Contributing Writer

Joseph Doescher and Daniel Raess worked side by side in the operating room at St. Francis Hospital in Beech Grove, Indiana. Doescher and the other perfusionists often had to put up with yelling, swearing, and belittling comments from Raess, the heart surgeon. Finally, Doescher reported the behavior to his supervisor. Raess got wind of it and retaliated.

In subsequent court proceedings, Doescher described looking up at Raess’ red face and popping veins. He was afraid Raess was going to hit him. In the end, Doescher left his job with a debilitating case of depression. Later, he sued Raess and was awarded $325,000 in compensatory (but not punitive) damages.

Shortly after the Indiana Supreme Court decided this high-profile medical case, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a safety alert, requiring hospitals to adopt a zero-tolerance policy toward workplace bullying. By January 2009, hospitals must also comply with the new disruptive behavior standard (LD.3.15). They will create new training, post a code of conduct for employees, and set up a mechanism for workers to report inappropriate outbursts.

“It’s been widely recognized that this kind of behavior goes on in health care settings,” says Peter Angood, MD, Chief Patient Safety Officer for JCAHO. “It seemed to be increasing in frequency, so we felt it was important to put standards in place.”

Perfect Targets
Researchers, including Gerald Hickson, MD, at Vanderbilt University, and Alan H. Rosenstein, MD, have shown how inappropriate workplace behavior can lead to increased legal costs and put patient safety at risk. Other studies have shown that clinicians working in a hostile environment make more errors while dispensing medication.

“If there are people in the workplace who don’t play well with others, sometimes they cause other members of the team to lose focus,” Hickson says, “and an error will occur.”

According to Gary Namie, PhD, Cofounder of the Workplace Bullying Institute in Bellingham, Washington, this issue is coming to the forefront, just as sexual harassment did about 20 years ago. Employers are starting to see training programs and prevention as a good investment. And Namie says the need is great—in all sectors of the work world. His organization conducted a survey and found that 37% of American workers say they have been victims of workplace bullying.

Health care, with its hierarchical structure of authority and caste-like training systems, is rife with this type of negative behavior. In part, Namie says, this is because there are so many caring and compassionate people in the field, who make perfect targets: They would rather help people and keep a low profile than fight back.

“It’s the people mix,” Namie says. “You’ve got just enough people with strong egos and narcissistic personalities. Then you’ve got this vast pool of targets who have an altruistic bent—they want to focus on the work itself, and they have a belief in a benevolent world. They don’t respond to aggression with aggression.”

Workplace bullies usually target a person with good social skills who is well liked, as Namie explains: “It’s usually a person with an established record who poses a threat, and the bully wants to take him or her down.”

Nurses at the Forefront
Frequently, physicians are the aggressors and nurses are the targets. In fact, a JCAHO survey found that 50% of nurses had been targets of this kind of intimidation, and 90% of nurses reported having witnessed it.

Dianne Felblinger, EdD, MSN, WHNP-BC, CNS, RN, a nursing instructor at the University of Cincinnati, believes the nursing shortage is driving some of the frustration—but also may hold the key to solving the problem.

First of all, many hospitals do not have optimal nurse-to-patient ratios right now, due to the shortage. That, in turn, leads to high stress and more confrontations. “I have pretty much seen it all,” Felblinger says. “I have seen yelling, screaming, and chart throwing. I once saw a physician throw a needle, and it pierced the nurse’s skin.”

On the other hand, she adds, the nursing shortage has helped nurses find their voices and ask for better treatment. Hospitals know if they don’t retain their nurses and keep them happy, nurses have a lot of career options these days—and they just might walk.

Felblinger worries about NPs who may be the sole nurse in a clinic, surrounded by physicians. Those NPs could become targets, since they don’t have other nurses to turn to for support.

The best prevention, according to Felblinger, is to speak up right away. Unfortunately, most targets of bullying let the problems continue for as long as two years.

“The most civil thing is to always address it with the person,” Felblinger says. “Get it out in the open, and request that the behavior stop.”

It’s about learning to set boundaries and deciding you want to be treated with respect, she adds. “Sometimes things can be worked out really well,” Felblinger says. “Sometimes people don’t realize they’re doing this, because nobody ever brought it to their attention.”

Building Momentum for Change
With the new JCAHO standards in place, clinicians should have an easier time reporting negative incidents.

Still, Namie warns, the JCAHO standards really don’t have teeth. Health care workers won’t truly be protected until legislators pass laws that will cause a workplace bully to lose his or her job (just as they did for sexual harassment). That’s still years away, but with two bills in the New York State Legislature and six other active bills in states across the country, Namie says the movement “continues to catch fire.”

Meanwhile, clinicians who do call out a bully may run into resistance at the top. Bullies are often adept at charming and building allies in high places. Felblinger says that some hospital administrators may also value the money top surgeons or physicians are able to attract to the institution—sometimes more than they value their own workers.

One shining star in this area is Vanderbilt University Medical Center, which has adopted effective prevention policies of its own and shared the model with 40 other hospitals around the country. (For details, visit www.mc.vanderbilt .edu/cppa.)

Vanderbilt uses patient surveys, suggestion cards, and waiting room videos to make it clear to patients that their feedback is welcome. Staff members use an online program to report unprofessional behavior, Hickson says. Once the data are there, the hospital searches for recurring names and patterns of negative behavior. Clinicians who are repeatedly mentioned must then go through training programs and, in certain cases, counseling through an employee assistance program.

It’s not as simple as printing up a statement about zero tolerance, Hickson says. “So many people think you can slap a policy on this and make it go away,” he adds. In fact, it can take years to make inroads and establish civil behavior as a core value for a medical institution.

For Patients and Clinicians
Clinical nurse specialist Theresa Mulherin, MSN, RN, CEN, is in charge of implementing the new JCAHO standards for workplace behavior at Sentara Careplex in Hampton, Virginia. At times, she feels as if she is operating in uncharted territory, but she is also honored to do this job.

“I’m excited about this,” Mulherin says. “As nurses, we’ve known for a long time that this needed to be addressed. This is about patient safety, and that’s why it’s so important to me.”

While it may be a far from perfect world for health care workers, it’s important not to lose heart. Clinicians need to stick together, support each other, and really work on this cause, Felblinger says: “We can lose some of our best and brightest if we don’t deal with it.”

Joseph Doescher and Daniel Raess worked side by side in the operating room at St. Francis Hospital in Beech Grove, Indiana. Doescher and the other perfusionists often had to put up with yelling, swearing, and belittling comments from Raess, the heart surgeon. Finally, Doescher reported the behavior to his supervisor. Raess got wind of it and retaliated.

In subsequent court proceedings, Doescher described looking up at Raess’ red face and popping veins. He was afraid Raess was going to hit him. In the end, Doescher left his job with a debilitating case of depression. Later, he sued Raess and was awarded $325,000 in compensatory (but not punitive) damages.

Shortly after the Indiana Supreme Court decided this high-profile medical case, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a safety alert, requiring hospitals to adopt a zero-tolerance policy toward workplace bullying. By January 2009, hospitals must also comply with the new disruptive behavior standard (LD.3.15). They will create new training, post a code of conduct for employees, and set up a mechanism for workers to report inappropriate outbursts.

“It’s been widely recognized that this kind of behavior goes on in health care settings,” says Peter Angood, MD, Chief Patient Safety Officer for JCAHO. “It seemed to be increasing in frequency, so we felt it was important to put standards in place.”

Perfect Targets
Researchers, including Gerald Hickson, MD, at Vanderbilt University, and Alan H. Rosenstein, MD, have shown how inappropriate workplace behavior can lead to increased legal costs and put patient safety at risk. Other studies have shown that clinicians working in a hostile environment make more errors while dispensing medication.

“If there are people in the workplace who don’t play well with others, sometimes they cause other members of the team to lose focus,” Hickson says, “and an error will occur.”

According to Gary Namie, PhD, Cofounder of the Workplace Bullying Institute in Bellingham, Washington, this issue is coming to the forefront, just as sexual harassment did about 20 years ago. Employers are starting to see training programs and prevention as a good investment. And Namie says the need is great—in all sectors of the work world. His organization conducted a survey and found that 37% of American workers say they have been victims of workplace bullying.

Health care, with its hierarchical structure of authority and caste-like training systems, is rife with this type of negative behavior. In part, Namie says, this is because there are so many caring and compassionate people in the field, who make perfect targets: They would rather help people and keep a low profile than fight back.

“It’s the people mix,” Namie says. “You’ve got just enough people with strong egos and narcissistic personalities. Then you’ve got this vast pool of targets who have an altruistic bent—they want to focus on the work itself, and they have a belief in a benevolent world. They don’t respond to aggression with aggression.”

Workplace bullies usually target a person with good social skills who is well liked, as Namie explains: “It’s usually a person with an established record who poses a threat, and the bully wants to take him or her down.”

Nurses at the Forefront
Frequently, physicians are the aggressors and nurses are the targets. In fact, a JCAHO survey found that 50% of nurses had been targets of this kind of intimidation, and 90% of nurses reported having witnessed it.

Dianne Felblinger, EdD, MSN, WHNP-BC, CNS, RN, a nursing instructor at the University of Cincinnati, believes the nursing shortage is driving some of the frustration—but also may hold the key to solving the problem.

First of all, many hospitals do not have optimal nurse-to-patient ratios right now, due to the shortage. That, in turn, leads to high stress and more confrontations. “I have pretty much seen it all,” Felblinger says. “I have seen yelling, screaming, and chart throwing. I once saw a physician throw a needle, and it pierced the nurse’s skin.”

On the other hand, she adds, the nursing shortage has helped nurses find their voices and ask for better treatment. Hospitals know if they don’t retain their nurses and keep them happy, nurses have a lot of career options these days—and they just might walk.

Felblinger worries about NPs who may be the sole nurse in a clinic, surrounded by physicians. Those NPs could become targets, since they don’t have other nurses to turn to for support.

The best prevention, according to Felblinger, is to speak up right away. Unfortunately, most targets of bullying let the problems continue for as long as two years.

“The most civil thing is to always address it with the person,” Felblinger says. “Get it out in the open, and request that the behavior stop.”

It’s about learning to set boundaries and deciding you want to be treated with respect, she adds. “Sometimes things can be worked out really well,” Felblinger says. “Sometimes people don’t realize they’re doing this, because nobody ever brought it to their attention.”

Building Momentum for Change
With the new JCAHO standards in place, clinicians should have an easier time reporting negative incidents.

Still, Namie warns, the JCAHO standards really don’t have teeth. Health care workers won’t truly be protected until legislators pass laws that will cause a workplace bully to lose his or her job (just as they did for sexual harassment). That’s still years away, but with two bills in the New York State Legislature and six other active bills in states across the country, Namie says the movement “continues to catch fire.”

Meanwhile, clinicians who do call out a bully may run into resistance at the top. Bullies are often adept at charming and building allies in high places. Felblinger says that some hospital administrators may also value the money top surgeons or physicians are able to attract to the institution—sometimes more than they value their own workers.

One shining star in this area is Vanderbilt University Medical Center, which has adopted effective prevention policies of its own and shared the model with 40 other hospitals around the country. (For details, visit www.mc.vanderbilt .edu/cppa.)

Vanderbilt uses patient surveys, suggestion cards, and waiting room videos to make it clear to patients that their feedback is welcome. Staff members use an online program to report unprofessional behavior, Hickson says. Once the data are there, the hospital searches for recurring names and patterns of negative behavior. Clinicians who are repeatedly mentioned must then go through training programs and, in certain cases, counseling through an employee assistance program.

It’s not as simple as printing up a statement about zero tolerance, Hickson says. “So many people think you can slap a policy on this and make it go away,” he adds. In fact, it can take years to make inroads and establish civil behavior as a core value for a medical institution.

For Patients and Clinicians
Clinical nurse specialist Theresa Mulherin, MSN, RN, CEN, is in charge of implementing the new JCAHO standards for workplace behavior at Sentara Careplex in Hampton, Virginia. At times, she feels as if she is operating in uncharted territory, but she is also honored to do this job.

“I’m excited about this,” Mulherin says. “As nurses, we’ve known for a long time that this needed to be addressed. This is about patient safety, and that’s why it’s so important to me.”

While it may be a far from perfect world for health care workers, it’s important not to lose heart. Clinicians need to stick together, support each other, and really work on this cause, Felblinger says: “We can lose some of our best and brightest if we don’t deal with it.”

Joseph Doescher and Daniel Raess worked side by side in the operating room at St. Francis Hospital in Beech Grove, Indiana. Doescher and the other perfusionists often had to put up with yelling, swearing, and belittling comments from Raess, the heart surgeon. Finally, Doescher reported the behavior to his supervisor. Raess got wind of it and retaliated.

In subsequent court proceedings, Doescher described looking up at Raess’ red face and popping veins. He was afraid Raess was going to hit him. In the end, Doescher left his job with a debilitating case of depression. Later, he sued Raess and was awarded $325,000 in compensatory (but not punitive) damages.

Shortly after the Indiana Supreme Court decided this high-profile medical case, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a safety alert, requiring hospitals to adopt a zero-tolerance policy toward workplace bullying. By January 2009, hospitals must also comply with the new disruptive behavior standard (LD.3.15). They will create new training, post a code of conduct for employees, and set up a mechanism for workers to report inappropriate outbursts.

“It’s been widely recognized that this kind of behavior goes on in health care settings,” says Peter Angood, MD, Chief Patient Safety Officer for JCAHO. “It seemed to be increasing in frequency, so we felt it was important to put standards in place.”

Perfect Targets
Researchers, including Gerald Hickson, MD, at Vanderbilt University, and Alan H. Rosenstein, MD, have shown how inappropriate workplace behavior can lead to increased legal costs and put patient safety at risk. Other studies have shown that clinicians working in a hostile environment make more errors while dispensing medication.

“If there are people in the workplace who don’t play well with others, sometimes they cause other members of the team to lose focus,” Hickson says, “and an error will occur.”

According to Gary Namie, PhD, Cofounder of the Workplace Bullying Institute in Bellingham, Washington, this issue is coming to the forefront, just as sexual harassment did about 20 years ago. Employers are starting to see training programs and prevention as a good investment. And Namie says the need is great—in all sectors of the work world. His organization conducted a survey and found that 37% of American workers say they have been victims of workplace bullying.

Health care, with its hierarchical structure of authority and caste-like training systems, is rife with this type of negative behavior. In part, Namie says, this is because there are so many caring and compassionate people in the field, who make perfect targets: They would rather help people and keep a low profile than fight back.

“It’s the people mix,” Namie says. “You’ve got just enough people with strong egos and narcissistic personalities. Then you’ve got this vast pool of targets who have an altruistic bent—they want to focus on the work itself, and they have a belief in a benevolent world. They don’t respond to aggression with aggression.”

Workplace bullies usually target a person with good social skills who is well liked, as Namie explains: “It’s usually a person with an established record who poses a threat, and the bully wants to take him or her down.”

Nurses at the Forefront
Frequently, physicians are the aggressors and nurses are the targets. In fact, a JCAHO survey found that 50% of nurses had been targets of this kind of intimidation, and 90% of nurses reported having witnessed it.

Dianne Felblinger, EdD, MSN, WHNP-BC, CNS, RN, a nursing instructor at the University of Cincinnati, believes the nursing shortage is driving some of the frustration—but also may hold the key to solving the problem.

First of all, many hospitals do not have optimal nurse-to-patient ratios right now, due to the shortage. That, in turn, leads to high stress and more confrontations. “I have pretty much seen it all,” Felblinger says. “I have seen yelling, screaming, and chart throwing. I once saw a physician throw a needle, and it pierced the nurse’s skin.”

On the other hand, she adds, the nursing shortage has helped nurses find their voices and ask for better treatment. Hospitals know if they don’t retain their nurses and keep them happy, nurses have a lot of career options these days—and they just might walk.

Felblinger worries about NPs who may be the sole nurse in a clinic, surrounded by physicians. Those NPs could become targets, since they don’t have other nurses to turn to for support.

The best prevention, according to Felblinger, is to speak up right away. Unfortunately, most targets of bullying let the problems continue for as long as two years.

“The most civil thing is to always address it with the person,” Felblinger says. “Get it out in the open, and request that the behavior stop.”

It’s about learning to set boundaries and deciding you want to be treated with respect, she adds. “Sometimes things can be worked out really well,” Felblinger says. “Sometimes people don’t realize they’re doing this, because nobody ever brought it to their attention.”

Building Momentum for Change
With the new JCAHO standards in place, clinicians should have an easier time reporting negative incidents.

Still, Namie warns, the JCAHO standards really don’t have teeth. Health care workers won’t truly be protected until legislators pass laws that will cause a workplace bully to lose his or her job (just as they did for sexual harassment). That’s still years away, but with two bills in the New York State Legislature and six other active bills in states across the country, Namie says the movement “continues to catch fire.”

Meanwhile, clinicians who do call out a bully may run into resistance at the top. Bullies are often adept at charming and building allies in high places. Felblinger says that some hospital administrators may also value the money top surgeons or physicians are able to attract to the institution—sometimes more than they value their own workers.

