Marie-Eileen Onieal, PhD, CPNP, FAANP

Personality quizzes abound on the Internet these days; you can find out everything from which Disney Princess you are to what type of fruit you would be. But there is a serious case to be made for how your personality type influences your work. It affects how you manage others, develop leadership skills, approach conflict resolution, and manage change.¹ Understanding your personality type assists in identifying your strengths, weaknesses, and areas in need of development.

My personality type is ENTP: someone who is “resourceful in solving new and challenging problems.”1 At many points in my career, I found myself in a leadership role. But truthfully, I never set out to be a leader—my career goals set me on that path. You might call me an “accidental leader.”

Recall my story about the founding of the American Academy of Nurse Practitioners (AANP; see Part 2): In the beginning, we were all encouraged to contribute whatever time and energy we could to getting the organization off the ground. I had plenty of time and energy to give. I saw the need for an NP-dedicated organization as a challenge. While I did not know my personality type at the time, I understood that I had a drive to meet challenges—those arising from the status quo and those of moving the vision for this new organization forward.

Our leadership skills are derived from everyday experiences—both the good and the bad. But we only grow if we study the consequences of those experiences to gain insights and to find new ways to manage ourselves and the team.² Understanding your own personality and skills helps you better appreciate the differences in those you lead and understand how to direct or utilize their particular skills.

Each team member brings a set of skills, range of ideas, and problem-solving approaches to a unique situation. You should identify your team members’ strengths and promote a culture in which the whole team feels comfortable, confident, supported, and encouraged to contribute.³

How do you do that? By initiating and maintaining effective working relationships within the team and demonstrating skills in care coordination and delegation. Everyone benefits when each team member’s unique abilities are used to progress toward the goal.

In my experience, a team is most effective when the leader

• knows each team members’ professional and personal goals
• sets real priorities and commitments
• establishes clear direction
• builds rapport
• is fair with everyone
• shares knowledge and resources
• mentors others to become effective leaders.

Continue to: Another thing that the most effective leaders do is...

Another thing that the most effective leaders do is manage their time and conserve their energy and focus. Think in both short- and long-term goals. Leaders are ordinary people with extraordinary determination, but they know when to stop working and how to recharge their batteries.^3,4

It is also important for leaders to acknowledge their accomplishments. All too often, we downplay the contributions we have made, the barriers we have overcome, and the sacrifices we have made to get to where we are today. Our accomplishments add to our body of experience and serve as the foundation for our growth.

Contrary to popular belief, leaders can be made. Anybody can be a leader. One just has to take the time to understand the commitment and the responsibilities. Leadership is a function of who you are, what you can do, and how you do it. Find a mission that ignites your passion, and go for it!

Personality quizzes abound on the Internet these days; you can find out everything from which Disney Princess you are to what type of fruit you would be. But there is a serious case to be made for how your personality type influences your work. It affects how you manage others, develop leadership skills, approach conflict resolution, and manage change.¹ Understanding your personality type assists in identifying your strengths, weaknesses, and areas in need of development.

My personality type is ENTP: someone who is “resourceful in solving new and challenging problems.”1 At many points in my career, I found myself in a leadership role. But truthfully, I never set out to be a leader—my career goals set me on that path. You might call me an “accidental leader.”

Recall my story about the founding of the American Academy of Nurse Practitioners (AANP; see Part 2): In the beginning, we were all encouraged to contribute whatever time and energy we could to getting the organization off the ground. I had plenty of time and energy to give. I saw the need for an NP-dedicated organization as a challenge. While I did not know my personality type at the time, I understood that I had a drive to meet challenges—those arising from the status quo and those of moving the vision for this new organization forward.

Our leadership skills are derived from everyday experiences—both the good and the bad. But we only grow if we study the consequences of those experiences to gain insights and to find new ways to manage ourselves and the team.² Understanding your own personality and skills helps you better appreciate the differences in those you lead and understand how to direct or utilize their particular skills.

Each team member brings a set of skills, range of ideas, and problem-solving approaches to a unique situation. You should identify your team members’ strengths and promote a culture in which the whole team feels comfortable, confident, supported, and encouraged to contribute.³

How do you do that? By initiating and maintaining effective working relationships within the team and demonstrating skills in care coordination and delegation. Everyone benefits when each team member’s unique abilities are used to progress toward the goal.

In my experience, a team is most effective when the leader

• knows each team members’ professional and personal goals
• sets real priorities and commitments
• establishes clear direction
• builds rapport
• is fair with everyone
• shares knowledge and resources
• mentors others to become effective leaders.

Continue to: Another thing that the most effective leaders do is...

Another thing that the most effective leaders do is manage their time and conserve their energy and focus. Think in both short- and long-term goals. Leaders are ordinary people with extraordinary determination, but they know when to stop working and how to recharge their batteries.^3,4

It is also important for leaders to acknowledge their accomplishments. All too often, we downplay the contributions we have made, the barriers we have overcome, and the sacrifices we have made to get to where we are today. Our accomplishments add to our body of experience and serve as the foundation for our growth.

Contrary to popular belief, leaders can be made. Anybody can be a leader. One just has to take the time to understand the commitment and the responsibilities. Leadership is a function of who you are, what you can do, and how you do it. Find a mission that ignites your passion, and go for it!

Personality quizzes abound on the Internet these days; you can find out everything from which Disney Princess you are to what type of fruit you would be. But there is a serious case to be made for how your personality type influences your work. It affects how you manage others, develop leadership skills, approach conflict resolution, and manage change.¹ Understanding your personality type assists in identifying your strengths, weaknesses, and areas in need of development.

My personality type is ENTP: someone who is “resourceful in solving new and challenging problems.”1 At many points in my career, I found myself in a leadership role. But truthfully, I never set out to be a leader—my career goals set me on that path. You might call me an “accidental leader.”

Recall my story about the founding of the American Academy of Nurse Practitioners (AANP; see Part 2): In the beginning, we were all encouraged to contribute whatever time and energy we could to getting the organization off the ground. I had plenty of time and energy to give. I saw the need for an NP-dedicated organization as a challenge. While I did not know my personality type at the time, I understood that I had a drive to meet challenges—those arising from the status quo and those of moving the vision for this new organization forward.

