raise PAs’ public profile.

Clinician Reviews: When you joined AAPA, what was your assessment of the profession’s needs?

Leinweber: My observation and experience was, from a PA perspective, a very high level of enthusiasm and commitment by PAs about the profession, and a strong desire for the profession to take its rightful, prominent place in health care. I really sensed a hunger, in those who make up the profession, for recognition, of wanting to be perceived as truly a player in the delivery of health care and the policy that accompanies that delivery.

CR: Of the changes implemented at AAPA in the past two years, which for you is the most significant and/or satisfying?

Leinweber: What jumps to mind is shifting the real focus and the work of the Board of Directors of the Academy from that of an operational board to a strategic board. What are the truly big issues and major priorities that the board needs to focus their time and attention on and allocate the organization’s resources to address? As we become more strategically focused, you’ll see continuity in terms of the goals that we’re working to achieve and the resources we’re putting behind achieving those goals.

We have also worked hard to shift—and this continues; I don’t want to suggest it’s completed—from a very process-driven organization to one that really wants to look at outcomes. You need some level of process, but if you have a lot of process but not the outcomes that really move the ball forward, then you’re not serving your members.

That said, there will be things that individuals or groups of individuals in the profession believe should be a priority that aren’t. I want to be clear that even in moving to a strategic focus and direction, everybody doesn’t get everything they want addressed all the time. That’s a challenge.

CR: What are your immediate and ongoing priorities for AAPA?

Leinweber: Our policymakers just passed historic health care reform legislation. There are clearly, even within our profession, varying points of view across the political spectrum in support for or opposition to health care reform.

The Academy had no position per se on any bill in its entirety. What we focused on was to ensure that as any and all legislation began to take shape, PAs were prominently and appropriately identified as key to the success of any reform effort.

I believe we made huge headway there. PAs are called out by name in the legislation, in terms of being critical to the success of the expansion of primary care and in a number of other ways.

That has implications in terms of priorities. The country will now move from a legislative process to the implementation of many of the provisions in the reform legislation over the next several years. That will have bearing on some of our work and some of our priorities. What will this mean for us as a profession? What does it mean for us as an Academy, and how do we respond?

Certainly the number of PAs in primary care today is not what it once was. We feel an obligation to really be looking for strategies to help grow, to the fullest degree possible, interest and commitment to primary care—and to do that in a way that doesn’t detract from the important contributions PAs in specialties are making.

I look at this as, how do we grow the whole “pie” of PAs exponentially, so that we can contribute larger numbers to the critical need in primary care, in addition to having PAs filling needs in surgery, surgical subspecialties, internal medicine, etc?

We continue to move forward with the development of a research agenda for the profession. In that regard, we hosted a research summit in early March, which was very well attended. We’ll be putting out a proceedings paper from that summit soon, which will outline the steps we will take to formulate a research agenda for the profession.

Also, we’re undertaking a lot of work on the governance front of the Academy. Over the next year, we’ll be looking at the relationship AAPA has with its state chapters and with its specialty organizations. The way those relationships have been chartered and have worked hasn’t really changed in 30 or 40 years, and I think the world in that time has changed dramatically.

The profession has grown dramatically, and it’s time for us to sit down with representatives of our constituent organizations and make sure that we’re working in the best model that we can to have the fullest impact at the local and the national level.

CR: How will AAPA address the increased movement by PAs from primary to specialty care?

Leinweber: If you step back and look at primary health care in its totality, the reality is that the demand for PAs continues to outstrip the supply. When you look at health care reform and the strong focus on primary care, I don’t think we’re necessarily going to see any immediate lessening of demand for PAs in specialty areas at the expense of growth in the primary care arena. So our challenge will be to grow that pie in totality.

We worked to have incentives built into the health care reform legislation that would encourage PA programs to participate in grant programs and other efforts that would really reward them for growing the number of PAs who choose primary care as their specialty, and to incentivize students who choose that path by increasing opportunities through the National Health Service Corps and loan forgiveness programs. Those things matter.

When you look at the primary care challenges of the country, the challenges that MDs or DOs face in terms of trying to grow the cadre of individuals going into primary care aren’t all that different from what we face. It comes down to quality of life, the compensation that’s tied to that particular kind of medicine, opportunities for advancement, flexibility.

Those are all issues that we’re going to have to address. We’ve begun to do that, but we’re going to have to work with organized medicine to continue to push for a shift in how the country rewards and positions primary care.

CR: How will AAPA provide support to PAs in specialties, while maintaining its commitment to primary care?