One shining star in this area is Vanderbilt University Medical Center, which has adopted effective prevention policies of its own and shared the model with 40 other hospitals around the country. (For details, visit www.mc.vanderbilt .edu/cppa.)

Vanderbilt uses patient surveys, suggestion cards, and waiting room videos to make it clear to patients that their feedback is welcome. Staff members use an online program to report unprofessional behavior, Hickson says. Once the data are there, the hospital searches for recurring names and patterns of negative behavior. Clinicians who are repeatedly mentioned must then go through training programs and, in certain cases, counseling through an employee assistance program.

It’s not as simple as printing up a statement about zero tolerance, Hickson says. “So many people think you can slap a policy on this and make it go away,” he adds. In fact, it can take years to make inroads and establish civil behavior as a core value for a medical institution.

For Patients and Clinicians
Clinical nurse specialist Theresa Mulherin, MSN, RN, CEN, is in charge of implementing the new JCAHO standards for workplace behavior at Sentara Careplex in Hampton, Virginia. At times, she feels as if she is operating in uncharted territory, but she is also honored to do this job.

“I’m excited about this,” Mulherin says. “As nurses, we’ve known for a long time that this needed to be addressed. This is about patient safety, and that’s why it’s so important to me.”

While it may be a far from perfect world for health care workers, it’s important not to lose heart. Clinicians need to stick together, support each other, and really work on this cause, Felblinger says: “We can lose some of our best and brightest if we don’t deal with it.”

A few months ago, a homeless woman stepped onto the mobile health clinic parked near a beach on Cape Cod. As she climbed aboard, the woman was holding her back, in pain.

An NP ushered the woman into an exam room, and the patient began to tell her story. She had tried to seek treatment for her back pain several times before, only to be turned away. The NP ordered some tests and found the woman had a legitimate problem with her back. She was sent to a homeless shelter with a prescription in hand, and the patient finally got relief from years of pain.

“The clinician did a really good job of listening to this patient,” says Elyse DeGroot, MSW, spokesperson for the mobile clinic and its sponsor, the Duffy Health Center in Hyannis, Massachusetts. “She didn’t see this woman as just another emergency room drug-seeking patient. You give people good care when you don’t presume to know what the problem is.”

Growing Need as the Economy Stalls
While many people have an image of Cape Cod as an affluent summer retreat, not everyone who lives there is wealthy. “There are a lot of homeless people here, but they are hidden from view,” DeGroot explains. Since the homeless population is growing due to the bad economy, and the public transportation system on Cape Cod is limited, the Duffy Health Center decided to take a clinic out to where the most needy patients are living. “We have patients who have not seen a doctor in 20 years,” she adds.

As more Americans go without health insurance, the need for mobile health care units is growing, says Darien DeLorenzo, Executive Director of the San Francisco–based Mobile Health Clinics Network. With millions of people visiting emergency departments for what amounts to basic primary care needs, hospitals are shifting their funds to preventive care, DeLorenzo says. Often, that means preventive care on wheels.

Mobile clinics are parking at schools, businesses, supermarkets, and big-box stores across the country. Clinicians on board are offering services that include mammograms and vaccines, as well as dental care, to veterans, homeless persons, and runaways. Mobile health care was especially effective in the aftermath of Hurricane Katrina and the more recent tropical storms, DeLorenzo adds.

Getting NPs and PAs on Board
DeGroot and DeLorenzo say this growing trend is especially well suited to advanced practice nurses and PAs. It takes a certain kind of person to work in a mobile clinic, as DeLorenzo explains.

“You need a person who is self-motivated, who can be very flexible and individualistic, because you’re not going to be sitting there in an office with a lot of staff people around you,” she says. “You’ve got to be confident in yourself—a decision-maker—because if a patient comes in, you’ve got to be able make decisions for yourself.”

NPs and PAs with the ability to practice independently can learn more about opportunities in the mobile health care field during the Mobile Health Clinics Network’s joint conference with the American Telemedicine Association in Las Vegas in April 2009. (For details, visit www.mobilehealthclinicsnetwork.org.) Topics on the agenda include everything from how to conduct a needs assessment and write a grant to how mobile clinics can maintain continuity of care.

Service for All in Need
As a veteran in the mobile health care arena, Larry Friedman, MD, is now seeing the fruits of 10 years of working with troubled youth on the streets of San Diego. Thanks to his mobile unit, which is largely staffed by medical students at the University of California–San Diego Medical School, countless pregnancies and cases of sexually transmitted disease have been prevented.

Ultimately, the clinic has offered a sympathetic ear and helped innumerable homeless teens find their way back into society. “A lot of times, it’s just a place where kids can come and talk about what’s going on in their lives,” he adds.

Friedman says he knew his program had built up trust with the local youth community when two girls from affluent La Jolla stepped onto the van one night. Usually, the mobile unit treats physical and sexual abuse victims, kids with substance abuse problems, and teens who have run away from home. But these girls were extremely well dressed, and they drove up in a nice car. They told Dr. Friedman they wanted an HIV test, but they didn’t want to go to their family doctor because they didn’t want their parents to know about it.

“That’s when I knew there was word on the street about this van,” Friedman says. “We were more than happy to do that for them.”

Setting the Wheels in Motion
Friedman and DeGroot say working onboard a mobile health clinic is one of the most satisfying types of medicine to practice. For those who want to consider a career in this area, or who might want to start up a new mobile clinic, they offer a few words of wisdom.

An important first step is to take the temperature of the community by creating a needs assessment. If another group is already meeting certain needs, then you will know to move in a different direction with your program, they say.

Also, it’s important to identify agencies that might be willing to collaborate. Friedman and DeGroot say their success is largely due to their wonderful community partners. The most successful mobile clinics operate in an environment where everyone knows his or her role and nobody steps on anyone else’s toes.

DeGroot advises new clinics to hire a dedicated program manager who oversees the clinic but does not work on the van. And Friedman says it’s also important to carefully identify your patient population (whom you will treat and whom you will not), so that you can really zero in on helping the people with the greatest needs in the community.

“These kinds of populations require somebody with a great deal of compassion,” DeLorenzo says. “It might be old people, poor people, and a lot of disenfranchised people.”

For health care providers who are looking to get rich quick, mobile clinics are probably not the way to go, she adds. Most mobile clinics get funding from nonprofit organizations and community groups that have a stake in keeping costs down. But if you are the kind of person who is concerned about social justice, fixing our country’s health care crisis, and helping the poor, DeLorenzo says, mobile health care could be a good fit.

A few months ago, a homeless woman stepped onto the mobile health clinic parked near a beach on Cape Cod. As she climbed aboard, the woman was holding her back, in pain.

An NP ushered the woman into an exam room, and the patient began to tell her story. She had tried to seek treatment for her back pain several times before, only to be turned away. The NP ordered some tests and found the woman had a legitimate problem with her back. She was sent to a homeless shelter with a prescription in hand, and the patient finally got relief from years of pain.

“The clinician did a really good job of listening to this patient,” says Elyse DeGroot, MSW, spokesperson for the mobile clinic and its sponsor, the Duffy Health Center in Hyannis, Massachusetts. “She didn’t see this woman as just another emergency room drug-seeking patient. You give people good care when you don’t presume to know what the problem is.”

Growing Need as the Economy Stalls
While many people have an image of Cape Cod as an affluent summer retreat, not everyone who lives there is wealthy. “There are a lot of homeless people here, but they are hidden from view,” DeGroot explains. Since the homeless population is growing due to the bad economy, and the public transportation system on Cape Cod is limited, the Duffy Health Center decided to take a clinic out to where the most needy patients are living. “We have patients who have not seen a doctor in 20 years,” she adds.

As more Americans go without health insurance, the need for mobile health care units is growing, says Darien DeLorenzo, Executive Director of the San Francisco–based Mobile Health Clinics Network. With millions of people visiting emergency departments for what amounts to basic primary care needs, hospitals are shifting their funds to preventive care, DeLorenzo says. Often, that means preventive care on wheels.

Mobile clinics are parking at schools, businesses, supermarkets, and big-box stores across the country. Clinicians on board are offering services that include mammograms and vaccines, as well as dental care, to veterans, homeless persons, and runaways. Mobile health care was especially effective in the aftermath of Hurricane Katrina and the more recent tropical storms, DeLorenzo adds.

Getting NPs and PAs on Board
DeGroot and DeLorenzo say this growing trend is especially well suited to advanced practice nurses and PAs. It takes a certain kind of person to work in a mobile clinic, as DeLorenzo explains.

“You need a person who is self-motivated, who can be very flexible and individualistic, because you’re not going to be sitting there in an office with a lot of staff people around you,” she says. “You’ve got to be confident in yourself—a decision-maker—because if a patient comes in, you’ve got to be able make decisions for yourself.”

NPs and PAs with the ability to practice independently can learn more about opportunities in the mobile health care field during the Mobile Health Clinics Network’s joint conference with the American Telemedicine Association in Las Vegas in April 2009. (For details, visit www.mobilehealthclinicsnetwork.org.) Topics on the agenda include everything from how to conduct a needs assessment and write a grant to how mobile clinics can maintain continuity of care.

Service for All in Need
As a veteran in the mobile health care arena, Larry Friedman, MD, is now seeing the fruits of 10 years of working with troubled youth on the streets of San Diego. Thanks to his mobile unit, which is largely staffed by medical students at the University of California–San Diego Medical School, countless pregnancies and cases of sexually transmitted disease have been prevented.

Ultimately, the clinic has offered a sympathetic ear and helped innumerable homeless teens find their way back into society. “A lot of times, it’s just a place where kids can come and talk about what’s going on in their lives,” he adds.

Friedman says he knew his program had built up trust with the local youth community when two girls from affluent La Jolla stepped onto the van one night. Usually, the mobile unit treats physical and sexual abuse victims, kids with substance abuse problems, and teens who have run away from home. But these girls were extremely well dressed, and they drove up in a nice car. They told Dr. Friedman they wanted an HIV test, but they didn’t want to go to their family doctor because they didn’t want their parents to know about it.

“That’s when I knew there was word on the street about this van,” Friedman says. “We were more than happy to do that for them.”

Setting the Wheels in Motion
Friedman and DeGroot say working onboard a mobile health clinic is one of the most satisfying types of medicine to practice. For those who want to consider a career in this area, or who might want to start up a new mobile clinic, they offer a few words of wisdom.

An important first step is to take the temperature of the community by creating a needs assessment. If another group is already meeting certain needs, then you will know to move in a different direction with your program, they say.

Also, it’s important to identify agencies that might be willing to collaborate. Friedman and DeGroot say their success is largely due to their wonderful community partners. The most successful mobile clinics operate in an environment where everyone knows his or her role and nobody steps on anyone else’s toes.

DeGroot advises new clinics to hire a dedicated program manager who oversees the clinic but does not work on the van. And Friedman says it’s also important to carefully identify your patient population (whom you will treat and whom you will not), so that you can really zero in on helping the people with the greatest needs in the community.

“These kinds of populations require somebody with a great deal of compassion,” DeLorenzo says. “It might be old people, poor people, and a lot of disenfranchised people.”

For health care providers who are looking to get rich quick, mobile clinics are probably not the way to go, she adds. Most mobile clinics get funding from nonprofit organizations and community groups that have a stake in keeping costs down. But if you are the kind of person who is concerned about social justice, fixing our country’s health care crisis, and helping the poor, DeLorenzo says, mobile health care could be a good fit.

A few months ago, a homeless woman stepped onto the mobile health clinic parked near a beach on Cape Cod. As she climbed aboard, the woman was holding her back, in pain.

An NP ushered the woman into an exam room, and the patient began to tell her story. She had tried to seek treatment for her back pain several times before, only to be turned away. The NP ordered some tests and found the woman had a legitimate problem with her back. She was sent to a homeless shelter with a prescription in hand, and the patient finally got relief from years of pain.

“The clinician did a really good job of listening to this patient,” says Elyse DeGroot, MSW, spokesperson for the mobile clinic and its sponsor, the Duffy Health Center in Hyannis, Massachusetts. “She didn’t see this woman as just another emergency room drug-seeking patient. You give people good care when you don’t presume to know what the problem is.”

Growing Need as the Economy Stalls
While many people have an image of Cape Cod as an affluent summer retreat, not everyone who lives there is wealthy. “There are a lot of homeless people here, but they are hidden from view,” DeGroot explains. Since the homeless population is growing due to the bad economy, and the public transportation system on Cape Cod is limited, the Duffy Health Center decided to take a clinic out to where the most needy patients are living. “We have patients who have not seen a doctor in 20 years,” she adds.

As more Americans go without health insurance, the need for mobile health care units is growing, says Darien DeLorenzo, Executive Director of the San Francisco–based Mobile Health Clinics Network. With millions of people visiting emergency departments for what amounts to basic primary care needs, hospitals are shifting their funds to preventive care, DeLorenzo says. Often, that means preventive care on wheels.

Mobile clinics are parking at schools, businesses, supermarkets, and big-box stores across the country. Clinicians on board are offering services that include mammograms and vaccines, as well as dental care, to veterans, homeless persons, and runaways. Mobile health care was especially effective in the aftermath of Hurricane Katrina and the more recent tropical storms, DeLorenzo adds.

Getting NPs and PAs on Board
DeGroot and DeLorenzo say this growing trend is especially well suited to advanced practice nurses and PAs. It takes a certain kind of person to work in a mobile clinic, as DeLorenzo explains.

“You need a person who is self-motivated, who can be very flexible and individualistic, because you’re not going to be sitting there in an office with a lot of staff people around you,” she says. “You’ve got to be confident in yourself—a decision-maker—because if a patient comes in, you’ve got to be able make decisions for yourself.”

NPs and PAs with the ability to practice independently can learn more about opportunities in the mobile health care field during the Mobile Health Clinics Network’s joint conference with the American Telemedicine Association in Las Vegas in April 2009. (For details, visit www.mobilehealthclinicsnetwork.org.) Topics on the agenda include everything from how to conduct a needs assessment and write a grant to how mobile clinics can maintain continuity of care.

Service for All in Need
As a veteran in the mobile health care arena, Larry Friedman, MD, is now seeing the fruits of 10 years of working with troubled youth on the streets of San Diego. Thanks to his mobile unit, which is largely staffed by medical students at the University of California–San Diego Medical School, countless pregnancies and cases of sexually transmitted disease have been prevented.

Ultimately, the clinic has offered a sympathetic ear and helped innumerable homeless teens find their way back into society. “A lot of times, it’s just a place where kids can come and talk about what’s going on in their lives,” he adds.

Friedman says he knew his program had built up trust with the local youth community when two girls from affluent La Jolla stepped onto the van one night. Usually, the mobile unit treats physical and sexual abuse victims, kids with substance abuse problems, and teens who have run away from home. But these girls were extremely well dressed, and they drove up in a nice car. They told Dr. Friedman they wanted an HIV test, but they didn’t want to go to their family doctor because they didn’t want their parents to know about it.

“That’s when I knew there was word on the street about this van,” Friedman says. “We were more than happy to do that for them.”

Setting the Wheels in Motion
Friedman and DeGroot say working onboard a mobile health clinic is one of the most satisfying types of medicine to practice. For those who want to consider a career in this area, or who might want to start up a new mobile clinic, they offer a few words of wisdom.

An important first step is to take the temperature of the community by creating a needs assessment. If another group is already meeting certain needs, then you will know to move in a different direction with your program, they say.

Also, it’s important to identify agencies that might be willing to collaborate. Friedman and DeGroot say their success is largely due to their wonderful community partners. The most successful mobile clinics operate in an environment where everyone knows his or her role and nobody steps on anyone else’s toes.

DeGroot advises new clinics to hire a dedicated program manager who oversees the clinic but does not work on the van. And Friedman says it’s also important to carefully identify your patient population (whom you will treat and whom you will not), so that you can really zero in on helping the people with the greatest needs in the community.

“These kinds of populations require somebody with a great deal of compassion,” DeLorenzo says. “It might be old people, poor people, and a lot of disenfranchised people.”

For health care providers who are looking to get rich quick, mobile clinics are probably not the way to go, she adds. Most mobile clinics get funding from nonprofit organizations and community groups that have a stake in keeping costs down. But if you are the kind of person who is concerned about social justice, fixing our country’s health care crisis, and helping the poor, DeLorenzo says, mobile health care could be a good fit.

Michele Kline, MSN, CNP, has a somewhat familiar story: As a family nurse practitioner at the Cleveland Clinic, she sees a lot of “snowbirds”—retired people who split their time between Ohio and Florida. Since they have two residences, these patients also get their health care in two different states.

There was a time when that situation was fraught with the potential for health issues to fall through the cracks, due to a lack of communication among health care providers. Thanks to electronic medical records (EMRs), Kline says she doesn’t miss a beat.

For example, when one of her patients underwent a heart scan while in Florida, Kline simply sent an e-mail to her counterpart there. With the click of a button, she was able to check the results. When her patient returned to Cleveland for the summer, they picked up where they left off, with no gaps in care.

Though the market for EMRs has grown steadily, many clinicians have been reluctant to adopt the necessary systems and procedures. But as major players launch patient-focused programs—the Cleveland Clinic helped Google Health test its own application, and Microsoft and WebMD are among other companies getting in on the action—health care providers may find themselves scrambling to meet demand.