Our leadership skills are derived from everyday experiences—both the good and the bad. But we only grow if we study the consequences of those experiences to gain insights and to find new ways to manage ourselves and the team.² Understanding your own personality and skills helps you better appreciate the differences in those you lead and understand how to direct or utilize their particular skills.

Each team member brings a set of skills, range of ideas, and problem-solving approaches to a unique situation. You should identify your team members’ strengths and promote a culture in which the whole team feels comfortable, confident, supported, and encouraged to contribute.³

How do you do that? By initiating and maintaining effective working relationships within the team and demonstrating skills in care coordination and delegation. Everyone benefits when each team member’s unique abilities are used to progress toward the goal.

In my experience, a team is most effective when the leader

• knows each team members’ professional and personal goals
• sets real priorities and commitments
• establishes clear direction
• builds rapport
• is fair with everyone
• shares knowledge and resources
• mentors others to become effective leaders.

Continue to: Another thing that the most effective leaders do is...

Another thing that the most effective leaders do is manage their time and conserve their energy and focus. Think in both short- and long-term goals. Leaders are ordinary people with extraordinary determination, but they know when to stop working and how to recharge their batteries.^3,4

It is also important for leaders to acknowledge their accomplishments. All too often, we downplay the contributions we have made, the barriers we have overcome, and the sacrifices we have made to get to where we are today. Our accomplishments add to our body of experience and serve as the foundation for our growth.

Contrary to popular belief, leaders can be made. Anybody can be a leader. One just has to take the time to understand the commitment and the responsibilities. Leadership is a function of who you are, what you can do, and how you do it. Find a mission that ignites your passion, and go for it!

“Lead, follow, or get out of the way” sounds pejorative—even arrogant—but it ultimately speaks truth about most situations involving a team. A leader must know, or at least sense, the right action to take at any given moment; sometimes that action entails yielding leadership to another team member. So let’s break down this quote to identify the functional behavioral requirements of leadership.

Northouse presents the notion that leadership is a relationship or process of collaboration in which each team member is needed. The leader should be cognizant of each member’s interests, ideas, passions, attitudes, and motivations.¹

As a leader, you must reflect on all of your output. This includes how you relate to those you lead; how you collaborate with and affect the actions of your teammates; and how you communicate the process and influence a team toward a goal—which is crucial to the entire team’s success. Allow me to illustrate these core principles.

Relating
Early in the NP movement, it was necessary to develop a collective vision for the profession’s future. What was the purpose of an NP? What could we add to the existing health care landscape? The founders and early proponents of our profession, recognizing that there was power in numbers and strength in collaboration, identified a mission: Provide health care services for those who were underserved. Working as a group, NPs leveraged strength in numbers, creating a more efficient way to move forward and achieve that mission.² In those early NP pioneers, I recognize the leadership skills—ability to engage individuals and coordinate activities to move an agenda forward—that are key components of any relationship.

Collaborating
Later, in 1984, a small group of like-minded NPs (of which I was one) joined together to investigate the possibility of a starting an organization dedicated to NPs. As a profession, we were woefully underrepresented nationally. Our role was not fully understood, especially by legislators, and there were laws in place that impeded patients’ access to care by NPs. The existing nursing organizations were in no position to dedicate their resources to represent us professionally or politically.

Several colleagues and I were willing to take a risk to move our profession forward, even if it meant alienating other NPs. Each of us was able to work autonomously, as well as in a team, and we all viewed adversity as an opportunity. This gave us the impetus and motivation to carry out the footwork needed to achieve our goal. These skills—determination, energy, persistence—are essential for anyone looking to start a business or get involved in an organization.

Maybe when my colleagues and I formed the American Academy of Nurse Practitioners (AANP), we weren’t all leaders … but our relationship consisted of the passion and collective vision needed to work together and achieve. We knew we had to build on each other’s strengths and remain open and respectful of each other’s ideas. We believed we had nothing to lose and everything to gain and—honestly—we succeeded on all fronts!

Continue to: Influencing

Influencing
One success story happened in 1988 when Title VIII of the Public Health Service Act—the Nurse Education Act—was under review. New provisions in the bill included specific penalties for NPs and nurses if they defaulted on their student loans—penalties that did not apply to other health care professionals. My colleagues and I were outraged! Like many others, I had such a loan, which had allowed me to pursue my dream of becoming an NP.

The AANP got the word out, and we bombarded our legislators’ offices with calls and a threat to “march on Washington.” For my part, I personally spoke with Senator Edward “Ted” Kennedy and asked him if he realized the revisions made him look like a “loan shark.” I told him that NPs were in direct competition with physicians in settings identified as “loan repayments sites” and that physicians were more apt to be hired in these settings than NPs. I quickly offered up alternatives to increase the number of eligible sites where NPs could work for loan repayment, such as community health centers—a system for which he had secured funding decades earlier.

The end result of our influence? Community health centers throughout the country would be considered “loan repayment” sites, which helped to expand the opportunities for NPs to fulfill their financial obligations. If that doesn’t show you that being a leader requires you to challenge unfairness and identify solutions to correct inequity, I don’t know what does.

In a health care organization, we all have multiple roles that require us to be leaders. We are collaborators, providers of care, advocates for our patients, problem-solvers, and idealists. We are also role models for nascent health care providers. A leader’s responsibility spans the breadth of the organization, and today’s health care system continues to demand strong leaders capable of utilizing a variety of skills.

Next Thursday, I will continue my investigation of how to become an effective leader. In our fourth and final part of this series, we will discuss how acknowledging our specific personality traits can strengthen the efforts of a leader.

“Lead, follow, or get out of the way” sounds pejorative—even arrogant—but it ultimately speaks truth about most situations involving a team. A leader must know, or at least sense, the right action to take at any given moment; sometimes that action entails yielding leadership to another team member. So let’s break down this quote to identify the functional behavioral requirements of leadership.