Leinweber: There are 24 specialty organizations that have a charter agreement with AAPA and are represented in our House of Delegates. We work closely with our specialty organizations; we collaborate with them, increasingly, on continuing medical education (CME) programs that they provide to their members.

The AAPA will work with the Society of PAs in Pediatrics, for example, and work to bring the American Academy of Pediatrics to the table so that we can contribute to shaping the delivery of programs that are of value to PAs in particular specialty fields. I certainly see us continuing to do that.

We completely recognize that the demographic has shifted. Our statistics now show that 35.7% of PAs identify themselves as practicing in primary care. So, that means almost 65% are in a specialized field. That’s a reality that we look at and we shape our services accordingly.

But considering how things are moving nationwide, relative to a reformed health care system, we very much feel the need, the pressure, and the obligation to do everything we can to grow those primary care numbers.

CR: What opportunities do you see for PAs to partner with NPs?

Leinweber: We are doing some partnering now in the form of joint CME programs that we’ve conducted in the past couple of years with the American Academy of Nurse Practitioners and various doctor specialty groups. For instance, there was a boot camp last August with the Society for Hospital Medicine. We will collaboratively put on programs that are designed to serve the CME needs of PAs and NPs primarily, although physicians can participate as well. Those have been tremendously successful. We certainly want to continue to do that.

On the legislative front, I think there is value in PAs and NPs working collaboratively wherever we can at the federal level. Wherever we have common messages that support our various legislative goals, we’re certainly open to that. I think when you start to look at the state level and where health care is delivered, on the front lines, things become a little more challenging because we don’t answer to the same regulatory body at that level.

But our philosophy is, the country has an enormous need in terms of individuals requiring care from qualified, competent providers. We need many more PAs, we need more NPs; there are very important and distinct roles that we play. And wherever we can work together to bring the wherewithal of our respective professions to improve health care and health care delivery, I think we need to be open to that and look for those opportunities.

CR: NPs have been touted for significantly raising their public profile, while many PAs feel their profession has lagged behind in this area. How is AAPA approaching the public perception and marketing of the profession?

Leinweber: First of all, I think it’s accurate to say that the NPs have been ahead of us from a policymaker and a public recognition/perception point of view. But I think we’ve made some significant strides over the past couple of years with the PA profession.

We have been very targeted in our approach. We made a conscious decision that it was critical to elevate the presence and the positioning of the profession first and foremost among policymakers and thought leaders who have the authority to impact how the profession is practiced. So, much of our work has focused on building understanding and awareness among members of Congress, among the administration, among state leaders, elected and appointed officials.

We have undertaken a variety of initiatives that we have not done before: briefings, roundtables, advertising that we’re doing in targeted publications, such as Congressional Daily, Politico, Roll Call. Some of these ads have really made a difference in terms of the role that we were invited to play in shaping health care reform. We were very much at the table. We were invited to the White House continually and invited to meetings with Congressional leaders throughout the drafting of health care reform legislation. So I think we’ve made some real strides there.

We’re not ignoring the public. But in an organization with limited resources, it’s been our feeling and our belief that the best service we can provide to our members and the best return we can put on their investment, in terms of their membership dues, is to make certain that policies are put in place that allow PAs to really practice to the full degree that they’re equipped to practice and to remove any barriers we can that prevent that.

We are beginning to make some inroads, from a public perception standpoint. Increasingly, as debate and understanding around health care reform begins to trickle across the country, we hear from and are engaging more and more folks from the mainstream media, such as MSNBC, Newsweek, the Wall Street Journal, and others.

They’re seeing, from a legislative point of view, multiple references to this profession called “physician assistants,” and they want to talk to us. They want to know about the profession so they can inform consumers on how to access and utilize PAs.

So I’m really proud of the work we’ve accomplished there. We have a long way to go—and really that work will never stop. But I think we have been on target in terms of how we have focused our resources, and we need to continue that very strongly in the future.

CR: What other messages do you have for PAs and their NP colleagues?

Leinweber: From a professional point of view, I can’t imagine a more well-positioned, exciting, and thriving profession at this point in history than the physician assistant profession. We are really poised to play the leadership role that some may argue we have played for decades quietly, but I think [now] much more visibly and with much more recognition. I just think there’s a level of relevance and consideration about the profession that hasn’t existed before. That’s very exciting, and it bodes very well for the future of the profession.

Relative to our work with our NP colleagues, there is an enormous amount of work needed by NPs and PAs across the country and across the health care spectrum. PAs and NPs work extremely well together and often seamlessly on the clinical level, and my hope would be to leverage every opportunity we can at the national level to make sure patients have access to the best quality of care, to the best providers, when they need it.