Concerns About Privacy
The growing trend toward EMRs, or the personal health records that Google has launched, has sparked debate among patients and clinicians. Some tout the benefits of EMRs, such as improved coordination of care and reduced medical errors, while others criticize them as creating more hassles for health care providers. Critics also worry about privacy breaches, since services like Google Health are not subject to the protection provided by HIPAA (although companies have developed their own privacy guidelines, which are similar to the federal regulations).

In an editorial recently published in the New England Journal of Medicine (2008;358[16]:1656-1658), two Massachusetts physicians, Pamela Hartzband, MD, and Jerome Groopman, MD, warned health care workers about the pitfalls of electronic records. Hartzband, an endocrinologist at Beth Israel Deaconess Medical Center in Boston, worries that clinicians might miss some important diagnostic clues if they no longer take a patient’s medical history by hand, with pen and paper.

“Talking to the patient independently may offer some new clues and symptoms,” Groopman explains. “But everybody is working under pressure, so they just copy and paste previous information without taking their own history.”

He also worries that placing a computer squarely between the provider and the patient will rob the health care setting of a valuable personal connection. “Patients feel their doctors are looking at the computer screen instead of actually talking with them,” says Groopman, a hematologist-oncologist at Beth Israel Deaconess.

Groopman also is unhappy with the number of computerized forms he is required to fill out for malpractice and insurance reasons—things that have very little to do with actually helping a patient feel better. Since his institution switched to EMRs, he says, he must stay late into the night doing extra paperwork.

Kline, 48, who has used EMRs during her entire 11-year career as a nurse practitioner, disagrees with Groopman’s assertion that computerized records slow down clinicians and create more work for them.

There is a learning curve, she says. But once you learn how to integrate an EMR system into your practice, it can make you much more efficient, Kline contends. Instead of spending the end of her day playing phone tag and fielding last-minute requests from patients, she calmly responds to their e-mails. In the end, using e-mail to communicate takes less time for both the clinician and the patient, Kline says.

Getting Patients Involved
Whether clinicians like it or not, experts say this trend is taking off, and it’s probably not going to disappear. The trick, according to C. Martin Harris, MD, Chief Information Officer at Cleveland Clinic, is to get a system that really works—for both patients and clinicians. In Cleveland, they use MyChart®, by Epic Systems Corporation. The hospital now has a total of 2.4 million patients using MyChart for everything from scheduling appointments and requesting prescription refills to receiving reminders about annual tests, such as mammograms.

At Cleveland Clinic, each exam room has a desktop computer for providers to use. Harris says the computers aren’t really barriers to care, because his staff has been specifically trained to avoid turning to the machine first. They still look the patient in the eye and make personal contact while doing a medical history, he explains. They just enter the data discreetly at another time, perhaps while the patient is changing into a gown or settling on the exam table.

Kline takes it a step further and actually tries to get her patients involved with using the computer. For example, she might turn the screen sideways so both she and the patients can look at it. She’ll show them a graph of their blood pressure or cholesterol before she discusses a change in medication with them. In one instance, a patient had a question about whether a certain blood pressure drug would be safe to take during pregnancy.

“I didn’t know the answer,” Kline admits. “So we turned to the computer and looked it up together.” That way, the patient was involved in her own health care decisions, and she didn’t have to wait until the next visit to get an answer.

Fine-Tuning the System
Kline says she uses the Cleveland Clinic’s MyChart system only with patients who tell her they are active computer users and check their e-mail every day. Kline relates that her group of “active computer users” includes patients in their 80s as well as those in their 20s. Senior citizens are some of the biggest fans of EMRs, she adds.

Besides knowing which patients might be comfortable with electronic records, Kline keeps tabs on whether her patients are receiving the information they need from the system. If she notices a patient’s MyChart data are not being viewed, she will print out the relevant pages and send them to the patient via “snail mail.” As a precaution, if she is sending lab results to a patient, Kline will request an automatic reply, which tells her the person received the information. If she doesn’t get a reply, she will personally follow up with a phone call.

Of course, there are certain times when e-mail communication is not appropriate, Kline says, and clinicians have to use their own discretion and common sense. For example, if a patient is diagnosed with a critical or terminal illness, a personal visit or phone call is the right way to go. Also, if there are time-sensitive test results, phone calls work better—an e-mail might get lost in the shuffle.

Overall, Kline is a fan of the EMR. She feels it has made life easier for her patients, and for her. But then, not all hospitals have worked out the bugs the way Cleveland Clinic has over the years.

Kline advises other clinicians to hang in there with it. “If you can be patient and embrace the learning curve,” she says, “this has the potential to add efficiency to your day.”        

Michele Kline, MSN, CNP, has a somewhat familiar story: As a family nurse practitioner at the Cleveland Clinic, she sees a lot of “snowbirds”—retired people who split their time between Ohio and Florida. Since they have two residences, these patients also get their health care in two different states.

There was a time when that situation was fraught with the potential for health issues to fall through the cracks, due to a lack of communication among health care providers. Thanks to electronic medical records (EMRs), Kline says she doesn’t miss a beat.

For example, when one of her patients underwent a heart scan while in Florida, Kline simply sent an e-mail to her counterpart there. With the click of a button, she was able to check the results. When her patient returned to Cleveland for the summer, they picked up where they left off, with no gaps in care.

Though the market for EMRs has grown steadily, many clinicians have been reluctant to adopt the necessary systems and procedures. But as major players launch patient-focused programs—the Cleveland Clinic helped Google Health test its own application, and Microsoft and WebMD are among other companies getting in on the action—health care providers may find themselves scrambling to meet demand.

Concerns About Privacy
The growing trend toward EMRs, or the personal health records that Google has launched, has sparked debate among patients and clinicians. Some tout the benefits of EMRs, such as improved coordination of care and reduced medical errors, while others criticize them as creating more hassles for health care providers. Critics also worry about privacy breaches, since services like Google Health are not subject to the protection provided by HIPAA (although companies have developed their own privacy guidelines, which are similar to the federal regulations).

In an editorial recently published in the New England Journal of Medicine (2008;358[16]:1656-1658), two Massachusetts physicians, Pamela Hartzband, MD, and Jerome Groopman, MD, warned health care workers about the pitfalls of electronic records. Hartzband, an endocrinologist at Beth Israel Deaconess Medical Center in Boston, worries that clinicians might miss some important diagnostic clues if they no longer take a patient’s medical history by hand, with pen and paper.

“Talking to the patient independently may offer some new clues and symptoms,” Groopman explains. “But everybody is working under pressure, so they just copy and paste previous information without taking their own history.”

He also worries that placing a computer squarely between the provider and the patient will rob the health care setting of a valuable personal connection. “Patients feel their doctors are looking at the computer screen instead of actually talking with them,” says Groopman, a hematologist-oncologist at Beth Israel Deaconess.

Groopman also is unhappy with the number of computerized forms he is required to fill out for malpractice and insurance reasons—things that have very little to do with actually helping a patient feel better. Since his institution switched to EMRs, he says, he must stay late into the night doing extra paperwork.

Kline, 48, who has used EMRs during her entire 11-year career as a nurse practitioner, disagrees with Groopman’s assertion that computerized records slow down clinicians and create more work for them.

There is a learning curve, she says. But once you learn how to integrate an EMR system into your practice, it can make you much more efficient, Kline contends. Instead of spending the end of her day playing phone tag and fielding last-minute requests from patients, she calmly responds to their e-mails. In the end, using e-mail to communicate takes less time for both the clinician and the patient, Kline says.

Getting Patients Involved
Whether clinicians like it or not, experts say this trend is taking off, and it’s probably not going to disappear. The trick, according to C. Martin Harris, MD, Chief Information Officer at Cleveland Clinic, is to get a system that really works—for both patients and clinicians. In Cleveland, they use MyChart®, by Epic Systems Corporation. The hospital now has a total of 2.4 million patients using MyChart for everything from scheduling appointments and requesting prescription refills to receiving reminders about annual tests, such as mammograms.

At Cleveland Clinic, each exam room has a desktop computer for providers to use. Harris says the computers aren’t really barriers to care, because his staff has been specifically trained to avoid turning to the machine first. They still look the patient in the eye and make personal contact while doing a medical history, he explains. They just enter the data discreetly at another time, perhaps while the patient is changing into a gown or settling on the exam table.

Kline takes it a step further and actually tries to get her patients involved with using the computer. For example, she might turn the screen sideways so both she and the patients can look at it. She’ll show them a graph of their blood pressure or cholesterol before she discusses a change in medication with them. In one instance, a patient had a question about whether a certain blood pressure drug would be safe to take during pregnancy.

“I didn’t know the answer,” Kline admits. “So we turned to the computer and looked it up together.” That way, the patient was involved in her own health care decisions, and she didn’t have to wait until the next visit to get an answer.

Fine-Tuning the System
Kline says she uses the Cleveland Clinic’s MyChart system only with patients who tell her they are active computer users and check their e-mail every day. Kline relates that her group of “active computer users” includes patients in their 80s as well as those in their 20s. Senior citizens are some of the biggest fans of EMRs, she adds.

Besides knowing which patients might be comfortable with electronic records, Kline keeps tabs on whether her patients are receiving the information they need from the system. If she notices a patient’s MyChart data are not being viewed, she will print out the relevant pages and send them to the patient via “snail mail.” As a precaution, if she is sending lab results to a patient, Kline will request an automatic reply, which tells her the person received the information. If she doesn’t get a reply, she will personally follow up with a phone call.

Of course, there are certain times when e-mail communication is not appropriate, Kline says, and clinicians have to use their own discretion and common sense. For example, if a patient is diagnosed with a critical or terminal illness, a personal visit or phone call is the right way to go. Also, if there are time-sensitive test results, phone calls work better—an e-mail might get lost in the shuffle.

Overall, Kline is a fan of the EMR. She feels it has made life easier for her patients, and for her. But then, not all hospitals have worked out the bugs the way Cleveland Clinic has over the years.

Kline advises other clinicians to hang in there with it. “If you can be patient and embrace the learning curve,” she says, “this has the potential to add efficiency to your day.”        

Michele Kline, MSN, CNP, has a somewhat familiar story: As a family nurse practitioner at the Cleveland Clinic, she sees a lot of “snowbirds”—retired people who split their time between Ohio and Florida. Since they have two residences, these patients also get their health care in two different states.

There was a time when that situation was fraught with the potential for health issues to fall through the cracks, due to a lack of communication among health care providers. Thanks to electronic medical records (EMRs), Kline says she doesn’t miss a beat.

For example, when one of her patients underwent a heart scan while in Florida, Kline simply sent an e-mail to her counterpart there. With the click of a button, she was able to check the results. When her patient returned to Cleveland for the summer, they picked up where they left off, with no gaps in care.

Though the market for EMRs has grown steadily, many clinicians have been reluctant to adopt the necessary systems and procedures. But as major players launch patient-focused programs—the Cleveland Clinic helped Google Health test its own application, and Microsoft and WebMD are among other companies getting in on the action—health care providers may find themselves scrambling to meet demand.

Concerns About Privacy
The growing trend toward EMRs, or the personal health records that Google has launched, has sparked debate among patients and clinicians. Some tout the benefits of EMRs, such as improved coordination of care and reduced medical errors, while others criticize them as creating more hassles for health care providers. Critics also worry about privacy breaches, since services like Google Health are not subject to the protection provided by HIPAA (although companies have developed their own privacy guidelines, which are similar to the federal regulations).

In an editorial recently published in the New England Journal of Medicine (2008;358[16]:1656-1658), two Massachusetts physicians, Pamela Hartzband, MD, and Jerome Groopman, MD, warned health care workers about the pitfalls of electronic records. Hartzband, an endocrinologist at Beth Israel Deaconess Medical Center in Boston, worries that clinicians might miss some important diagnostic clues if they no longer take a patient’s medical history by hand, with pen and paper.

“Talking to the patient independently may offer some new clues and symptoms,” Groopman explains. “But everybody is working under pressure, so they just copy and paste previous information without taking their own history.”

He also worries that placing a computer squarely between the provider and the patient will rob the health care setting of a valuable personal connection. “Patients feel their doctors are looking at the computer screen instead of actually talking with them,” says Groopman, a hematologist-oncologist at Beth Israel Deaconess.

Groopman also is unhappy with the number of computerized forms he is required to fill out for malpractice and insurance reasons—things that have very little to do with actually helping a patient feel better. Since his institution switched to EMRs, he says, he must stay late into the night doing extra paperwork.

Kline, 48, who has used EMRs during her entire 11-year career as a nurse practitioner, disagrees with Groopman’s assertion that computerized records slow down clinicians and create more work for them.

There is a learning curve, she says. But once you learn how to integrate an EMR system into your practice, it can make you much more efficient, Kline contends. Instead of spending the end of her day playing phone tag and fielding last-minute requests from patients, she calmly responds to their e-mails. In the end, using e-mail to communicate takes less time for both the clinician and the patient, Kline says.

Getting Patients Involved
Whether clinicians like it or not, experts say this trend is taking off, and it’s probably not going to disappear. The trick, according to C. Martin Harris, MD, Chief Information Officer at Cleveland Clinic, is to get a system that really works—for both patients and clinicians. In Cleveland, they use MyChart®, by Epic Systems Corporation. The hospital now has a total of 2.4 million patients using MyChart for everything from scheduling appointments and requesting prescription refills to receiving reminders about annual tests, such as mammograms.

At Cleveland Clinic, each exam room has a desktop computer for providers to use. Harris says the computers aren’t really barriers to care, because his staff has been specifically trained to avoid turning to the machine first. They still look the patient in the eye and make personal contact while doing a medical history, he explains. They just enter the data discreetly at another time, perhaps while the patient is changing into a gown or settling on the exam table.

Kline takes it a step further and actually tries to get her patients involved with using the computer. For example, she might turn the screen sideways so both she and the patients can look at it. She’ll show them a graph of their blood pressure or cholesterol before she discusses a change in medication with them. In one instance, a patient had a question about whether a certain blood pressure drug would be safe to take during pregnancy.

“I didn’t know the answer,” Kline admits. “So we turned to the computer and looked it up together.” That way, the patient was involved in her own health care decisions, and she didn’t have to wait until the next visit to get an answer.

Fine-Tuning the System
Kline says she uses the Cleveland Clinic’s MyChart system only with patients who tell her they are active computer users and check their e-mail every day. Kline relates that her group of “active computer users” includes patients in their 80s as well as those in their 20s. Senior citizens are some of the biggest fans of EMRs, she adds.

Besides knowing which patients might be comfortable with electronic records, Kline keeps tabs on whether her patients are receiving the information they need from the system. If she notices a patient’s MyChart data are not being viewed, she will print out the relevant pages and send them to the patient via “snail mail.” As a precaution, if she is sending lab results to a patient, Kline will request an automatic reply, which tells her the person received the information. If she doesn’t get a reply, she will personally follow up with a phone call.

Of course, there are certain times when e-mail communication is not appropriate, Kline says, and clinicians have to use their own discretion and common sense. For example, if a patient is diagnosed with a critical or terminal illness, a personal visit or phone call is the right way to go. Also, if there are time-sensitive test results, phone calls work better—an e-mail might get lost in the shuffle.

Overall, Kline is a fan of the EMR. She feels it has made life easier for her patients, and for her. But then, not all hospitals have worked out the bugs the way Cleveland Clinic has over the years.

Kline advises other clinicians to hang in there with it. “If you can be patient and embrace the learning curve,” she says, “this has the potential to add efficiency to your day.”        

Ever since direct-to-consumer (DTC) drug ads started airing on television, advanced practice nurses and physician assistants have been trading stories about confused patients.

Mary Jo Goolsby, EdD, MSN, NP-C, Director of Research and Education for the American Academy of Nurse Practitioners (AANP), recalls, with chagrin, the handful of patients who walked into her Florida primary care practice and asked for a referral to a physician. Despite the fact that Goolsby had been diagnosing their ailments and legally prescribing medication for them for years, they had seen an ad that said “only your doctor can prescribe.” And so, they wanted to switch their care to a physician.

But what might have started out as mildly exasperating has grown troublesome: A new study by the American College of Clinicians (ACC) shows PAs and NPs are fielding similar questions regarding their ability to prescribe from about one-third of their patients.

This problem, which AANP President Mona Counts, PhD, CRNP, FNAP, FAANP, describes as “a most troubling issue,” has been around for more than a decade. But it’s one that NPs and PAs are getting increasingly tired of dealing with. As the number of ads increases—a report by the American Academy of Physician Assistants (AAPA) shows pharmaceutical companies increased their spending on DTC television ads from $791 million in 1996 to $3 billion in 2001—clinicians are starting to take increasingly aggressive action to make the language in the ads more “provider neutral.”

Taking Action
The recent survey by the ACC indicates that nearly half of PAs and NPs are starting to rebel: They are actually boycotting drugs whose ads use the “only your doctor” language. To be specific, 41% of those who responded to the survey said they would choose to prescribe a similar drug that does not have the “offensive” DTC wording if such an alternative exists.

“It demonstrates that people are starting to express their dismay with their prescription pad,” says ACC President-Elect Elayne DeSimone, PhD, PA, NPc, FAANP.