Northouse presents the notion that leadership is a relationship or process of collaboration in which each team member is needed. The leader should be cognizant of each member’s interests, ideas, passions, attitudes, and motivations.¹

As a leader, you must reflect on all of your output. This includes how you relate to those you lead; how you collaborate with and affect the actions of your teammates; and how you communicate the process and influence a team toward a goal—which is crucial to the entire team’s success. Allow me to illustrate these core principles.

Relating
Early in the NP movement, it was necessary to develop a collective vision for the profession’s future. What was the purpose of an NP? What could we add to the existing health care landscape? The founders and early proponents of our profession, recognizing that there was power in numbers and strength in collaboration, identified a mission: Provide health care services for those who were underserved. Working as a group, NPs leveraged strength in numbers, creating a more efficient way to move forward and achieve that mission.² In those early NP pioneers, I recognize the leadership skills—ability to engage individuals and coordinate activities to move an agenda forward—that are key components of any relationship.

Collaborating
Later, in 1984, a small group of like-minded NPs (of which I was one) joined together to investigate the possibility of a starting an organization dedicated to NPs. As a profession, we were woefully underrepresented nationally. Our role was not fully understood, especially by legislators, and there were laws in place that impeded patients’ access to care by NPs. The existing nursing organizations were in no position to dedicate their resources to represent us professionally or politically.

Several colleagues and I were willing to take a risk to move our profession forward, even if it meant alienating other NPs. Each of us was able to work autonomously, as well as in a team, and we all viewed adversity as an opportunity. This gave us the impetus and motivation to carry out the footwork needed to achieve our goal. These skills—determination, energy, persistence—are essential for anyone looking to start a business or get involved in an organization.

Maybe when my colleagues and I formed the American Academy of Nurse Practitioners (AANP), we weren’t all leaders … but our relationship consisted of the passion and collective vision needed to work together and achieve. We knew we had to build on each other’s strengths and remain open and respectful of each other’s ideas. We believed we had nothing to lose and everything to gain and—honestly—we succeeded on all fronts!

Continue to: Influencing

Influencing
One success story happened in 1988 when Title VIII of the Public Health Service Act—the Nurse Education Act—was under review. New provisions in the bill included specific penalties for NPs and nurses if they defaulted on their student loans—penalties that did not apply to other health care professionals. My colleagues and I were outraged! Like many others, I had such a loan, which had allowed me to pursue my dream of becoming an NP.

The AANP got the word out, and we bombarded our legislators’ offices with calls and a threat to “march on Washington.” For my part, I personally spoke with Senator Edward “Ted” Kennedy and asked him if he realized the revisions made him look like a “loan shark.” I told him that NPs were in direct competition with physicians in settings identified as “loan repayments sites” and that physicians were more apt to be hired in these settings than NPs. I quickly offered up alternatives to increase the number of eligible sites where NPs could work for loan repayment, such as community health centers—a system for which he had secured funding decades earlier.

The end result of our influence? Community health centers throughout the country would be considered “loan repayment” sites, which helped to expand the opportunities for NPs to fulfill their financial obligations. If that doesn’t show you that being a leader requires you to challenge unfairness and identify solutions to correct inequity, I don’t know what does.

In a health care organization, we all have multiple roles that require us to be leaders. We are collaborators, providers of care, advocates for our patients, problem-solvers, and idealists. We are also role models for nascent health care providers. A leader’s responsibility spans the breadth of the organization, and today’s health care system continues to demand strong leaders capable of utilizing a variety of skills.

Next Thursday, I will continue my investigation of how to become an effective leader. In our fourth and final part of this series, we will discuss how acknowledging our specific personality traits can strengthen the efforts of a leader.

“Lead, follow, or get out of the way” sounds pejorative—even arrogant—but it ultimately speaks truth about most situations involving a team. A leader must know, or at least sense, the right action to take at any given moment; sometimes that action entails yielding leadership to another team member. So let’s break down this quote to identify the functional behavioral requirements of leadership.

Northouse presents the notion that leadership is a relationship or process of collaboration in which each team member is needed. The leader should be cognizant of each member’s interests, ideas, passions, attitudes, and motivations.¹

As a leader, you must reflect on all of your output. This includes how you relate to those you lead; how you collaborate with and affect the actions of your teammates; and how you communicate the process and influence a team toward a goal—which is crucial to the entire team’s success. Allow me to illustrate these core principles.

Relating
Early in the NP movement, it was necessary to develop a collective vision for the profession’s future. What was the purpose of an NP? What could we add to the existing health care landscape? The founders and early proponents of our profession, recognizing that there was power in numbers and strength in collaboration, identified a mission: Provide health care services for those who were underserved. Working as a group, NPs leveraged strength in numbers, creating a more efficient way to move forward and achieve that mission.² In those early NP pioneers, I recognize the leadership skills—ability to engage individuals and coordinate activities to move an agenda forward—that are key components of any relationship.

Collaborating
Later, in 1984, a small group of like-minded NPs (of which I was one) joined together to investigate the possibility of a starting an organization dedicated to NPs. As a profession, we were woefully underrepresented nationally. Our role was not fully understood, especially by legislators, and there were laws in place that impeded patients’ access to care by NPs. The existing nursing organizations were in no position to dedicate their resources to represent us professionally or politically.

Several colleagues and I were willing to take a risk to move our profession forward, even if it meant alienating other NPs. Each of us was able to work autonomously, as well as in a team, and we all viewed adversity as an opportunity. This gave us the impetus and motivation to carry out the footwork needed to achieve our goal. These skills—determination, energy, persistence—are essential for anyone looking to start a business or get involved in an organization.

Maybe when my colleagues and I formed the American Academy of Nurse Practitioners (AANP), we weren’t all leaders … but our relationship consisted of the passion and collective vision needed to work together and achieve. We knew we had to build on each other’s strengths and remain open and respectful of each other’s ideas. We believed we had nothing to lose and everything to gain and—honestly—we succeeded on all fronts!

Continue to: Influencing

Influencing
One success story happened in 1988 when Title VIII of the Public Health Service Act—the Nurse Education Act—was under review. New provisions in the bill included specific penalties for NPs and nurses if they defaulted on their student loans—penalties that did not apply to other health care professionals. My colleagues and I were outraged! Like many others, I had such a loan, which had allowed me to pursue my dream of becoming an NP.

The AANP got the word out, and we bombarded our legislators’ offices with calls and a threat to “march on Washington.” For my part, I personally spoke with Senator Edward “Ted” Kennedy and asked him if he realized the revisions made him look like a “loan shark.” I told him that NPs were in direct competition with physicians in settings identified as “loan repayments sites” and that physicians were more apt to be hired in these settings than NPs. I quickly offered up alternatives to increase the number of eligible sites where NPs could work for loan repayment, such as community health centers—a system for which he had secured funding decades earlier.

The end result of our influence? Community health centers throughout the country would be considered “loan repayment” sites, which helped to expand the opportunities for NPs to fulfill their financial obligations. If that doesn’t show you that being a leader requires you to challenge unfairness and identify solutions to correct inequity, I don’t know what does.

In a health care organization, we all have multiple roles that require us to be leaders. We are collaborators, providers of care, advocates for our patients, problem-solvers, and idealists. We are also role models for nascent health care providers. A leader’s responsibility spans the breadth of the organization, and today’s health care system continues to demand strong leaders capable of utilizing a variety of skills.

Next Thursday, I will continue my investigation of how to become an effective leader. In our fourth and final part of this series, we will discuss how acknowledging our specific personality traits can strengthen the efforts of a leader.

Leadership is both a science and an art, requiring a process, influence, and vision.¹ And—coincidentally?—we could also define nursing in those terms. After all, health care leaders must possess the vision and ability to translate their passion and establish an environment of trust with their teams to achieve the desired outcome.

When I reflect on my experiences as an NP, I think about those who influenced me to pursue this career. My mentors were both scientists and artists who translated their passion to me. Without their combination of caring and competence, I wouldn’t be where I am today. There’d be one less NP—and for me, part of being an NP is showing others the essential value of our profession.

Throughout my career, my mission was to bring NPs into more health care settings—such as urgent care and emergency departments in rural areas—where greater access to care was needed and where NPs were woefully underutilized. Advocating for NPs also led me into nonclinical settings, such as my time as a Health Policy Coordinator. As mentioned last week, this position required me to communicate the needs of both patients and health care providers to multiple groups, including industry associations, federal agencies, and professional licensure boards. No matter the setting, I had to understand its specific function and needs in order to envision and then explain how it would benefit from a stronger NP presence. This always included how NPs would complement other health care providers and professionals.

My mission to bring the NP role to new settings led me to surprising places. For example, I had the opportunity to be the first NP to serve as a Medical Officer on an expedition for JASON Learning—a pioneering nonprofit organization established to engage students in scientific research and expeditions led by leading scientists.² How did I do that, you ask? Well, as a graduate student, I worked on a project with the JASON team. When I had the chance to speak with the expedition coordinator, I mentioned my interest in marine biology. I then asked about the composition of the expedition support team and discovered that they didn’t have an NP. Here was the chance to utilize my communication skills to sell the idea of having a pediatric NP (PNP) on an expedition! I explained my vision of the role a PNP could play, emphasizing how an expedition would benefit from an NP with experience in caring for teenagers.

I must have been persuasive, because that conversation landed me with a primary role as the health care provider on an expedition to the Everglades National Park in Florida. In addition to reviewing the medical history of each “Argonaut” (participant), I treated minor illnesses and injuries and prevented sunburn during the expedition. I also had the opportunity to become certified in Snorkel and SCUBA—and I still use the former today. As a bonus, I met Bob Ballard (known for finding the wreckage of the RMS Titanic) and learned how to tag an alligator.

The excursion to the Everglades was an accomplishment that needed a process, influence, and vision. Later, when championing the creation of AANP, I was able to put these skills into action again. In 1984, when there was no group dedicated to representing NPs, I challenged an audience of colleagues to start a new organization and offered up seed money. A small group of us soon banded together and eventually rallied other NPs to embrace the concept of an NP-specific organization. We developed bylaws, and a year later, our organization was incorporated as a 501(c)(3). The legal address was my home in Lowell, Massachusetts.

Each of these situations required a relationship with the people on the team and a mission to expand the NP profession. In every situation, I translated my vision to others, and we worked together to achieve goals—just as I had been taught through the example of my own mentors.

Continue to: Keep the concepts of...

Keep the concepts of relationship and vison in mind as we continue discussing leadership next Thursday in Part 3. In the meantime, please share your thoughts, approaches, and accomplishments as a leader.

Leadership is both a science and an art, requiring a process, influence, and vision.¹ And—coincidentally?—we could also define nursing in those terms. After all, health care leaders must possess the vision and ability to translate their passion and establish an environment of trust with their teams to achieve the desired outcome.

When I reflect on my experiences as an NP, I think about those who influenced me to pursue this career. My mentors were both scientists and artists who translated their passion to me. Without their combination of caring and competence, I wouldn’t be where I am today. There’d be one less NP—and for me, part of being an NP is showing others the essential value of our profession.

Throughout my career, my mission was to bring NPs into more health care settings—such as urgent care and emergency departments in rural areas—where greater access to care was needed and where NPs were woefully underutilized. Advocating for NPs also led me into nonclinical settings, such as my time as a Health Policy Coordinator. As mentioned last week, this position required me to communicate the needs of both patients and health care providers to multiple groups, including industry associations, federal agencies, and professional licensure boards. No matter the setting, I had to understand its specific function and needs in order to envision and then explain how it would benefit from a stronger NP presence. This always included how NPs would complement other health care providers and professionals.