Not all efforts at change are so extreme (officials from the AAPA specifically stated that they do not condone the boycotting of certain drugs). Leaders from both AANP and ACC are actively submitting petitions to pharmaceutical companies; AANP alone has gathered more than 12,000 signatures. Both groups, and the AAPA as well, have also been meeting regularly with pharmaceutical companies about this issue. Many individual clinicians also raise their concerns about DTC language on a daily basis when drug reps stop by with samples.

And progress is being made, even if it’s not as quickly as advocates would like. For example, Sanofi-Aventis has already agreed to use provider-neutral terms in their new ads for Lunesta^® CR. After meeting with NPs and PAs last fall, GlaxoSmithKline now alternates between “only your doctor” and “only your health care provider” when the company airs television ads for Avodart^®, a popular prostate drug. Reportedly, Pfizer executives are considering using health care provider instead of doctor in some of their newer DTC ads. (Representatives from these companies were not available for comment.)

Why the Fuss?
DeSimone explains why clinicians from her group felt strongly enough to pick this battle. Put simply, she says, advertisements that say “only your doctor can prescribe” are insulting to the 200,000 PAs and NPs who are out there, actively caring for patients and writing, on average, more than 50 prescriptions each per week.

Clinicians who sought an active leadership role in this area argue there’s a lot at stake for NPs and PAs, both professionally and financially. They contend they have spent years fighting for the right to prescribe in their home states. And they have spent even more time trying to educate consumers about their key role in the health care marketplace. When those physician-centric ads come on, they threaten to undo all of that progress.

“To say, ‘only your doctor can diagnose’ and ‘only your doctor can prescribe,’ that’s a lie,” says ACC President Bob Blumm, RPA-C. “It’s false advertising.”

That’s How It’s Always Been
Despite all of this awareness and activity, why do drug companies still persist in saying “only your doctor can prescribe”? Some of the companies told ACC co-founder and PA Dave Mittman they thought this phrasing was required by the FDA. (It’s not.) Others felt it was obvious that PAs and NPs were naturally included under the term doctor because so many work collaboratively with a physician. (In a related story, the American Medical Association is actively pursuing this issue, trying to limit the use of doctor to MDs, DOs, and podiatrists.)

Pharmaceutical company consultant Carla Duryee, who is based in North Carolina, offers perspective on why this dilemma continues to exist. In her opinion, it’s a financial and bureaucratic issue. The companies started out using doctor. To change the terms, they have to get approval from the FDA (a long process), and it would cost a lot to change all of the ad materials. Duryee feels upbeat, however. She believes the industry will eventually change the language.

Positive Change
PA and NP groups say their ultimate goal is to persuade all of the pharmaceutical companies to adopt provider-neutral terms, such as provider, health care professional, or prescriber, across the board in all of their advertising materials.

That is a fine goal, Goolsby says. But it will require finesse and patience. “We have a lot of partners in the pharmaceutical industry, and we need to keep working with them,” she relates. “We don’t expect things are going to change overnight, so we keep at it.”

Change will come, Duryee predicts, and it will be good for NPs and PAs. “The positive impact to PAs and NPs would be, I believe, better relationships with the pharma industry, solidifying their place in the medical community, and a positive perception of their profession with patients,” she adds.  

Ever since direct-to-consumer (DTC) drug ads started airing on television, advanced practice nurses and physician assistants have been trading stories about confused patients.

Mary Jo Goolsby, EdD, MSN, NP-C, Director of Research and Education for the American Academy of Nurse Practitioners (AANP), recalls, with chagrin, the handful of patients who walked into her Florida primary care practice and asked for a referral to a physician. Despite the fact that Goolsby had been diagnosing their ailments and legally prescribing medication for them for years, they had seen an ad that said “only your doctor can prescribe.” And so, they wanted to switch their care to a physician.

But what might have started out as mildly exasperating has grown troublesome: A new study by the American College of Clinicians (ACC) shows PAs and NPs are fielding similar questions regarding their ability to prescribe from about one-third of their patients.

This problem, which AANP President Mona Counts, PhD, CRNP, FNAP, FAANP, describes as “a most troubling issue,” has been around for more than a decade. But it’s one that NPs and PAs are getting increasingly tired of dealing with. As the number of ads increases—a report by the American Academy of Physician Assistants (AAPA) shows pharmaceutical companies increased their spending on DTC television ads from $791 million in 1996 to $3 billion in 2001—clinicians are starting to take increasingly aggressive action to make the language in the ads more “provider neutral.”

Taking Action
The recent survey by the ACC indicates that nearly half of PAs and NPs are starting to rebel: They are actually boycotting drugs whose ads use the “only your doctor” language. To be specific, 41% of those who responded to the survey said they would choose to prescribe a similar drug that does not have the “offensive” DTC wording if such an alternative exists.

“It demonstrates that people are starting to express their dismay with their prescription pad,” says ACC President-Elect Elayne DeSimone, PhD, PA, NPc, FAANP.

Not all efforts at change are so extreme (officials from the AAPA specifically stated that they do not condone the boycotting of certain drugs). Leaders from both AANP and ACC are actively submitting petitions to pharmaceutical companies; AANP alone has gathered more than 12,000 signatures. Both groups, and the AAPA as well, have also been meeting regularly with pharmaceutical companies about this issue. Many individual clinicians also raise their concerns about DTC language on a daily basis when drug reps stop by with samples.

And progress is being made, even if it’s not as quickly as advocates would like. For example, Sanofi-Aventis has already agreed to use provider-neutral terms in their new ads for Lunesta^® CR. After meeting with NPs and PAs last fall, GlaxoSmithKline now alternates between “only your doctor” and “only your health care provider” when the company airs television ads for Avodart^®, a popular prostate drug. Reportedly, Pfizer executives are considering using health care provider instead of doctor in some of their newer DTC ads. (Representatives from these companies were not available for comment.)

Why the Fuss?
DeSimone explains why clinicians from her group felt strongly enough to pick this battle. Put simply, she says, advertisements that say “only your doctor can prescribe” are insulting to the 200,000 PAs and NPs who are out there, actively caring for patients and writing, on average, more than 50 prescriptions each per week.

Clinicians who sought an active leadership role in this area argue there’s a lot at stake for NPs and PAs, both professionally and financially. They contend they have spent years fighting for the right to prescribe in their home states. And they have spent even more time trying to educate consumers about their key role in the health care marketplace. When those physician-centric ads come on, they threaten to undo all of that progress.

“To say, ‘only your doctor can diagnose’ and ‘only your doctor can prescribe,’ that’s a lie,” says ACC President Bob Blumm, RPA-C. “It’s false advertising.”

That’s How It’s Always Been
Despite all of this awareness and activity, why do drug companies still persist in saying “only your doctor can prescribe”? Some of the companies told ACC co-founder and PA Dave Mittman they thought this phrasing was required by the FDA. (It’s not.) Others felt it was obvious that PAs and NPs were naturally included under the term doctor because so many work collaboratively with a physician. (In a related story, the American Medical Association is actively pursuing this issue, trying to limit the use of doctor to MDs, DOs, and podiatrists.)

Pharmaceutical company consultant Carla Duryee, who is based in North Carolina, offers perspective on why this dilemma continues to exist. In her opinion, it’s a financial and bureaucratic issue. The companies started out using doctor. To change the terms, they have to get approval from the FDA (a long process), and it would cost a lot to change all of the ad materials. Duryee feels upbeat, however. She believes the industry will eventually change the language.

Positive Change
PA and NP groups say their ultimate goal is to persuade all of the pharmaceutical companies to adopt provider-neutral terms, such as provider, health care professional, or prescriber, across the board in all of their advertising materials.

That is a fine goal, Goolsby says. But it will require finesse and patience. “We have a lot of partners in the pharmaceutical industry, and we need to keep working with them,” she relates. “We don’t expect things are going to change overnight, so we keep at it.”

Change will come, Duryee predicts, and it will be good for NPs and PAs. “The positive impact to PAs and NPs would be, I believe, better relationships with the pharma industry, solidifying their place in the medical community, and a positive perception of their profession with patients,” she adds.  

Ever since direct-to-consumer (DTC) drug ads started airing on television, advanced practice nurses and physician assistants have been trading stories about confused patients.

Mary Jo Goolsby, EdD, MSN, NP-C, Director of Research and Education for the American Academy of Nurse Practitioners (AANP), recalls, with chagrin, the handful of patients who walked into her Florida primary care practice and asked for a referral to a physician. Despite the fact that Goolsby had been diagnosing their ailments and legally prescribing medication for them for years, they had seen an ad that said “only your doctor can prescribe.” And so, they wanted to switch their care to a physician.

But what might have started out as mildly exasperating has grown troublesome: A new study by the American College of Clinicians (ACC) shows PAs and NPs are fielding similar questions regarding their ability to prescribe from about one-third of their patients.

This problem, which AANP President Mona Counts, PhD, CRNP, FNAP, FAANP, describes as “a most troubling issue,” has been around for more than a decade. But it’s one that NPs and PAs are getting increasingly tired of dealing with. As the number of ads increases—a report by the American Academy of Physician Assistants (AAPA) shows pharmaceutical companies increased their spending on DTC television ads from $791 million in 1996 to $3 billion in 2001—clinicians are starting to take increasingly aggressive action to make the language in the ads more “provider neutral.”

Taking Action
The recent survey by the ACC indicates that nearly half of PAs and NPs are starting to rebel: They are actually boycotting drugs whose ads use the “only your doctor” language. To be specific, 41% of those who responded to the survey said they would choose to prescribe a similar drug that does not have the “offensive” DTC wording if such an alternative exists.

“It demonstrates that people are starting to express their dismay with their prescription pad,” says ACC President-Elect Elayne DeSimone, PhD, PA, NPc, FAANP.

Not all efforts at change are so extreme (officials from the AAPA specifically stated that they do not condone the boycotting of certain drugs). Leaders from both AANP and ACC are actively submitting petitions to pharmaceutical companies; AANP alone has gathered more than 12,000 signatures. Both groups, and the AAPA as well, have also been meeting regularly with pharmaceutical companies about this issue. Many individual clinicians also raise their concerns about DTC language on a daily basis when drug reps stop by with samples.

And progress is being made, even if it’s not as quickly as advocates would like. For example, Sanofi-Aventis has already agreed to use provider-neutral terms in their new ads for Lunesta^® CR. After meeting with NPs and PAs last fall, GlaxoSmithKline now alternates between “only your doctor” and “only your health care provider” when the company airs television ads for Avodart^®, a popular prostate drug. Reportedly, Pfizer executives are considering using health care provider instead of doctor in some of their newer DTC ads. (Representatives from these companies were not available for comment.)

Why the Fuss?
DeSimone explains why clinicians from her group felt strongly enough to pick this battle. Put simply, she says, advertisements that say “only your doctor can prescribe” are insulting to the 200,000 PAs and NPs who are out there, actively caring for patients and writing, on average, more than 50 prescriptions each per week.

Clinicians who sought an active leadership role in this area argue there’s a lot at stake for NPs and PAs, both professionally and financially. They contend they have spent years fighting for the right to prescribe in their home states. And they have spent even more time trying to educate consumers about their key role in the health care marketplace. When those physician-centric ads come on, they threaten to undo all of that progress.

“To say, ‘only your doctor can diagnose’ and ‘only your doctor can prescribe,’ that’s a lie,” says ACC President Bob Blumm, RPA-C. “It’s false advertising.”

That’s How It’s Always Been
Despite all of this awareness and activity, why do drug companies still persist in saying “only your doctor can prescribe”? Some of the companies told ACC co-founder and PA Dave Mittman they thought this phrasing was required by the FDA. (It’s not.) Others felt it was obvious that PAs and NPs were naturally included under the term doctor because so many work collaboratively with a physician. (In a related story, the American Medical Association is actively pursuing this issue, trying to limit the use of doctor to MDs, DOs, and podiatrists.)

Pharmaceutical company consultant Carla Duryee, who is based in North Carolina, offers perspective on why this dilemma continues to exist. In her opinion, it’s a financial and bureaucratic issue. The companies started out using doctor. To change the terms, they have to get approval from the FDA (a long process), and it would cost a lot to change all of the ad materials. Duryee feels upbeat, however. She believes the industry will eventually change the language.

Positive Change
PA and NP groups say their ultimate goal is to persuade all of the pharmaceutical companies to adopt provider-neutral terms, such as provider, health care professional, or prescriber, across the board in all of their advertising materials.

That is a fine goal, Goolsby says. But it will require finesse and patience. “We have a lot of partners in the pharmaceutical industry, and we need to keep working with them,” she relates. “We don’t expect things are going to change overnight, so we keep at it.”

Change will come, Duryee predicts, and it will be good for NPs and PAs. “The positive impact to PAs and NPs would be, I believe, better relationships with the pharma industry, solidifying their place in the medical community, and a positive perception of their profession with patients,” she adds.  

As a lieutenant colonel in the US Army, Steve Gallegos spent his days coordinating medical care for soldiers, officers, and retired military personnel who needed it while living overseas. By doing this job day in and day out, Gallegos began to realize the United States isn’t the only country that has top-quality health care. In some cases, the services and facilities were even better—and the out-of-pocket cost was about half.

After retiring from the service, Gallegos parlayed his in-ter-national medical expertise into a medical-tourism business, the San Antonio, Texas–based Medcentrek (www.medcentrek.com). Today, he helps private clients find good-quality health care in places like Costa Rica and Monterrey, Mexico. Gallegos estimates 70% of his clients are interested in cosmetic surgery, while 30% need dental help.

As founder of Medcentrek, Gallegos has tapped into an incredibly fast-growing market: medical tourism. According to Renee-Marie Stephano, founder of the Medical Tourism Association, a nonprofit organization that advocates for high standards and best practices in this relatively new corner of the health care market, “This is a $20 billion industry.”

Health Care Beyond the US
Countries like Thailand, Costa Rica, India, and South Africa are actively promoting medical tourism. Another company, called Fly2Doc, is now also marketing medical facilities in Spain and Portugal. Industry analysts estimate this market is growing at a rate of 25% per year.

Why the fantastic growth? Because in many European countries and Canada, national health care systems have waiting lists for nonemergency surgery, such as cosmetic and dental work. “In the UK, they have these long waiting lists, and also there are problems with deadly infections in the hospitals,” says Cristina Madeira, founder of Fly2Doc, based in Lisbon. “People need to go abroad because they don’t feel safe.”

Madeira points to an analysis by the World Health Organization (WHO) of health care in different countries (available at www.photius.com/rankings/healthranks.html). Spain and Portugal, it turns out, rank higher than the US (seventh, 12th, and 37th, respectively). France received the highest rating from WHO. “We’re among the best 15 in the world,” Madeira says. “That’s why we felt very secure about starting this business.”

Medical tourism experts claim the key to the industry’s future success is being able to connect patients with high-quality, fully accredited hospitals. Many foreign hospitals are seeking the international equivalent of Joint Commission accreditation here in the US. “They are marketing themselves as international centers of excellence,” Stephano explains. By choosing surgeons and hospitals that have been approved by Stephano’s organization (www.medicaltravelauthority.com), patients can be sure they will have a safe experience abroad.

Through his military experience and international contacts, Gallegos is able to offer clients some top-notch surgeons and hospitals. The hospital in Monterrey, Mexico, for example, is a 50-minute flight from the US. It is owned by a Houston-based health care management company, and the administrator is an American who did his training in Boston. The only thing that is different from an American hospital is the nurse coverage, which is better.

“People are amazed at the quality of care in these hospitals,” Gallegos says. “The nurse-patient ratio just blasts the hospitals in the US out of the water.”

Oh, there is one other difference: the price tag.

All-Inclusive Deals, One Low Price
In the US, the health insurance crisis is driving interest in medical tourism. An estimated 50 million Americans don’t have any insurance. Those who do have some sort of coverage find that the out-of-pocket portion of surgery costs is becoming sky-high. An additional 150 million Americans are underinsured; they may have catastrophic coverage, but if they need a knee replacement, they’re out of luck. Even fewer Americans have decent dental plans.

In many cases, medical tourists discover they can afford to pay for the surgery, plus a flight to and a hotel in an exotic locale, for the same price of doing the procedure at home. So if you have to pay out of pocket anyway, for something as unpleasant as a root canal, why not sweeten the deal with a fun trip?

The New York Times recently reported that health travelers are saving 30% to 80% on the cost of their medical and dental bills by going abroad. Stephano estimates the cost is as much as 90% less in certain places, such as India.

Gallegos explains that the cost of health care is so much lower in other countries because “they are not run amok with lawsuits.” In Mexico, for example, the government charges a $5,000 fee just to initiate a lawsuit. So that keeps down the number of frivolous lawsuits, he says. Also, nurses and practitioners in less-developed countries are not paid as much, he adds. Prescription drug costs are also much lower.

Meanwhile, many cosmetic procedures, especially those in the dental realm, are becoming more popular and accessible. Tooth whitening and veneers—once only for movie stars—are now for everyone. For that reason, HealthCare Tourism International, a nonprofit research group, estimates the number of medical travel agents will double in the near future. These specialty travel professionals bank their business on the stellar reputation of the medical providers and hospitals they suggest to clients. The travel agent can also find a luxury hotel, soothing beach, or golf course for a companion or spouse to enjoy while the patient is recuperating.