My mission to bring the NP role to new settings led me to surprising places. For example, I had the opportunity to be the first NP to serve as a Medical Officer on an expedition for JASON Learning—a pioneering nonprofit organization established to engage students in scientific research and expeditions led by leading scientists.² How did I do that, you ask? Well, as a graduate student, I worked on a project with the JASON team. When I had the chance to speak with the expedition coordinator, I mentioned my interest in marine biology. I then asked about the composition of the expedition support team and discovered that they didn’t have an NP. Here was the chance to utilize my communication skills to sell the idea of having a pediatric NP (PNP) on an expedition! I explained my vision of the role a PNP could play, emphasizing how an expedition would benefit from an NP with experience in caring for teenagers.

I must have been persuasive, because that conversation landed me with a primary role as the health care provider on an expedition to the Everglades National Park in Florida. In addition to reviewing the medical history of each “Argonaut” (participant), I treated minor illnesses and injuries and prevented sunburn during the expedition. I also had the opportunity to become certified in Snorkel and SCUBA—and I still use the former today. As a bonus, I met Bob Ballard (known for finding the wreckage of the RMS Titanic) and learned how to tag an alligator.

The excursion to the Everglades was an accomplishment that needed a process, influence, and vision. Later, when championing the creation of AANP, I was able to put these skills into action again. In 1984, when there was no group dedicated to representing NPs, I challenged an audience of colleagues to start a new organization and offered up seed money. A small group of us soon banded together and eventually rallied other NPs to embrace the concept of an NP-specific organization. We developed bylaws, and a year later, our organization was incorporated as a 501(c)(3). The legal address was my home in Lowell, Massachusetts.

Each of these situations required a relationship with the people on the team and a mission to expand the NP profession. In every situation, I translated my vision to others, and we worked together to achieve goals—just as I had been taught through the example of my own mentors.

Continue to: Keep the concepts of...

Keep the concepts of relationship and vison in mind as we continue discussing leadership next Thursday in Part 3. In the meantime, please share your thoughts, approaches, and accomplishments as a leader.

Leadership is both a science and an art, requiring a process, influence, and vision.¹ And—coincidentally?—we could also define nursing in those terms. After all, health care leaders must possess the vision and ability to translate their passion and establish an environment of trust with their teams to achieve the desired outcome.

When I reflect on my experiences as an NP, I think about those who influenced me to pursue this career. My mentors were both scientists and artists who translated their passion to me. Without their combination of caring and competence, I wouldn’t be where I am today. There’d be one less NP—and for me, part of being an NP is showing others the essential value of our profession.

Throughout my career, my mission was to bring NPs into more health care settings—such as urgent care and emergency departments in rural areas—where greater access to care was needed and where NPs were woefully underutilized. Advocating for NPs also led me into nonclinical settings, such as my time as a Health Policy Coordinator. As mentioned last week, this position required me to communicate the needs of both patients and health care providers to multiple groups, including industry associations, federal agencies, and professional licensure boards. No matter the setting, I had to understand its specific function and needs in order to envision and then explain how it would benefit from a stronger NP presence. This always included how NPs would complement other health care providers and professionals.

My mission to bring the NP role to new settings led me to surprising places. For example, I had the opportunity to be the first NP to serve as a Medical Officer on an expedition for JASON Learning—a pioneering nonprofit organization established to engage students in scientific research and expeditions led by leading scientists.² How did I do that, you ask? Well, as a graduate student, I worked on a project with the JASON team. When I had the chance to speak with the expedition coordinator, I mentioned my interest in marine biology. I then asked about the composition of the expedition support team and discovered that they didn’t have an NP. Here was the chance to utilize my communication skills to sell the idea of having a pediatric NP (PNP) on an expedition! I explained my vision of the role a PNP could play, emphasizing how an expedition would benefit from an NP with experience in caring for teenagers.

I must have been persuasive, because that conversation landed me with a primary role as the health care provider on an expedition to the Everglades National Park in Florida. In addition to reviewing the medical history of each “Argonaut” (participant), I treated minor illnesses and injuries and prevented sunburn during the expedition. I also had the opportunity to become certified in Snorkel and SCUBA—and I still use the former today. As a bonus, I met Bob Ballard (known for finding the wreckage of the RMS Titanic) and learned how to tag an alligator.

The excursion to the Everglades was an accomplishment that needed a process, influence, and vision. Later, when championing the creation of AANP, I was able to put these skills into action again. In 1984, when there was no group dedicated to representing NPs, I challenged an audience of colleagues to start a new organization and offered up seed money. A small group of us soon banded together and eventually rallied other NPs to embrace the concept of an NP-specific organization. We developed bylaws, and a year later, our organization was incorporated as a 501(c)(3). The legal address was my home in Lowell, Massachusetts.

Each of these situations required a relationship with the people on the team and a mission to expand the NP profession. In every situation, I translated my vision to others, and we worked together to achieve goals—just as I had been taught through the example of my own mentors.

Continue to: Keep the concepts of...

Keep the concepts of relationship and vison in mind as we continue discussing leadership next Thursday in Part 3. In the meantime, please share your thoughts, approaches, and accomplishments as a leader.

Is it my imagination, or has there been a lot of discussion on leadership lately? In the past 3 years, all the meetings I have attended had at least 1 presentation on leadership or the traits of leaders. Sometimes—even in the oddest places—I have come across an article with “leadership” in the title. In fact, a serendipitous discovery of 2 publications is what inspired me to write this.

I spotted the first one in a reading basket when I was on vacation: It was an interview with Benjamin Zander, the conductor of the Boston Philharmonic Orchestra and the Boston Philharmonic Youth Orchestra.¹ I was especially interested to read this because when I was in graduate school, Benjamin (the father of one of my classmates) visited our campus to give a presentation on talent and self-confidence. I can still hear him conducting us to emphatically believe in ourselves and others. This was echoed in his interview: “Never doubt the capacity of the people you lead to accomplish whatever you dream for them.” What a powerful concept: Believe in the possibilities of someone!

The second was an American Legion Auxiliary column, which emphasized that “leadership is not a title, but a responsibility.”² This struck a chord with me because some prominent leaders don’t appear to ascribe to that assessment (although they should!).

After digesting these articles, I started thinking: What, exactly, is leadership? What do we even mean by leadership? How do we measure it? Is it measurable? How do we know when we see or experience good leadership? Can one learn to become a leader by simply reading a “how-to” article?

I think I can answer these questions with 2 principles that have guided me through my career as an NP: (1) Make use of another leader’s expertise to guide you, and (2) Continue to grow amid any setbacks.

For example, my transition from a full-time clinician to a Health Policy Coordinator or “policy wonk” did not have a distinct trajectory. Although my core set of clinical skills were essential, I knew early on that I had to expand by adapting specific organizational skills that would enable me to grow in my new role. But how was I to prioritize which skills to improve? More than a simple trial-and-error approach was required; I needed guidance. Fortunately, my new boss was willing to share her experience and the lessons she learned on the job. Key among them was to recognize the skills I already had—communicating and coordinating—and to develop those skills to be more effective in my new position.

Later in my career, I worked with colleagues to pursue legislation for NP prescriptive authority in Massachusetts. The political arena of Commonwealth’s health care laws was especially pivotal in changing how I saw setbacks. These weren’t to be accepted as a failure but as a challenge to figure out how to better succeed the next time. For several years, I was told “No” before we finally got a bill passed. But each round of my testimony was an opportunity to educate lawmakers and the public on the valuable role of NPs and the quality of care we provide. I try to share this story with new NPs as a good example of why they should persist through adversity.

Continue to: Over the next 3 weeks...

Over the next 3 weeks, join us on Thursdays as we continue to discuss what it means to be a leader—from the pitfalls to the victories. For those who are leaders or who work for one, please share your thoughts, experiences, and lessons learned. Maybe you can give a shoutout to someone who was a positive influence!

Is it my imagination, or has there been a lot of discussion on leadership lately? In the past 3 years, all the meetings I have attended had at least 1 presentation on leadership or the traits of leaders. Sometimes—even in the oddest places—I have come across an article with “leadership” in the title. In fact, a serendipitous discovery of 2 publications is what inspired me to write this.

I spotted the first one in a reading basket when I was on vacation: It was an interview with Benjamin Zander, the conductor of the Boston Philharmonic Orchestra and the Boston Philharmonic Youth Orchestra.¹ I was especially interested to read this because when I was in graduate school, Benjamin (the father of one of my classmates) visited our campus to give a presentation on talent and self-confidence. I can still hear him conducting us to emphatically believe in ourselves and others. This was echoed in his interview: “Never doubt the capacity of the people you lead to accomplish whatever you dream for them.” What a powerful concept: Believe in the possibilities of someone!

The second was an American Legion Auxiliary column, which emphasized that “leadership is not a title, but a responsibility.”² This struck a chord with me because some prominent leaders don’t appear to ascribe to that assessment (although they should!).

After digesting these articles, I started thinking: What, exactly, is leadership? What do we even mean by leadership? How do we measure it? Is it measurable? How do we know when we see or experience good leadership? Can one learn to become a leader by simply reading a “how-to” article?

I think I can answer these questions with 2 principles that have guided me through my career as an NP: (1) Make use of another leader’s expertise to guide you, and (2) Continue to grow amid any setbacks.

For example, my transition from a full-time clinician to a Health Policy Coordinator or “policy wonk” did not have a distinct trajectory. Although my core set of clinical skills were essential, I knew early on that I had to expand by adapting specific organizational skills that would enable me to grow in my new role. But how was I to prioritize which skills to improve? More than a simple trial-and-error approach was required; I needed guidance. Fortunately, my new boss was willing to share her experience and the lessons she learned on the job. Key among them was to recognize the skills I already had—communicating and coordinating—and to develop those skills to be more effective in my new position.

Later in my career, I worked with colleagues to pursue legislation for NP prescriptive authority in Massachusetts. The political arena of Commonwealth’s health care laws was especially pivotal in changing how I saw setbacks. These weren’t to be accepted as a failure but as a challenge to figure out how to better succeed the next time. For several years, I was told “No” before we finally got a bill passed. But each round of my testimony was an opportunity to educate lawmakers and the public on the valuable role of NPs and the quality of care we provide. I try to share this story with new NPs as a good example of why they should persist through adversity.

Continue to: Over the next 3 weeks...

Over the next 3 weeks, join us on Thursdays as we continue to discuss what it means to be a leader—from the pitfalls to the victories. For those who are leaders or who work for one, please share your thoughts, experiences, and lessons learned. Maybe you can give a shoutout to someone who was a positive influence!

Is it my imagination, or has there been a lot of discussion on leadership lately? In the past 3 years, all the meetings I have attended had at least 1 presentation on leadership or the traits of leaders. Sometimes—even in the oddest places—I have come across an article with “leadership” in the title. In fact, a serendipitous discovery of 2 publications is what inspired me to write this.

I spotted the first one in a reading basket when I was on vacation: It was an interview with Benjamin Zander, the conductor of the Boston Philharmonic Orchestra and the Boston Philharmonic Youth Orchestra.¹ I was especially interested to read this because when I was in graduate school, Benjamin (the father of one of my classmates) visited our campus to give a presentation on talent and self-confidence. I can still hear him conducting us to emphatically believe in ourselves and others. This was echoed in his interview: “Never doubt the capacity of the people you lead to accomplish whatever you dream for them.” What a powerful concept: Believe in the possibilities of someone!

The second was an American Legion Auxiliary column, which emphasized that “leadership is not a title, but a responsibility.”² This struck a chord with me because some prominent leaders don’t appear to ascribe to that assessment (although they should!).

After digesting these articles, I started thinking: What, exactly, is leadership? What do we even mean by leadership? How do we measure it? Is it measurable? How do we know when we see or experience good leadership? Can one learn to become a leader by simply reading a “how-to” article?

I think I can answer these questions with 2 principles that have guided me through my career as an NP: (1) Make use of another leader’s expertise to guide you, and (2) Continue to grow amid any setbacks.

For example, my transition from a full-time clinician to a Health Policy Coordinator or “policy wonk” did not have a distinct trajectory. Although my core set of clinical skills were essential, I knew early on that I had to expand by adapting specific organizational skills that would enable me to grow in my new role. But how was I to prioritize which skills to improve? More than a simple trial-and-error approach was required; I needed guidance. Fortunately, my new boss was willing to share her experience and the lessons she learned on the job. Key among them was to recognize the skills I already had—communicating and coordinating—and to develop those skills to be more effective in my new position.