Gallegos believes many of his clients have a better recovery because they recuperate at a seaside hotel with skilled nursing staff on site (instead of relying on an untrained spouse or relative at home). “It’s a resort atmosphere,” he says. “People recover quicker because they are more relaxed.” It’s also more private for clients who may not want friends and neighbors to know they have had a facelift or breast implants.

Once word of mouth spreads, and the industry creates a successful track record with global-minded clients, Gallegos predicts US health insurance companies will start to buy into this trend, because the cost savings will become obvious.

Wish You Were There?
For clinicians here in the US, the medical tourism boom could offer new career opportunities and new chances to travel the world. Many medical travel agents, for example, may have a head for business, but they often have no medical background. They may need a physician assistant or nurse practitioner to serve as a consultant as they wade through health records and regulations in other countries.

Patients who have a relationship with a particular provider may also want to pay that clinician to travel with them, just to oversee all the details during a medical tourism trip. In some cases, PAs might be able to perform the surgery themselves, at a much lower rate, in a foreign hospital—especially if that facility is affiliated with an American hospital.

“We’re seeing a lot of medical-global cross-fertilization happening,” Gallegos says. “There’s going to be a market for clinicians to travel and perform procedures for their clients.”

As a lieutenant colonel in the US Army, Steve Gallegos spent his days coordinating medical care for soldiers, officers, and retired military personnel who needed it while living overseas. By doing this job day in and day out, Gallegos began to realize the United States isn’t the only country that has top-quality health care. In some cases, the services and facilities were even better—and the out-of-pocket cost was about half.

After retiring from the service, Gallegos parlayed his in-ter-national medical expertise into a medical-tourism business, the San Antonio, Texas–based Medcentrek (www.medcentrek.com). Today, he helps private clients find good-quality health care in places like Costa Rica and Monterrey, Mexico. Gallegos estimates 70% of his clients are interested in cosmetic surgery, while 30% need dental help.

As founder of Medcentrek, Gallegos has tapped into an incredibly fast-growing market: medical tourism. According to Renee-Marie Stephano, founder of the Medical Tourism Association, a nonprofit organization that advocates for high standards and best practices in this relatively new corner of the health care market, “This is a $20 billion industry.”

Health Care Beyond the US
Countries like Thailand, Costa Rica, India, and South Africa are actively promoting medical tourism. Another company, called Fly2Doc, is now also marketing medical facilities in Spain and Portugal. Industry analysts estimate this market is growing at a rate of 25% per year.

Why the fantastic growth? Because in many European countries and Canada, national health care systems have waiting lists for nonemergency surgery, such as cosmetic and dental work. “In the UK, they have these long waiting lists, and also there are problems with deadly infections in the hospitals,” says Cristina Madeira, founder of Fly2Doc, based in Lisbon. “People need to go abroad because they don’t feel safe.”

Madeira points to an analysis by the World Health Organization (WHO) of health care in different countries (available at www.photius.com/rankings/healthranks.html). Spain and Portugal, it turns out, rank higher than the US (seventh, 12th, and 37th, respectively). France received the highest rating from WHO. “We’re among the best 15 in the world,” Madeira says. “That’s why we felt very secure about starting this business.”

Medical tourism experts claim the key to the industry’s future success is being able to connect patients with high-quality, fully accredited hospitals. Many foreign hospitals are seeking the international equivalent of Joint Commission accreditation here in the US. “They are marketing themselves as international centers of excellence,” Stephano explains. By choosing surgeons and hospitals that have been approved by Stephano’s organization (www.medicaltravelauthority.com), patients can be sure they will have a safe experience abroad.

Through his military experience and international contacts, Gallegos is able to offer clients some top-notch surgeons and hospitals. The hospital in Monterrey, Mexico, for example, is a 50-minute flight from the US. It is owned by a Houston-based health care management company, and the administrator is an American who did his training in Boston. The only thing that is different from an American hospital is the nurse coverage, which is better.

“People are amazed at the quality of care in these hospitals,” Gallegos says. “The nurse-patient ratio just blasts the hospitals in the US out of the water.”

Oh, there is one other difference: the price tag.

All-Inclusive Deals, One Low Price
In the US, the health insurance crisis is driving interest in medical tourism. An estimated 50 million Americans don’t have any insurance. Those who do have some sort of coverage find that the out-of-pocket portion of surgery costs is becoming sky-high. An additional 150 million Americans are underinsured; they may have catastrophic coverage, but if they need a knee replacement, they’re out of luck. Even fewer Americans have decent dental plans.

In many cases, medical tourists discover they can afford to pay for the surgery, plus a flight to and a hotel in an exotic locale, for the same price of doing the procedure at home. So if you have to pay out of pocket anyway, for something as unpleasant as a root canal, why not sweeten the deal with a fun trip?

The New York Times recently reported that health travelers are saving 30% to 80% on the cost of their medical and dental bills by going abroad. Stephano estimates the cost is as much as 90% less in certain places, such as India.

Gallegos explains that the cost of health care is so much lower in other countries because “they are not run amok with lawsuits.” In Mexico, for example, the government charges a $5,000 fee just to initiate a lawsuit. So that keeps down the number of frivolous lawsuits, he says. Also, nurses and practitioners in less-developed countries are not paid as much, he adds. Prescription drug costs are also much lower.

Meanwhile, many cosmetic procedures, especially those in the dental realm, are becoming more popular and accessible. Tooth whitening and veneers—once only for movie stars—are now for everyone. For that reason, HealthCare Tourism International, a nonprofit research group, estimates the number of medical travel agents will double in the near future. These specialty travel professionals bank their business on the stellar reputation of the medical providers and hospitals they suggest to clients. The travel agent can also find a luxury hotel, soothing beach, or golf course for a companion or spouse to enjoy while the patient is recuperating.

Gallegos believes many of his clients have a better recovery because they recuperate at a seaside hotel with skilled nursing staff on site (instead of relying on an untrained spouse or relative at home). “It’s a resort atmosphere,” he says. “People recover quicker because they are more relaxed.” It’s also more private for clients who may not want friends and neighbors to know they have had a facelift or breast implants.

Once word of mouth spreads, and the industry creates a successful track record with global-minded clients, Gallegos predicts US health insurance companies will start to buy into this trend, because the cost savings will become obvious.

Wish You Were There?
For clinicians here in the US, the medical tourism boom could offer new career opportunities and new chances to travel the world. Many medical travel agents, for example, may have a head for business, but they often have no medical background. They may need a physician assistant or nurse practitioner to serve as a consultant as they wade through health records and regulations in other countries.

Patients who have a relationship with a particular provider may also want to pay that clinician to travel with them, just to oversee all the details during a medical tourism trip. In some cases, PAs might be able to perform the surgery themselves, at a much lower rate, in a foreign hospital—especially if that facility is affiliated with an American hospital.

“We’re seeing a lot of medical-global cross-fertilization happening,” Gallegos says. “There’s going to be a market for clinicians to travel and perform procedures for their clients.”

As a lieutenant colonel in the US Army, Steve Gallegos spent his days coordinating medical care for soldiers, officers, and retired military personnel who needed it while living overseas. By doing this job day in and day out, Gallegos began to realize the United States isn’t the only country that has top-quality health care. In some cases, the services and facilities were even better—and the out-of-pocket cost was about half.

After retiring from the service, Gallegos parlayed his in-ter-national medical expertise into a medical-tourism business, the San Antonio, Texas–based Medcentrek (www.medcentrek.com). Today, he helps private clients find good-quality health care in places like Costa Rica and Monterrey, Mexico. Gallegos estimates 70% of his clients are interested in cosmetic surgery, while 30% need dental help.

As founder of Medcentrek, Gallegos has tapped into an incredibly fast-growing market: medical tourism. According to Renee-Marie Stephano, founder of the Medical Tourism Association, a nonprofit organization that advocates for high standards and best practices in this relatively new corner of the health care market, “This is a $20 billion industry.”

Health Care Beyond the US
Countries like Thailand, Costa Rica, India, and South Africa are actively promoting medical tourism. Another company, called Fly2Doc, is now also marketing medical facilities in Spain and Portugal. Industry analysts estimate this market is growing at a rate of 25% per year.

Why the fantastic growth? Because in many European countries and Canada, national health care systems have waiting lists for nonemergency surgery, such as cosmetic and dental work. “In the UK, they have these long waiting lists, and also there are problems with deadly infections in the hospitals,” says Cristina Madeira, founder of Fly2Doc, based in Lisbon. “People need to go abroad because they don’t feel safe.”

Madeira points to an analysis by the World Health Organization (WHO) of health care in different countries (available at www.photius.com/rankings/healthranks.html). Spain and Portugal, it turns out, rank higher than the US (seventh, 12th, and 37th, respectively). France received the highest rating from WHO. “We’re among the best 15 in the world,” Madeira says. “That’s why we felt very secure about starting this business.”

Medical tourism experts claim the key to the industry’s future success is being able to connect patients with high-quality, fully accredited hospitals. Many foreign hospitals are seeking the international equivalent of Joint Commission accreditation here in the US. “They are marketing themselves as international centers of excellence,” Stephano explains. By choosing surgeons and hospitals that have been approved by Stephano’s organization (www.medicaltravelauthority.com), patients can be sure they will have a safe experience abroad.

Through his military experience and international contacts, Gallegos is able to offer clients some top-notch surgeons and hospitals. The hospital in Monterrey, Mexico, for example, is a 50-minute flight from the US. It is owned by a Houston-based health care management company, and the administrator is an American who did his training in Boston. The only thing that is different from an American hospital is the nurse coverage, which is better.

“People are amazed at the quality of care in these hospitals,” Gallegos says. “The nurse-patient ratio just blasts the hospitals in the US out of the water.”

Oh, there is one other difference: the price tag.

All-Inclusive Deals, One Low Price
In the US, the health insurance crisis is driving interest in medical tourism. An estimated 50 million Americans don’t have any insurance. Those who do have some sort of coverage find that the out-of-pocket portion of surgery costs is becoming sky-high. An additional 150 million Americans are underinsured; they may have catastrophic coverage, but if they need a knee replacement, they’re out of luck. Even fewer Americans have decent dental plans.

In many cases, medical tourists discover they can afford to pay for the surgery, plus a flight to and a hotel in an exotic locale, for the same price of doing the procedure at home. So if you have to pay out of pocket anyway, for something as unpleasant as a root canal, why not sweeten the deal with a fun trip?

The New York Times recently reported that health travelers are saving 30% to 80% on the cost of their medical and dental bills by going abroad. Stephano estimates the cost is as much as 90% less in certain places, such as India.

Gallegos explains that the cost of health care is so much lower in other countries because “they are not run amok with lawsuits.” In Mexico, for example, the government charges a $5,000 fee just to initiate a lawsuit. So that keeps down the number of frivolous lawsuits, he says. Also, nurses and practitioners in less-developed countries are not paid as much, he adds. Prescription drug costs are also much lower.

Meanwhile, many cosmetic procedures, especially those in the dental realm, are becoming more popular and accessible. Tooth whitening and veneers—once only for movie stars—are now for everyone. For that reason, HealthCare Tourism International, a nonprofit research group, estimates the number of medical travel agents will double in the near future. These specialty travel professionals bank their business on the stellar reputation of the medical providers and hospitals they suggest to clients. The travel agent can also find a luxury hotel, soothing beach, or golf course for a companion or spouse to enjoy while the patient is recuperating.

Gallegos believes many of his clients have a better recovery because they recuperate at a seaside hotel with skilled nursing staff on site (instead of relying on an untrained spouse or relative at home). “It’s a resort atmosphere,” he says. “People recover quicker because they are more relaxed.” It’s also more private for clients who may not want friends and neighbors to know they have had a facelift or breast implants.

Once word of mouth spreads, and the industry creates a successful track record with global-minded clients, Gallegos predicts US health insurance companies will start to buy into this trend, because the cost savings will become obvious.

Wish You Were There?
For clinicians here in the US, the medical tourism boom could offer new career opportunities and new chances to travel the world. Many medical travel agents, for example, may have a head for business, but they often have no medical background. They may need a physician assistant or nurse practitioner to serve as a consultant as they wade through health records and regulations in other countries.

Patients who have a relationship with a particular provider may also want to pay that clinician to travel with them, just to oversee all the details during a medical tourism trip. In some cases, PAs might be able to perform the surgery themselves, at a much lower rate, in a foreign hospital—especially if that facility is affiliated with an American hospital.

“We’re seeing a lot of medical-global cross-fertilization happening,” Gallegos says. “There’s going to be a market for clinicians to travel and perform procedures for their clients.”

The recognition that NPs and PAs—so-called (if reluctantly) midlevel providers—are enormously beneficial to the functioning of the US health care system has led to the introduction of similar practitioners in specialty areas such as dentistry, EMS, and radiology. Unlike PAs and NPs, with their broad areas of expertise and primary care focus, this new generation of health care professionals tends to have a more limited scope of practice.

What impact their presence may ultimately have on NPs and PAs is, for the moment, mostly hypothetical; resistance to these new professional categories has limited their use and acceptance in this country. But their positions within the health care team—and their struggles to practice and prosper—may remind PAs and NPs of their own professional journeys.

Dental Health Aide Therapists
Dental health aide therapists (DHATs) were introduced in Alaska in 2003 to meet a very specific need: dental care among Alaska Natives. This population experiences tooth decay at 2.5 times the national average, creating a substantial burden on both children and adults.

Further complicating matters, an estimated 85,000 people live in small villages (population 400 or below) in rural areas, according to the Alaska Native Tribal Health Consortium. Many cannot afford health or dental insurance and find that high travel costs prohibit them from seeking care in more developed, populous areas. (Sound familiar?)

So how can the dental health needs of this underserved population be met? Enter the DHAT, which was developed under the auspices of the Community Health Aide/Practitioner Program (CHAP). Since the 1960s, this federal program—a collaboration of the Indian Health Service with Alaska Native tribes—has brought more than 550 midlevel medical providers to work in small community clinics.

Taking its cue from more than 40 other countries in which DHATs or their equivalent are fairly common, CHAP conferred upon DHATs a rather broad therapeutic mandate. These practitioners are trained to do cleanings, fillings, and uncomplicated extractions, as well as to provide preventive services, under the general supervision of dentists who work at regional hospitals in the state.

Ironically, DHATs currently must complete their two-year education program through a New Zealand university, because there are no midlevel dental practitioner training programs in the US. While state licensure is not a requirement for DHATs, federal certification, continuing education, and biannual recertification are.

DHATs have been seen as an important solution to Alaska’s dental health problems and have earned praise from organizations involved in Native American health (as well as from former US Department of Health and Human Services Secretary Tommy Thompson).

But—cue the development that PAs and NPs may recognize from their own professional experiences—the American Dental Association (ADA) has been less than enthusiastic. In fact, the ADA and the Alaska Dental Society sued to abolish DHATs, insisting that their very existence violated state law regarding dental licensing. They were unsuccessful.

Despite this setback, opponents to the DHAT model persisted. Their lobbying efforts began to pay off in late February, when the reauthorization of the Indian Health Care Improvement Act—with amendments—passed the US Senate. (It is currently languishing in the US House of Representatives.)

If the act becomes law in its current form, the amendments would prevent DHATs from performing any oral or jaw surgeries and would allow extraction and pulpal therapy only in an emergency and only after consultation with a licensed dentist. The idea is that DHATs would not be allowed to engage in irreversible procedures—and while this would not entirely negate their purpose, it would certainly limit their utility.

Further keeping a lid on these midlevel practitioners, the Senate version of the bill would also prevent—at least for the time being—any expansion of the DHAT program to other states. But a similar concept is already in development in the lower 48 states.

Advanced Dental Hygiene Practitioners
Advanced dental hygiene practitioners (ADHPs) resemble DHATs both in their therapeutic role and in the necessity of slugging it out in the political arena just to be allowed to exist. The Minnesota legislature is the first state political body to consider bestowing official sanction upon the ADHP and has made itself a battleground in a drawn-out fight. The primary combatants are the Minnesota Dental Hygienists’ Association (MNDHA), which supports the new designation, and the Minnesota Dental Association, which (surprise!) opposes it.

According to Mary Beth Kensek, RDH, RF, President of the MNDHA, the idea for the ADHP originated from the American Dental Hygienists’ Association in response to the Surgeon General’s 2000 report that highlighted issues of access to dental care in the US. In other words, much like the situation in Alaska, a lot of people who need dental care are not getting it for a variety of reasons, and the midlevel practitioner has been seen as part of the solution to that problem.

In describing the new professional designation, Kensek was at pains to distinguish the ADHP from the traditional dental hygienist. “It’s a new level of practitioner, and so, at least in our state, it’s not [simply] expanding the role of the dental hygienist,” Kensek explained. “It’s creating a whole different level of practitioner—a midlevel practitioner.”

When asked whether she thought the ADHP was akin to an NP or a PA, Kensek said, “The specifics are different, but in a very broad sense, yes, it’s a fair comparison. They’re both midlevel positions—that’s a good way to put it.”