Later in my career, I worked with colleagues to pursue legislation for NP prescriptive authority in Massachusetts. The political arena of Commonwealth’s health care laws was especially pivotal in changing how I saw setbacks. These weren’t to be accepted as a failure but as a challenge to figure out how to better succeed the next time. For several years, I was told “No” before we finally got a bill passed. But each round of my testimony was an opportunity to educate lawmakers and the public on the valuable role of NPs and the quality of care we provide. I try to share this story with new NPs as a good example of why they should persist through adversity.

Continue to: Over the next 3 weeks...

Over the next 3 weeks, join us on Thursdays as we continue to discuss what it means to be a leader—from the pitfalls to the victories. For those who are leaders or who work for one, please share your thoughts, experiences, and lessons learned. Maybe you can give a shoutout to someone who was a positive influence!

I have been ruminating about the Bai et al article on independent billing in the emergency department (ED) for weeks.¹ I keep wondering why the data analysis seems so off base. Don’t get me wrong: The data gathered from Medicare is what it is—but a key piece of information is not present in the pure numbers input to the Medicare database.

So, I continued to probe this study with my colleagues. To a person, their comments supported that the intent of the study is unclear. The authors posit their objective to be an examination of the “involvement of NPs and PAs” in emergency services, using billing data. But to use billing data as a measure of “involvement” does not tell the whole story.

Independence in billing does not mean that the care NPs and PAs are providing is “beyond their scope of practice.” Moreover, the billing does not capture whether, or to what extent, physician consultation or assistance was involved. If the NP or PA dictated the chart, then they are by default the “only” (independent) provider. However, billing independently does not mean a physician (or other provider) was not consulted about the plan of care. 

Case in point: Years ago, I had a young woman present to the ED with a sore throat. Her presenting complaint was a symptom of a peritonsillar abscess. So I phoned an ENT colleague (a physician) and asked him about the best treatment and follow-up in this case. Did he make a note in or sign the chart? No. Was I the only provider of record? Yes. Was that care “independent,” if you only look at the billing (done by a coder, for the record)? Yes. 

Admittedly, Bai and colleagues do add in their conclusion that “independence in billing … does not necessarily indicate [NPs’/PAs’] independence in care delivery.”1 And they do note that the true challenge in the ED is determining how best to “blend” the expertise of the three professions (MD, NP, and PA) to provide efficient and cost-effective care.

However, throughout the article, there is an underpinning of inference that NPs and PAs are potentially practicing beyond their scope. Their comment that the increase in billing for NP and PA services results in a “reduction of the proportion of emergency physicians” speaks volumes.¹ Perhaps there is more concern here about ED physician job security than about independent billing!

Regardless of the intention by Bai et al—and acknowledging that the analysis they presented is somewhat interesting—I see two missed opportunities to “actionalize” the data.² One is to use the information to identify whether a problem with billing exists (ie, is there upcharging as a result of more details contained within the electronic health record?). The second is to use the data to investigate innovative ways to improve access to care across the continuum. Essentially, how do we use the results of any data analysis in a way that can be useful? That is the real challenge. 

Continue to: The biggest conclusion I've drawn...

The biggest conclusion I’ve drawn from my exploration of these study findings? The opportunity to investigate the competencies of all ED providers, with the goal of improving access and controlling costs, is there. And as the NPs and PAs providing the care, we should undertake the next research study or data analysis and not leave the research on us to other professions!

I’d love to hear your thoughts on the Bai et al study or any aspect of this 4-part discussion! Drop me a line at NPEditor@mdege.com.

I have been ruminating about the Bai et al article on independent billing in the emergency department (ED) for weeks.¹ I keep wondering why the data analysis seems so off base. Don’t get me wrong: The data gathered from Medicare is what it is—but a key piece of information is not present in the pure numbers input to the Medicare database.

So, I continued to probe this study with my colleagues. To a person, their comments supported that the intent of the study is unclear. The authors posit their objective to be an examination of the “involvement of NPs and PAs” in emergency services, using billing data. But to use billing data as a measure of “involvement” does not tell the whole story.

Independence in billing does not mean that the care NPs and PAs are providing is “beyond their scope of practice.” Moreover, the billing does not capture whether, or to what extent, physician consultation or assistance was involved. If the NP or PA dictated the chart, then they are by default the “only” (independent) provider. However, billing independently does not mean a physician (or other provider) was not consulted about the plan of care. 

Case in point: Years ago, I had a young woman present to the ED with a sore throat. Her presenting complaint was a symptom of a peritonsillar abscess. So I phoned an ENT colleague (a physician) and asked him about the best treatment and follow-up in this case. Did he make a note in or sign the chart? No. Was I the only provider of record? Yes. Was that care “independent,” if you only look at the billing (done by a coder, for the record)? Yes. 

Admittedly, Bai and colleagues do add in their conclusion that “independence in billing … does not necessarily indicate [NPs’/PAs’] independence in care delivery.”1 And they do note that the true challenge in the ED is determining how best to “blend” the expertise of the three professions (MD, NP, and PA) to provide efficient and cost-effective care.

However, throughout the article, there is an underpinning of inference that NPs and PAs are potentially practicing beyond their scope. Their comment that the increase in billing for NP and PA services results in a “reduction of the proportion of emergency physicians” speaks volumes.¹ Perhaps there is more concern here about ED physician job security than about independent billing!

Regardless of the intention by Bai et al—and acknowledging that the analysis they presented is somewhat interesting—I see two missed opportunities to “actionalize” the data.² One is to use the information to identify whether a problem with billing exists (ie, is there upcharging as a result of more details contained within the electronic health record?). The second is to use the data to investigate innovative ways to improve access to care across the continuum. Essentially, how do we use the results of any data analysis in a way that can be useful? That is the real challenge. 

Continue to: The biggest conclusion I've drawn...