To be more specific, ADHPs will not be independent practitioners; like DHATs, they will work under general supervision in collaboration with a licensed dentist. ADHPs will be trained to the master’s level in a curriculum developed by MNDHA in collaboration with the Minnesota Safety Net Coalition. The program will be similar to that for dental hygienists but will include additional qualifications.

“In addition to being able to provide any of the preventive services that traditional hygienists do, we’re also looking at doing different types of therapeutic activities, like some extractions that aren’t very involved, in order to relieve patients’ discomfort,” Kensek elaborated, “doing pulpotomies, and doing minimal prep and restorative work.” Limited prescribing privileges, within well-defined parameters, would also be available to the ADHP.

At the moment, “We’re looking at doing a pilot study so that we can examine this concept a little bit more and establish that it’s safe and effective,” Kensek said. “That way we can alleviate some of the fear and show that there is a need for this practitioner.”

Advanced Practice Paramedic
It is ironic that while PAs were virtually unheard of in the United Kingdom until a few years ago, and NPs are still a relatively recent phenomenon there, midlevel practitioners of other kinds have been thriving. One is what the Brits call an emergency care practitioner (ECP; or paramedic practitioner) and what Americans call the advanced practice paramedic (APP)—or at least they would if such a thing existed.

In the UK, the ECP delivers “unscheduled care” with a defined set of available interventions and medications. For example, therapeutic scope includes defibrillation, intubation, and thoracostomy, while prescriptive authority is granted for drugs such as adrenaline, naloxone, heparin, and hydrocortisone. Perhaps the most significant privilege given the ECP is the ability to treat-and-release or treat-and-refer.

In the US, the APP was originally proposed in the first draft of the National EMS Scope of Practice Model (2005), a semiformal “constitution” for the world of emergency medicine. The proposal was met with considerable con-sternation when its intended audience realized that the introduction of the APP would mean an entirely new class of emergency practi-tioners.

The American Ambulance Association, for example, noted in their position paper in response to the draft, “We take exception to the creation of [the APP] as defined in the document. The reasons for the creation of such a certification level seem to be far-reaching and only vaguely connected.…

“Further, we believe the educational requirement necessary for a paramedic to advance to the APP certification would severely constrain a local medical community from implementing creative and innovative integrated delivery systems that allow for referral/transport to alternative health care facilities.”

The APP was not to be—at least then. Some emergency medicine leaders continue to express support for the concept itself or for the idea of treat-and-release/refer privileges.

This support may receive a boost from a pilot program conducted in Arizona earlier this year, in which a Mesa fire department replaced their EMS technician with a PA who could evaluate patients on the scene and determine whether they should be treated, transported to a hospital, or referred to their usual health care provider. The idea was to free up the EMS team for response to true emergencies—but it could point to a need for a practitioner like the APP.

Radiologist Assistant
How many practitioner designations does one specialty need? The radiologist assistant (RA)—first recognized by the American College of Radiology and the American Society of Radiologic Technologists in 2003—should not be confused with the radiology practitioner assistant (RPA), which was introduced in the 1990s as a way to address a shortage of radiologists in the armed forces.

The therapeutic scope of RAs depends on their level of education and training and which certifying body they are associated with. That said, RAs typically assist with patient management, radiology exams, and preliminary image evaluation—although image interpretation is not within their purview.

The RA may be the one to prepare patients for radiologic exams, obtain patient consent for the injection of diagnostic agents, address patient questions—in short, serve as a patient advocate. The RA might assist with invasive procedures or perform fluoroscopy for noninvasive procedures under the supervision of a radiologist.

RAs can also undertake certain peripheral venous diagnostic procedures and place feeding tubes in patients without complications. Once the examination has taken place, the RA may be involved in determining image quality and may also provide preliminary observations—but purely in the context of assisting the radiologist and not for presentation to the patient.

While a certain amount of controversy inevitably surrounds their emergence as distinct midlevel practitioners, RAs are currently recognized in 10 states, each with its own requirements for education and accreditation. RAs must obtain at least a bachelor’s degree, and master’s degrees are fairly common.

It should be noted that PAs frequently perform many of the tasks for which RAs are trained. PAs, of course, have a broader educational background than RAs and possess certain advantages in the breadth of their capabilities and privileges as health care practitioners. However, within the narrower scope of radiologic duties, the RA may be regarded as having more specific training than the PA. What impact this will have on PAs who practice in radiology remains to be seen.     

The recognition that NPs and PAs—so-called (if reluctantly) midlevel providers—are enormously beneficial to the functioning of the US health care system has led to the introduction of similar practitioners in specialty areas such as dentistry, EMS, and radiology. Unlike PAs and NPs, with their broad areas of expertise and primary care focus, this new generation of health care professionals tends to have a more limited scope of practice.

What impact their presence may ultimately have on NPs and PAs is, for the moment, mostly hypothetical; resistance to these new professional categories has limited their use and acceptance in this country. But their positions within the health care team—and their struggles to practice and prosper—may remind PAs and NPs of their own professional journeys.

Dental Health Aide Therapists
Dental health aide therapists (DHATs) were introduced in Alaska in 2003 to meet a very specific need: dental care among Alaska Natives. This population experiences tooth decay at 2.5 times the national average, creating a substantial burden on both children and adults.

Further complicating matters, an estimated 85,000 people live in small villages (population 400 or below) in rural areas, according to the Alaska Native Tribal Health Consortium. Many cannot afford health or dental insurance and find that high travel costs prohibit them from seeking care in more developed, populous areas. (Sound familiar?)

So how can the dental health needs of this underserved population be met? Enter the DHAT, which was developed under the auspices of the Community Health Aide/Practitioner Program (CHAP). Since the 1960s, this federal program—a collaboration of the Indian Health Service with Alaska Native tribes—has brought more than 550 midlevel medical providers to work in small community clinics.

Taking its cue from more than 40 other countries in which DHATs or their equivalent are fairly common, CHAP conferred upon DHATs a rather broad therapeutic mandate. These practitioners are trained to do cleanings, fillings, and uncomplicated extractions, as well as to provide preventive services, under the general supervision of dentists who work at regional hospitals in the state.

Ironically, DHATs currently must complete their two-year education program through a New Zealand university, because there are no midlevel dental practitioner training programs in the US. While state licensure is not a requirement for DHATs, federal certification, continuing education, and biannual recertification are.

DHATs have been seen as an important solution to Alaska’s dental health problems and have earned praise from organizations involved in Native American health (as well as from former US Department of Health and Human Services Secretary Tommy Thompson).

But—cue the development that PAs and NPs may recognize from their own professional experiences—the American Dental Association (ADA) has been less than enthusiastic. In fact, the ADA and the Alaska Dental Society sued to abolish DHATs, insisting that their very existence violated state law regarding dental licensing. They were unsuccessful.

Despite this setback, opponents to the DHAT model persisted. Their lobbying efforts began to pay off in late February, when the reauthorization of the Indian Health Care Improvement Act—with amendments—passed the US Senate. (It is currently languishing in the US House of Representatives.)

If the act becomes law in its current form, the amendments would prevent DHATs from performing any oral or jaw surgeries and would allow extraction and pulpal therapy only in an emergency and only after consultation with a licensed dentist. The idea is that DHATs would not be allowed to engage in irreversible procedures—and while this would not entirely negate their purpose, it would certainly limit their utility.

Further keeping a lid on these midlevel practitioners, the Senate version of the bill would also prevent—at least for the time being—any expansion of the DHAT program to other states. But a similar concept is already in development in the lower 48 states.

Advanced Dental Hygiene Practitioners
Advanced dental hygiene practitioners (ADHPs) resemble DHATs both in their therapeutic role and in the necessity of slugging it out in the political arena just to be allowed to exist. The Minnesota legislature is the first state political body to consider bestowing official sanction upon the ADHP and has made itself a battleground in a drawn-out fight. The primary combatants are the Minnesota Dental Hygienists’ Association (MNDHA), which supports the new designation, and the Minnesota Dental Association, which (surprise!) opposes it.

According to Mary Beth Kensek, RDH, RF, President of the MNDHA, the idea for the ADHP originated from the American Dental Hygienists’ Association in response to the Surgeon General’s 2000 report that highlighted issues of access to dental care in the US. In other words, much like the situation in Alaska, a lot of people who need dental care are not getting it for a variety of reasons, and the midlevel practitioner has been seen as part of the solution to that problem.

In describing the new professional designation, Kensek was at pains to distinguish the ADHP from the traditional dental hygienist. “It’s a new level of practitioner, and so, at least in our state, it’s not [simply] expanding the role of the dental hygienist,” Kensek explained. “It’s creating a whole different level of practitioner—a midlevel practitioner.”

When asked whether she thought the ADHP was akin to an NP or a PA, Kensek said, “The specifics are different, but in a very broad sense, yes, it’s a fair comparison. They’re both midlevel positions—that’s a good way to put it.”

To be more specific, ADHPs will not be independent practitioners; like DHATs, they will work under general supervision in collaboration with a licensed dentist. ADHPs will be trained to the master’s level in a curriculum developed by MNDHA in collaboration with the Minnesota Safety Net Coalition. The program will be similar to that for dental hygienists but will include additional qualifications.

“In addition to being able to provide any of the preventive services that traditional hygienists do, we’re also looking at doing different types of therapeutic activities, like some extractions that aren’t very involved, in order to relieve patients’ discomfort,” Kensek elaborated, “doing pulpotomies, and doing minimal prep and restorative work.” Limited prescribing privileges, within well-defined parameters, would also be available to the ADHP.

At the moment, “We’re looking at doing a pilot study so that we can examine this concept a little bit more and establish that it’s safe and effective,” Kensek said. “That way we can alleviate some of the fear and show that there is a need for this practitioner.”

Advanced Practice Paramedic
It is ironic that while PAs were virtually unheard of in the United Kingdom until a few years ago, and NPs are still a relatively recent phenomenon there, midlevel practitioners of other kinds have been thriving. One is what the Brits call an emergency care practitioner (ECP; or paramedic practitioner) and what Americans call the advanced practice paramedic (APP)—or at least they would if such a thing existed.

In the UK, the ECP delivers “unscheduled care” with a defined set of available interventions and medications. For example, therapeutic scope includes defibrillation, intubation, and thoracostomy, while prescriptive authority is granted for drugs such as adrenaline, naloxone, heparin, and hydrocortisone. Perhaps the most significant privilege given the ECP is the ability to treat-and-release or treat-and-refer.

In the US, the APP was originally proposed in the first draft of the National EMS Scope of Practice Model (2005), a semiformal “constitution” for the world of emergency medicine. The proposal was met with considerable con-sternation when its intended audience realized that the introduction of the APP would mean an entirely new class of emergency practi-tioners.

The American Ambulance Association, for example, noted in their position paper in response to the draft, “We take exception to the creation of [the APP] as defined in the document. The reasons for the creation of such a certification level seem to be far-reaching and only vaguely connected.…

“Further, we believe the educational requirement necessary for a paramedic to advance to the APP certification would severely constrain a local medical community from implementing creative and innovative integrated delivery systems that allow for referral/transport to alternative health care facilities.”

The APP was not to be—at least then. Some emergency medicine leaders continue to express support for the concept itself or for the idea of treat-and-release/refer privileges.

This support may receive a boost from a pilot program conducted in Arizona earlier this year, in which a Mesa fire department replaced their EMS technician with a PA who could evaluate patients on the scene and determine whether they should be treated, transported to a hospital, or referred to their usual health care provider. The idea was to free up the EMS team for response to true emergencies—but it could point to a need for a practitioner like the APP.

Radiologist Assistant
How many practitioner designations does one specialty need? The radiologist assistant (RA)—first recognized by the American College of Radiology and the American Society of Radiologic Technologists in 2003—should not be confused with the radiology practitioner assistant (RPA), which was introduced in the 1990s as a way to address a shortage of radiologists in the armed forces.

The therapeutic scope of RAs depends on their level of education and training and which certifying body they are associated with. That said, RAs typically assist with patient management, radiology exams, and preliminary image evaluation—although image interpretation is not within their purview.

The RA may be the one to prepare patients for radiologic exams, obtain patient consent for the injection of diagnostic agents, address patient questions—in short, serve as a patient advocate. The RA might assist with invasive procedures or perform fluoroscopy for noninvasive procedures under the supervision of a radiologist.

RAs can also undertake certain peripheral venous diagnostic procedures and place feeding tubes in patients without complications. Once the examination has taken place, the RA may be involved in determining image quality and may also provide preliminary observations—but purely in the context of assisting the radiologist and not for presentation to the patient.

While a certain amount of controversy inevitably surrounds their emergence as distinct midlevel practitioners, RAs are currently recognized in 10 states, each with its own requirements for education and accreditation. RAs must obtain at least a bachelor’s degree, and master’s degrees are fairly common.

It should be noted that PAs frequently perform many of the tasks for which RAs are trained. PAs, of course, have a broader educational background than RAs and possess certain advantages in the breadth of their capabilities and privileges as health care practitioners. However, within the narrower scope of radiologic duties, the RA may be regarded as having more specific training than the PA. What impact this will have on PAs who practice in radiology remains to be seen.     

The recognition that NPs and PAs—so-called (if reluctantly) midlevel providers—are enormously beneficial to the functioning of the US health care system has led to the introduction of similar practitioners in specialty areas such as dentistry, EMS, and radiology. Unlike PAs and NPs, with their broad areas of expertise and primary care focus, this new generation of health care professionals tends to have a more limited scope of practice.

What impact their presence may ultimately have on NPs and PAs is, for the moment, mostly hypothetical; resistance to these new professional categories has limited their use and acceptance in this country. But their positions within the health care team—and their struggles to practice and prosper—may remind PAs and NPs of their own professional journeys.

Dental Health Aide Therapists
Dental health aide therapists (DHATs) were introduced in Alaska in 2003 to meet a very specific need: dental care among Alaska Natives. This population experiences tooth decay at 2.5 times the national average, creating a substantial burden on both children and adults.

Further complicating matters, an estimated 85,000 people live in small villages (population 400 or below) in rural areas, according to the Alaska Native Tribal Health Consortium. Many cannot afford health or dental insurance and find that high travel costs prohibit them from seeking care in more developed, populous areas. (Sound familiar?)

So how can the dental health needs of this underserved population be met? Enter the DHAT, which was developed under the auspices of the Community Health Aide/Practitioner Program (CHAP). Since the 1960s, this federal program—a collaboration of the Indian Health Service with Alaska Native tribes—has brought more than 550 midlevel medical providers to work in small community clinics.

Taking its cue from more than 40 other countries in which DHATs or their equivalent are fairly common, CHAP conferred upon DHATs a rather broad therapeutic mandate. These practitioners are trained to do cleanings, fillings, and uncomplicated extractions, as well as to provide preventive services, under the general supervision of dentists who work at regional hospitals in the state.

Ironically, DHATs currently must complete their two-year education program through a New Zealand university, because there are no midlevel dental practitioner training programs in the US. While state licensure is not a requirement for DHATs, federal certification, continuing education, and biannual recertification are.

DHATs have been seen as an important solution to Alaska’s dental health problems and have earned praise from organizations involved in Native American health (as well as from former US Department of Health and Human Services Secretary Tommy Thompson).

But—cue the development that PAs and NPs may recognize from their own professional experiences—the American Dental Association (ADA) has been less than enthusiastic. In fact, the ADA and the Alaska Dental Society sued to abolish DHATs, insisting that their very existence violated state law regarding dental licensing. They were unsuccessful.

Despite this setback, opponents to the DHAT model persisted. Their lobbying efforts began to pay off in late February, when the reauthorization of the Indian Health Care Improvement Act—with amendments—passed the US Senate. (It is currently languishing in the US House of Representatives.)

If the act becomes law in its current form, the amendments would prevent DHATs from performing any oral or jaw surgeries and would allow extraction and pulpal therapy only in an emergency and only after consultation with a licensed dentist. The idea is that DHATs would not be allowed to engage in irreversible procedures—and while this would not entirely negate their purpose, it would certainly limit their utility.

Further keeping a lid on these midlevel practitioners, the Senate version of the bill would also prevent—at least for the time being—any expansion of the DHAT program to other states. But a similar concept is already in development in the lower 48 states.

Advanced Dental Hygiene Practitioners
Advanced dental hygiene practitioners (ADHPs) resemble DHATs both in their therapeutic role and in the necessity of slugging it out in the political arena just to be allowed to exist. The Minnesota legislature is the first state political body to consider bestowing official sanction upon the ADHP and has made itself a battleground in a drawn-out fight. The primary combatants are the Minnesota Dental Hygienists’ Association (MNDHA), which supports the new designation, and the Minnesota Dental Association, which (surprise!) opposes it.

According to Mary Beth Kensek, RDH, RF, President of the MNDHA, the idea for the ADHP originated from the American Dental Hygienists’ Association in response to the Surgeon General’s 2000 report that highlighted issues of access to dental care in the US. In other words, much like the situation in Alaska, a lot of people who need dental care are not getting it for a variety of reasons, and the midlevel practitioner has been seen as part of the solution to that problem.

In describing the new professional designation, Kensek was at pains to distinguish the ADHP from the traditional dental hygienist. “It’s a new level of practitioner, and so, at least in our state, it’s not [simply] expanding the role of the dental hygienist,” Kensek explained. “It’s creating a whole different level of practitioner—a midlevel practitioner.”

When asked whether she thought the ADHP was akin to an NP or a PA, Kensek said, “The specifics are different, but in a very broad sense, yes, it’s a fair comparison. They’re both midlevel positions—that’s a good way to put it.”

To be more specific, ADHPs will not be independent practitioners; like DHATs, they will work under general supervision in collaboration with a licensed dentist. ADHPs will be trained to the master’s level in a curriculum developed by MNDHA in collaboration with the Minnesota Safety Net Coalition. The program will be similar to that for dental hygienists but will include additional qualifications.

“In addition to being able to provide any of the preventive services that traditional hygienists do, we’re also looking at doing different types of therapeutic activities, like some extractions that aren’t very involved, in order to relieve patients’ discomfort,” Kensek elaborated, “doing pulpotomies, and doing minimal prep and restorative work.” Limited prescribing privileges, within well-defined parameters, would also be available to the ADHP.

At the moment, “We’re looking at doing a pilot study so that we can examine this concept a little bit more and establish that it’s safe and effective,” Kensek said. “That way we can alleviate some of the fear and show that there is a need for this practitioner.”

Advanced Practice Paramedic
It is ironic that while PAs were virtually unheard of in the United Kingdom until a few years ago, and NPs are still a relatively recent phenomenon there, midlevel practitioners of other kinds have been thriving. One is what the Brits call an emergency care practitioner (ECP; or paramedic practitioner) and what Americans call the advanced practice paramedic (APP)—or at least they would if such a thing existed.

In the UK, the ECP delivers “unscheduled care” with a defined set of available interventions and medications. For example, therapeutic scope includes defibrillation, intubation, and thoracostomy, while prescriptive authority is granted for drugs such as adrenaline, naloxone, heparin, and hydrocortisone. Perhaps the most significant privilege given the ECP is the ability to treat-and-release or treat-and-refer.

In the US, the APP was originally proposed in the first draft of the National EMS Scope of Practice Model (2005), a semiformal “constitution” for the world of emergency medicine. The proposal was met with considerable con-sternation when its intended audience realized that the introduction of the APP would mean an entirely new class of emergency practi-tioners.

The American Ambulance Association, for example, noted in their position paper in response to the draft, “We take exception to the creation of [the APP] as defined in the document. The reasons for the creation of such a certification level seem to be far-reaching and only vaguely connected.…

“Further, we believe the educational requirement necessary for a paramedic to advance to the APP certification would severely constrain a local medical community from implementing creative and innovative integrated delivery systems that allow for referral/transport to alternative health care facilities.”

The APP was not to be—at least then. Some emergency medicine leaders continue to express support for the concept itself or for the idea of treat-and-release/refer privileges.

This support may receive a boost from a pilot program conducted in Arizona earlier this year, in which a Mesa fire department replaced their EMS technician with a PA who could evaluate patients on the scene and determine whether they should be treated, transported to a hospital, or referred to their usual health care provider. The idea was to free up the EMS team for response to true emergencies—but it could point to a need for a practitioner like the APP.

Radiologist Assistant
How many practitioner designations does one specialty need? The radiologist assistant (RA)—first recognized by the American College of Radiology and the American Society of Radiologic Technologists in 2003—should not be confused with the radiology practitioner assistant (RPA), which was introduced in the 1990s as a way to address a shortage of radiologists in the armed forces.

The therapeutic scope of RAs depends on their level of education and training and which certifying body they are associated with. That said, RAs typically assist with patient management, radiology exams, and preliminary image evaluation—although image interpretation is not within their purview.

The RA may be the one to prepare patients for radiologic exams, obtain patient consent for the injection of diagnostic agents, address patient questions—in short, serve as a patient advocate. The RA might assist with invasive procedures or perform fluoroscopy for noninvasive procedures under the supervision of a radiologist.

RAs can also undertake certain peripheral venous diagnostic procedures and place feeding tubes in patients without complications. Once the examination has taken place, the RA may be involved in determining image quality and may also provide preliminary observations—but purely in the context of assisting the radiologist and not for presentation to the patient.

While a certain amount of controversy inevitably surrounds their emergence as distinct midlevel practitioners, RAs are currently recognized in 10 states, each with its own requirements for education and accreditation. RAs must obtain at least a bachelor’s degree, and master’s degrees are fairly common.

It should be noted that PAs frequently perform many of the tasks for which RAs are trained. PAs, of course, have a broader educational background than RAs and possess certain advantages in the breadth of their capabilities and privileges as health care practitioners. However, within the narrower scope of radiologic duties, the RA may be regarded as having more specific training than the PA. What impact this will have on PAs who practice in radiology remains to be seen.     

Mark S. DeFrancesco, MD, didn’t realize it, but sometimes he used to rest his hand on the doorknob while talking with patients at his Waterbury, Connecticut, gynecology practice. This unconscious habit gave the impression that his attention was already shifting to his next appointment.

A couple of patients mentioned the doorknob grasp in an anonymous office survey 10 years ago. As a result, DeFrancesco became aware of his habit and has worked to become a better listener. (He also now avoids the doorknob at all costs.) “If there’s something negative, I want to hear about it,” DeFrancesco says. “There’s no room for arrogance here.”

That’s why DeFrancesco and his colleagues in a large group practice, Women’s Health Connecticut (based in Avon), agreed to participate in a new medical ratings effort: the Zagat Health Survey.

From Dining to Health Care
Consumers already page through the famous Zagat guides for reliable restaurant and hotel suggestions. Now, they will be able to apply the same principles to find a five-star health care provider.

Although the Zagat Health Survey is not open to the general public, it will eventually be available online to 35 million people across the country who have WellPoint and/or Blue Cross/Anthem health insurance. WellPoint’s survey went live in January in three areas (Los Angeles, Cincinnati/Dayton, and Connecticut). Along with 150 physicians, 30 collaborative providers (advanced practice nurses, physician assistants, and nurse-midwives) will be evaluated on four criteria: trust, communication, availability, and environment. The best providers will receive a perfect score of 30.

“We launched this because consumer research indicated that peer-to-peer feedback was an important piece of the puzzle,” says WellPoint spokesperson Jill Becher. While similar online rating tools exist, WellPoint is the first health insurance company to partner with Zagat.

“We believe the methodology Zagat uses—and their expertise in assessing consumer experiences—is something that will strike a chord with our members,” Becher adds. Many WellPoint members already use Zagat guides in their daily lives, she says, so they will have confidence in the information offered on the Web site.

Rating Tools Are Booming
The WellPoint/Zagat survey is part of a growing trend toward online health care rating tools. Others include HealthGrades.com and Hospital Compare (www.hospitalcompare.hhs.gov). So who’s driving this movement? Look to the baby boomers, says Rick Wade, senior vice president of the American Hospital Association (AHA).

“They’re the best educated, most information-savvy, most affluent generation of senior citizens this country has ever known,” Wade says. “They have a totally different attitude toward the medical establishment than their parents did.”

The new Zagat survey should satisfy some of that demand for information, but it has a narrow focus. It is not designed to reflect hard data about the quality of care in a particular medical office, says Zagat spokesperson Betsy Haworth. Users won’t find any stats about board exams or malpractice claims. It’s more like word of mouth—people asking around to see if friends and family members know any good clinicians. “The goal here is to create a trusted resource that supports informed decision making,” Haworth says.

So far, Becher says, most patients are logging on to tell others about good experiences they’ve had with a clinician (rather than to complain). It’s still early, but Becher says the project will build momentum as WellPoint brings more patients on board in more cities. Providers like DeFrancesco also have been upbeat about it, she adds.

“What we’re really talking about here is an electronic patient-satisfaction survey,” DeFrancesco says. “We understand patient satisfaction is very important, so we welcome feedback and ideas. We’re not afraid of that.”

Speaking of Feedback
But officials at the American Medical Association (AMA) took a more negative view of the Zagat Health Survey. “Choosing a good physician is more complicated than choosing a good restaurant,” AMA President-Elect Nancy H. Nielson, MD, said in a recent statement. “Patients owe it to themselves to use the best available resources when making this important decision.”

Nielson raised concerns about the potential for fraudulent online posts. “Anonymous online opinions of physicians should be taken with a grain of salt and should certainly not be a patient’s sole source of information when looking for a new physician,” she said. For example, what happens if a mentally unstable patient or an angry competitor tries to post unfair comments about a provider?

Zagat and Wellpoint executives contend their online tool has safeguards and filters in place to prevent that type of scenario. In the end, they believe the benefits will outweigh any risks.

AMA officials say medical rating sites should offer information about quality of care, not just bedside manner and office decor. Instead, the AMA encourages consumers to seek several sources of information, such as checking with local medical socie-ties to confirm that a practitioner has a valid license. Asking another clinician for a referral or using the AMA’s DoctorFinder service might be better options, they advise.

At the AHA, experts who are working on the new Hospital Compare Web site feel a combination of public and private information will offer patients the best way to judge clinicians and hospitals. The site is a collaboration between the Centers for Medicare and Medicare Services and the Hospital Quality Alliance (which includes the AHA, the Federation of American Hospitals, and the Association of American Medical Colleges).

Wade says this arena of competing online rating tools will probably get more confusing before it gets better. But that doesn’t mean we should abandon the process, he says, because it will change health care for the better. “This has already forced more transparency in the system,” he says.

Clinicians Need to Talk the Talk
Health care providers who excel in certain specialties will no longer be able to simply ignore their bedside manner. “Those guys will have to go drive a cab,” jokes Wade. Clinicians with the best communication skills will come out ahead in surveys and ratings.

Medical training program directors have realized that patient satisfaction is going to drive health care decisions more than ever before, so they are encouraging students to work on their bedside manner as much as their organic chemistry and diagnostic skills.

You can have all the fancy online tools in the world, Wade says, but there’s still no substitute for basic human contact. “The average person is going to be overwhelmed by all of the information that’s out there,” he adds. “The key is to have a provider you feel you can communicate with.”     

Mark S. DeFrancesco, MD, didn’t realize it, but sometimes he used to rest his hand on the doorknob while talking with patients at his Waterbury, Connecticut, gynecology practice. This unconscious habit gave the impression that his attention was already shifting to his next appointment.

A couple of patients mentioned the doorknob grasp in an anonymous office survey 10 years ago. As a result, DeFrancesco became aware of his habit and has worked to become a better listener. (He also now avoids the doorknob at all costs.) “If there’s something negative, I want to hear about it,” DeFrancesco says. “There’s no room for arrogance here.”

That’s why DeFrancesco and his colleagues in a large group practice, Women’s Health Connecticut (based in Avon), agreed to participate in a new medical ratings effort: the Zagat Health Survey.

From Dining to Health Care
Consumers already page through the famous Zagat guides for reliable restaurant and hotel suggestions. Now, they will be able to apply the same principles to find a five-star health care provider.

Although the Zagat Health Survey is not open to the general public, it will eventually be available online to 35 million people across the country who have WellPoint and/or Blue Cross/Anthem health insurance. WellPoint’s survey went live in January in three areas (Los Angeles, Cincinnati/Dayton, and Connecticut). Along with 150 physicians, 30 collaborative providers (advanced practice nurses, physician assistants, and nurse-midwives) will be evaluated on four criteria: trust, communication, availability, and environment. The best providers will receive a perfect score of 30.

“We launched this because consumer research indicated that peer-to-peer feedback was an important piece of the puzzle,” says WellPoint spokesperson Jill Becher. While similar online rating tools exist, WellPoint is the first health insurance company to partner with Zagat.

“We believe the methodology Zagat uses—and their expertise in assessing consumer experiences—is something that will strike a chord with our members,” Becher adds. Many WellPoint members already use Zagat guides in their daily lives, she says, so they will have confidence in the information offered on the Web site.

Rating Tools Are Booming
The WellPoint/Zagat survey is part of a growing trend toward online health care rating tools. Others include HealthGrades.com and Hospital Compare (www.hospitalcompare.hhs.gov). So who’s driving this movement? Look to the baby boomers, says Rick Wade, senior vice president of the American Hospital Association (AHA).

“They’re the best educated, most information-savvy, most affluent generation of senior citizens this country has ever known,” Wade says. “They have a totally different attitude toward the medical establishment than their parents did.”

The new Zagat survey should satisfy some of that demand for information, but it has a narrow focus. It is not designed to reflect hard data about the quality of care in a particular medical office, says Zagat spokesperson Betsy Haworth. Users won’t find any stats about board exams or malpractice claims. It’s more like word of mouth—people asking around to see if friends and family members know any good clinicians. “The goal here is to create a trusted resource that supports informed decision making,” Haworth says.

So far, Becher says, most patients are logging on to tell others about good experiences they’ve had with a clinician (rather than to complain). It’s still early, but Becher says the project will build momentum as WellPoint brings more patients on board in more cities. Providers like DeFrancesco also have been upbeat about it, she adds.

“What we’re really talking about here is an electronic patient-satisfaction survey,” DeFrancesco says. “We understand patient satisfaction is very important, so we welcome feedback and ideas. We’re not afraid of that.”

Speaking of Feedback
But officials at the American Medical Association (AMA) took a more negative view of the Zagat Health Survey. “Choosing a good physician is more complicated than choosing a good restaurant,” AMA President-Elect Nancy H. Nielson, MD, said in a recent statement. “Patients owe it to themselves to use the best available resources when making this important decision.”

Nielson raised concerns about the potential for fraudulent online posts. “Anonymous online opinions of physicians should be taken with a grain of salt and should certainly not be a patient’s sole source of information when looking for a new physician,” she said. For example, what happens if a mentally unstable patient or an angry competitor tries to post unfair comments about a provider?

Zagat and Wellpoint executives contend their online tool has safeguards and filters in place to prevent that type of scenario. In the end, they believe the benefits will outweigh any risks.

AMA officials say medical rating sites should offer information about quality of care, not just bedside manner and office decor. Instead, the AMA encourages consumers to seek several sources of information, such as checking with local medical socie-ties to confirm that a practitioner has a valid license. Asking another clinician for a referral or using the AMA’s DoctorFinder service might be better options, they advise.

At the AHA, experts who are working on the new Hospital Compare Web site feel a combination of public and private information will offer patients the best way to judge clinicians and hospitals. The site is a collaboration between the Centers for Medicare and Medicare Services and the Hospital Quality Alliance (which includes the AHA, the Federation of American Hospitals, and the Association of American Medical Colleges).

Wade says this arena of competing online rating tools will probably get more confusing before it gets better. But that doesn’t mean we should abandon the process, he says, because it will change health care for the better. “This has already forced more transparency in the system,” he says.

Clinicians Need to Talk the Talk
Health care providers who excel in certain specialties will no longer be able to simply ignore their bedside manner. “Those guys will have to go drive a cab,” jokes Wade. Clinicians with the best communication skills will come out ahead in surveys and ratings.

Medical training program directors have realized that patient satisfaction is going to drive health care decisions more than ever before, so they are encouraging students to work on their bedside manner as much as their organic chemistry and diagnostic skills.

You can have all the fancy online tools in the world, Wade says, but there’s still no substitute for basic human contact. “The average person is going to be overwhelmed by all of the information that’s out there,” he adds. “The key is to have a provider you feel you can communicate with.”     

Mark S. DeFrancesco, MD, didn’t realize it, but sometimes he used to rest his hand on the doorknob while talking with patients at his Waterbury, Connecticut, gynecology practice. This unconscious habit gave the impression that his attention was already shifting to his next appointment.

A couple of patients mentioned the doorknob grasp in an anonymous office survey 10 years ago. As a result, DeFrancesco became aware of his habit and has worked to become a better listener. (He also now avoids the doorknob at all costs.) “If there’s something negative, I want to hear about it,” DeFrancesco says. “There’s no room for arrogance here.”

That’s why DeFrancesco and his colleagues in a large group practice, Women’s Health Connecticut (based in Avon), agreed to participate in a new medical ratings effort: the Zagat Health Survey.

From Dining to Health Care
Consumers already page through the famous Zagat guides for reliable restaurant and hotel suggestions. Now, they will be able to apply the same principles to find a five-star health care provider.

Although the Zagat Health Survey is not open to the general public, it will eventually be available online to 35 million people across the country who have WellPoint and/or Blue Cross/Anthem health insurance. WellPoint’s survey went live in January in three areas (Los Angeles, Cincinnati/Dayton, and Connecticut). Along with 150 physicians, 30 collaborative providers (advanced practice nurses, physician assistants, and nurse-midwives) will be evaluated on four criteria: trust, communication, availability, and environment. The best providers will receive a perfect score of 30.

“We launched this because consumer research indicated that peer-to-peer feedback was an important piece of the puzzle,” says WellPoint spokesperson Jill Becher. While similar online rating tools exist, WellPoint is the first health insurance company to partner with Zagat.

“We believe the methodology Zagat uses—and their expertise in assessing consumer experiences—is something that will strike a chord with our members,” Becher adds. Many WellPoint members already use Zagat guides in their daily lives, she says, so they will have confidence in the information offered on the Web site.

Rating Tools Are Booming
The WellPoint/Zagat survey is part of a growing trend toward online health care rating tools. Others include HealthGrades.com and Hospital Compare (www.hospitalcompare.hhs.gov). So who’s driving this movement? Look to the baby boomers, says Rick Wade, senior vice president of the American Hospital Association (AHA).

“They’re the best educated, most information-savvy, most affluent generation of senior citizens this country has ever known,” Wade says. “They have a totally different attitude toward the medical establishment than their parents did.”

The new Zagat survey should satisfy some of that demand for information, but it has a narrow focus. It is not designed to reflect hard data about the quality of care in a particular medical office, says Zagat spokesperson Betsy Haworth. Users won’t find any stats about board exams or malpractice claims. It’s more like word of mouth—people asking around to see if friends and family members know any good clinicians. “The goal here is to create a trusted resource that supports informed decision making,” Haworth says.

So far, Becher says, most patients are logging on to tell others about good experiences they’ve had with a clinician (rather than to complain). It’s still early, but Becher says the project will build momentum as WellPoint brings more patients on board in more cities. Providers like DeFrancesco also have been upbeat about it, she adds.

“What we’re really talking about here is an electronic patient-satisfaction survey,” DeFrancesco says. “We understand patient satisfaction is very important, so we welcome feedback and ideas. We’re not afraid of that.”

Speaking of Feedback
But officials at the American Medical Association (AMA) took a more negative view of the Zagat Health Survey. “Choosing a good physician is more complicated than choosing a good restaurant,” AMA President-Elect Nancy H. Nielson, MD, said in a recent statement. “Patients owe it to themselves to use the best available resources when making this important decision.”

Nielson raised concerns about the potential for fraudulent online posts. “Anonymous online opinions of physicians should be taken with a grain of salt and should certainly not be a patient’s sole source of information when looking for a new physician,” she said. For example, what happens if a mentally unstable patient or an angry competitor tries to post unfair comments about a provider?

Zagat and Wellpoint executives contend their online tool has safeguards and filters in place to prevent that type of scenario. In the end, they believe the benefits will outweigh any risks.

AMA officials say medical rating sites should offer information about quality of care, not just bedside manner and office decor. Instead, the AMA encourages consumers to seek several sources of information, such as checking with local medical socie-ties to confirm that a practitioner has a valid license. Asking another clinician for a referral or using the AMA’s DoctorFinder service might be better options, they advise.

At the AHA, experts who are working on the new Hospital Compare Web site feel a combination of public and private information will offer patients the best way to judge clinicians and hospitals. The site is a collaboration between the Centers for Medicare and Medicare Services and the Hospital Quality Alliance (which includes the AHA, the Federation of American Hospitals, and the Association of American Medical Colleges).

Wade says this arena of competing online rating tools will probably get more confusing before it gets better. But that doesn’t mean we should abandon the process, he says, because it will change health care for the better. “This has already forced more transparency in the system,” he says.

Clinicians Need to Talk the Talk
Health care providers who excel in certain specialties will no longer be able to simply ignore their bedside manner. “Those guys will have to go drive a cab,” jokes Wade. Clinicians with the best communication skills will come out ahead in surveys and ratings.

Medical training program directors have realized that patient satisfaction is going to drive health care decisions more than ever before, so they are encouraging students to work on their bedside manner as much as their organic chemistry and diagnostic skills.

You can have all the fancy online tools in the world, Wade says, but there’s still no substitute for basic human contact. “The average person is going to be overwhelmed by all of the information that’s out there,” he adds. “The key is to have a provider you feel you can communicate with.”     

Grandma Louise had become increasingly forgetful. Could she have Alzheimer’s disease? Concerned, her adult daughter contacted Bronx-based House Call Medical Services of NY, PLLC, founded by Edwin Quinones, RPA-C, and Sumir Sahgal, MD. An hour later, when Sahgal visited Louise, she offered him a cup of coffee. “She put on coffee and turned on the gas, but forgot to light the burner,” Sahgal recalls. He quickly removed the knobs from the woman’s gas stove, and House Call made arrangements for an aide to cook for her.

This is only one of House Call’s many success stories. For Quinones, who has been a PA for 14 years in a variety of settings, house call work is his passion and his true calling. “I just love what I do,” he says. “My patients treat me like family, and I really feel like I’m doing some good.”

Whether they serve high-end business travelers in big cities, homebound mothers in the suburbs, or rural elderly patients, house call services are becoming increasingly popular throughout the country. In just three years, Quinones and Sahgal have expanded their practice from 70 to 400 patients. “There’s a little bit of a buzz about house calls,” says Naomi Friedman, RPA-C, founder and chief medical officer of Sickday Medical House Calls, LLC, a thriving practice that addresses acute care needs in Manhattan. “This is a growing trend.”

A Welcome Option
So what’s driving the demand for good, old-fashioned house calls? Many factors come into play, says Friedman, beginning with changes in the US health care system. With 47 million uninsured, emergency departments (EDs) are crowded, unpleasant places to be. The average wait time for an ED visit is about four hours, Friedman says.

Meanwhile, as financial pressures force many primary care practices to fold, patients wait an average of two days to see the family provider. For many, time is money. They would rather pay $250 out of pocket than sit with a sick child for hours in an uncomfortable ED.

A Perfect Fit
As house call services grow and expand, physician assistants and nurse practitioners are a key part of their success. That’s because NPs and PAs are so well suited to this type of care, says Deonne Brown, DNP, APRN-BC, a researcher and faculty member at Seattle University College of Nursing. Advanced practice clinicians are more holistic—more interested in the big picture and in preventive care. They also work well in a highly collaborative environment.

For entrepreneurial PAs and NPs, the house call market is one to be considered, says Brown. A study that she conducted showed growing acceptance and appreciation of advanced practice nurses. Compared with health care consumers of 20 years ago, today’s patient is more willing to visit an NP for primary medical care. Patients in western states are especially familiar with NPs and report high satisfaction levels, Brown says.

Brown links the growing demand for house call services with the recent trend toward concierge medicine. “It’s related to consumer-directed care,” she says. “It’s centering things around the patients’ needs, and this is just an extension of that.”

At Sickday, PAs and MDs actually deal with hotel concierges. Many of their clients are business travelers who develop urgent health needs away from home. One businessman awoke with an earache the morning before his flight home. A Sickday provider was able to reduce the man’s pain and resolve his concerns.

Stay-at-home moms love the service too, Friedman says, because they don’t have to bring all three kids to their clinician’s office when just one of them comes down with strep throat or the flu.

Many patients are young, healthy, and self-employed—film directors, writers, and fashion designers. They may have only catastrophic insurance but are willing to pay for house call service on the infrequent occasions when health issues arise.

Sickday charges a flat $250 fee for each house call. Insurance often covers that, so the patient’s out-of-pocket cost may be about $40.

Expanding Markets
Another successful house call company, Miami-based My Home Doctor, LLC, has entered the corporate market, offering packages to busy executives who can’t afford to lose a day waiting in the urgent care clinic. The company also serves the area’s elderly population, which will continue to grow as more baby boomers turn 65.

With plans to expand into the Los Angeles market in 2008, both My Home Doctor and Sickday expect to add advanced practice clinicians to their staffs. “As our business grows and our patient population grows on the chronic care side, PAs and NPs will have all the skills and qualifications necessary,” says Mark Price, CEO of My Home Doctor. His company has plans to expand into 14 US cities.

Are You Cut Out for House Calls?
House call work may be a lucrative market, but it’s also very satisfying, Quinones says. Every day is a different adventure, and providers feel that they are helping people who might otherwise fall through the cracks in the US health care system.

Some practitioners are attracted to house calls because they believe the start-up costs and overhead will be lower than in other types of medical practice, but Quinones and Sahgal strongly advise investing in an office and a full-time scheduling staff. They also favor electronic record-keeping software and small portable devices, including a pulse oximeter and a portable x-ray machine.

Other components they would recommend? A strong marketing plan, excellent communication skills, a collaborative outlook—and a good set of tires.

But most importantly, Quinones says, house call practitioners need the right kind of personality and worldview to be cut out for this kind of practice. “This is part of the global outlook for us,” he says. “We’re trying to give people better quality of life and keep them out of the emergency room.”      

Grandma Louise had become increasingly forgetful. Could she have Alzheimer’s disease? Concerned, her adult daughter contacted Bronx-based House Call Medical Services of NY, PLLC, founded by Edwin Quinones, RPA-C, and Sumir Sahgal, MD. An hour later, when Sahgal visited Louise, she offered him a cup of coffee. “She put on coffee and turned on the gas, but forgot to light the burner,” Sahgal recalls. He quickly removed the knobs from the woman’s gas stove, and House Call made arrangements for an aide to cook for her.

This is only one of House Call’s many success stories. For Quinones, who has been a PA for 14 years in a variety of settings, house call work is his passion and his true calling. “I just love what I do,” he says. “My patients treat me like family, and I really feel like I’m doing some good.”

Whether they serve high-end business travelers in big cities, homebound mothers in the suburbs, or rural elderly patients, house call services are becoming increasingly popular throughout the country. In just three years, Quinones and Sahgal have expanded their practice from 70 to 400 patients. “There’s a little bit of a buzz about house calls,” says Naomi Friedman, RPA-C, founder and chief medical officer of Sickday Medical House Calls, LLC, a thriving practice that addresses acute care needs in Manhattan. “This is a growing trend.”

A Welcome Option
So what’s driving the demand for good, old-fashioned house calls? Many factors come into play, says Friedman, beginning with changes in the US health care system. With 47 million uninsured, emergency departments (EDs) are crowded, unpleasant places to be. The average wait time for an ED visit is about four hours, Friedman says.

Meanwhile, as financial pressures force many primary care practices to fold, patients wait an average of two days to see the family provider. For many, time is money. They would rather pay $250 out of pocket than sit with a sick child for hours in an uncomfortable ED.

A Perfect Fit
As house call services grow and expand, physician assistants and nurse practitioners are a key part of their success. That’s because NPs and PAs are so well suited to this type of care, says Deonne Brown, DNP, APRN-BC, a researcher and faculty member at Seattle University College of Nursing. Advanced practice clinicians are more holistic—more interested in the big picture and in preventive care. They also work well in a highly collaborative environment.

For entrepreneurial PAs and NPs, the house call market is one to be considered, says Brown. A study that she conducted showed growing acceptance and appreciation of advanced practice nurses. Compared with health care consumers of 20 years ago, today’s patient is more willing to visit an NP for primary medical care. Patients in western states are especially familiar with NPs and report high satisfaction levels, Brown says.

Brown links the growing demand for house call services with the recent trend toward concierge medicine. “It’s related to consumer-directed care,” she says. “It’s centering things around the patients’ needs, and this is just an extension of that.”

At Sickday, PAs and MDs actually deal with hotel concierges. Many of their clients are business travelers who develop urgent health needs away from home. One businessman awoke with an earache the morning before his flight home. A Sickday provider was able to reduce the man’s pain and resolve his concerns.

Stay-at-home moms love the service too, Friedman says, because they don’t have to bring all three kids to their clinician’s office when just one of them comes down with strep throat or the flu.

Many patients are young, healthy, and self-employed—film directors, writers, and fashion designers. They may have only catastrophic insurance but are willing to pay for house call service on the infrequent occasions when health issues arise.

Sickday charges a flat $250 fee for each house call. Insurance often covers that, so the patient’s out-of-pocket cost may be about $40.

Expanding Markets
Another successful house call company, Miami-based My Home Doctor, LLC, has entered the corporate market, offering packages to busy executives who can’t afford to lose a day waiting in the urgent care clinic. The company also serves the area’s elderly population, which will continue to grow as more baby boomers turn 65.

With plans to expand into the Los Angeles market in 2008, both My Home Doctor and Sickday expect to add advanced practice clinicians to their staffs. “As our business grows and our patient population grows on the chronic care side, PAs and NPs will have all the skills and qualifications necessary,” says Mark Price, CEO of My Home Doctor. His company has plans to expand into 14 US cities.

Are You Cut Out for House Calls?
House call work may be a lucrative market, but it’s also very satisfying, Quinones says. Every day is a different adventure, and providers feel that they are helping people who might otherwise fall through the cracks in the US health care system.

Some practitioners are attracted to house calls because they believe the start-up costs and overhead will be lower than in other types of medical practice, but Quinones and Sahgal strongly advise investing in an office and a full-time scheduling staff. They also favor electronic record-keeping software and small portable devices, including a pulse oximeter and a portable x-ray machine.

Other components they would recommend? A strong marketing plan, excellent communication skills, a collaborative outlook—and a good set of tires.

But most importantly, Quinones says, house call practitioners need the right kind of personality and worldview to be cut out for this kind of practice. “This is part of the global outlook for us,” he says. “We’re trying to give people better quality of life and keep them out of the emergency room.”      

Grandma Louise had become increasingly forgetful. Could she have Alzheimer’s disease? Concerned, her adult daughter contacted Bronx-based House Call Medical Services of NY, PLLC, founded by Edwin Quinones, RPA-C, and Sumir Sahgal, MD. An hour later, when Sahgal visited Louise, she offered him a cup of coffee. “She put on coffee and turned on the gas, but forgot to light the burner,” Sahgal recalls. He quickly removed the knobs from the woman’s gas stove, and House Call made arrangements for an aide to cook for her.

This is only one of House Call’s many success stories. For Quinones, who has been a PA for 14 years in a variety of settings, house call work is his passion and his true calling. “I just love what I do,” he says. “My patients treat me like family, and I really feel like I’m doing some good.”

Whether they serve high-end business travelers in big cities, homebound mothers in the suburbs, or rural elderly patients, house call services are becoming increasingly popular throughout the country. In just three years, Quinones and Sahgal have expanded their practice from 70 to 400 patients. “There’s a little bit of a buzz about house calls,” says Naomi Friedman, RPA-C, founder and chief medical officer of Sickday Medical House Calls, LLC, a thriving practice that addresses acute care needs in Manhattan. “This is a growing trend.”

A Welcome Option
So what’s driving the demand for good, old-fashioned house calls? Many factors come into play, says Friedman, beginning with changes in the US health care system. With 47 million uninsured, emergency departments (EDs) are crowded, unpleasant places to be. The average wait time for an ED visit is about four hours, Friedman says.

Meanwhile, as financial pressures force many primary care practices to fold, patients wait an average of two days to see the family provider. For many, time is money. They would rather pay $250 out of pocket than sit with a sick child for hours in an uncomfortable ED.

A Perfect Fit
As house call services grow and expand, physician assistants and nurse practitioners are a key part of their success. That’s because NPs and PAs are so well suited to this type of care, says Deonne Brown, DNP, APRN-BC, a researcher and faculty member at Seattle University College of Nursing. Advanced practice clinicians are more holistic—more interested in the big picture and in preventive care. They also work well in a highly collaborative environment.

For entrepreneurial PAs and NPs, the house call market is one to be considered, says Brown. A study that she conducted showed growing acceptance and appreciation of advanced practice nurses. Compared with health care consumers of 20 years ago, today’s patient is more willing to visit an NP for primary medical care. Patients in western states are especially familiar with NPs and report high satisfaction levels, Brown says.

Brown links the growing demand for house call services with the recent trend toward concierge medicine. “It’s related to consumer-directed care,” she says. “It’s centering things around the patients’ needs, and this is just an extension of that.”

At Sickday, PAs and MDs actually deal with hotel concierges. Many of their clients are business travelers who develop urgent health needs away from home. One businessman awoke with an earache the morning before his flight home. A Sickday provider was able to reduce the man’s pain and resolve his concerns.

Stay-at-home moms love the service too, Friedman says, because they don’t have to bring all three kids to their clinician’s office when just one of them comes down with strep throat or the flu.

Many patients are young, healthy, and self-employed—film directors, writers, and fashion designers. They may have only catastrophic insurance but are willing to pay for house call service on the infrequent occasions when health issues arise.

Sickday charges a flat $250 fee for each house call. Insurance often covers that, so the patient’s out-of-pocket cost may be about $40.

Expanding Markets
Another successful house call company, Miami-based My Home Doctor, LLC, has entered the corporate market, offering packages to busy executives who can’t afford to lose a day waiting in the urgent care clinic. The company also serves the area’s elderly population, which will continue to grow as more baby boomers turn 65.

With plans to expand into the Los Angeles market in 2008, both My Home Doctor and Sickday expect to add advanced practice clinicians to their staffs. “As our business grows and our patient population grows on the chronic care side, PAs and NPs will have all the skills and qualifications necessary,” says Mark Price, CEO of My Home Doctor. His company has plans to expand into 14 US cities.

Are You Cut Out for House Calls?
House call work may be a lucrative market, but it’s also very satisfying, Quinones says. Every day is a different adventure, and providers feel that they are helping people who might otherwise fall through the cracks in the US health care system.

Some practitioners are attracted to house calls because they believe the start-up costs and overhead will be lower than in other types of medical practice, but Quinones and Sahgal strongly advise investing in an office and a full-time scheduling staff. They also favor electronic record-keeping software and small portable devices, including a pulse oximeter and a portable x-ray machine.

Other components they would recommend? A strong marketing plan, excellent communication skills, a collaborative outlook—and a good set of tires.

But most importantly, Quinones says, house call practitioners need the right kind of personality and worldview to be cut out for this kind of practice. “This is part of the global outlook for us,” he says. “We’re trying to give people better quality of life and keep them out of the emergency room.”