The biggest conclusion I’ve drawn from my exploration of these study findings? The opportunity to investigate the competencies of all ED providers, with the goal of improving access and controlling costs, is there. And as the NPs and PAs providing the care, we should undertake the next research study or data analysis and not leave the research on us to other professions!

I’d love to hear your thoughts on the Bai et al study or any aspect of this 4-part discussion! Drop me a line at NPEditor@mdege.com.

I have been ruminating about the Bai et al article on independent billing in the emergency department (ED) for weeks.¹ I keep wondering why the data analysis seems so off base. Don’t get me wrong: The data gathered from Medicare is what it is—but a key piece of information is not present in the pure numbers input to the Medicare database.

So, I continued to probe this study with my colleagues. To a person, their comments supported that the intent of the study is unclear. The authors posit their objective to be an examination of the “involvement of NPs and PAs” in emergency services, using billing data. But to use billing data as a measure of “involvement” does not tell the whole story.

Independence in billing does not mean that the care NPs and PAs are providing is “beyond their scope of practice.” Moreover, the billing does not capture whether, or to what extent, physician consultation or assistance was involved. If the NP or PA dictated the chart, then they are by default the “only” (independent) provider. However, billing independently does not mean a physician (or other provider) was not consulted about the plan of care. 

Case in point: Years ago, I had a young woman present to the ED with a sore throat. Her presenting complaint was a symptom of a peritonsillar abscess. So I phoned an ENT colleague (a physician) and asked him about the best treatment and follow-up in this case. Did he make a note in or sign the chart? No. Was I the only provider of record? Yes. Was that care “independent,” if you only look at the billing (done by a coder, for the record)? Yes. 

Admittedly, Bai and colleagues do add in their conclusion that “independence in billing … does not necessarily indicate [NPs’/PAs’] independence in care delivery.”1 And they do note that the true challenge in the ED is determining how best to “blend” the expertise of the three professions (MD, NP, and PA) to provide efficient and cost-effective care.

However, throughout the article, there is an underpinning of inference that NPs and PAs are potentially practicing beyond their scope. Their comment that the increase in billing for NP and PA services results in a “reduction of the proportion of emergency physicians” speaks volumes.¹ Perhaps there is more concern here about ED physician job security than about independent billing!

Regardless of the intention by Bai et al—and acknowledging that the analysis they presented is somewhat interesting—I see two missed opportunities to “actionalize” the data.² One is to use the information to identify whether a problem with billing exists (ie, is there upcharging as a result of more details contained within the electronic health record?). The second is to use the data to investigate innovative ways to improve access to care across the continuum. Essentially, how do we use the results of any data analysis in a way that can be useful? That is the real challenge. 

Continue to: The biggest conclusion I've drawn...

The biggest conclusion I’ve drawn from my exploration of these study findings? The opportunity to investigate the competencies of all ED providers, with the goal of improving access and controlling costs, is there. And as the NPs and PAs providing the care, we should undertake the next research study or data analysis and not leave the research on us to other professions!

I’d love to hear your thoughts on the Bai et al study or any aspect of this 4-part discussion! Drop me a line at NPEditor@mdege.com.

Nurse practitioners (and PAs, I would submit) have been the most researched group of health care professionals since the inception of the role. Much of that research has focused on evaluating our contributions to primary care. Numerous studies of NP performance in various settings have concluded that we perform as well as physicians with respect to patient outcomes, proper diagnosis, management of specific medical conditions, and patient satisfaction.¹

Over the past 10 years, however, the interest in our roles has shifted from the primary care arena to the emergency department (ED). Even before the introduction of the Affordable Care Act (ACA), two-thirds of all EDs utilized NPs and PAs.² The ACA increased the number of Americans with insurance coverage, resulting in a greater demand for health care services—including ED utilization. Faced with an already strained system, hospital administrators looked for a solution and found one: hiring NPs and PAs to augment the clinician workforce.

This decision to (increasingly) employ NPs and PAs in ED settings was based on a desire to reduce wait times, increase throughput, improve access to care, and control costs. For the most part, these goals have been achieved. A systematic review of the impact of NPs in the ED on quality of care and patient satisfaction demonstrated a reduction in wait times.³ Moreover, in a national survey that included a review of the types of visits made to the ED, NPs and PAs were comparable to MDs in terms of reasons for care, diagnosis, and treatment.⁴

Given these results, I again ask: What was the intent of the research by Bai et al?⁵ Surely proper and prompt care is the goal of every ED provider. So the decision to examine only the billing is confounding.

Are the authors suggesting that hospital administrators prefer employing NPs and PAs over MDs? Are we replacing physicians in certain areas or filling voids where the physician workforce is inadequate to meet the community demands? Maybe yes to both. But, if the goal is to improve access, then we should focus on meeting the needs and on the quality of the care, not on who bills for it.

My cynical self says the goal of Bai et al was to establish that NPs and PAs are taking the jobs of ED physicians, and we must be stopped! Am I tilting at windmills with this train of thought? Next week, we’ll conclude our examination and draw our own conclusions! You can join the conversation by writing to NPEditor@mdedge.com.

Nurse practitioners (and PAs, I would submit) have been the most researched group of health care professionals since the inception of the role. Much of that research has focused on evaluating our contributions to primary care. Numerous studies of NP performance in various settings have concluded that we perform as well as physicians with respect to patient outcomes, proper diagnosis, management of specific medical conditions, and patient satisfaction.¹

Over the past 10 years, however, the interest in our roles has shifted from the primary care arena to the emergency department (ED). Even before the introduction of the Affordable Care Act (ACA), two-thirds of all EDs utilized NPs and PAs.² The ACA increased the number of Americans with insurance coverage, resulting in a greater demand for health care services—including ED utilization. Faced with an already strained system, hospital administrators looked for a solution and found one: hiring NPs and PAs to augment the clinician workforce.

This decision to (increasingly) employ NPs and PAs in ED settings was based on a desire to reduce wait times, increase throughput, improve access to care, and control costs. For the most part, these goals have been achieved. A systematic review of the impact of NPs in the ED on quality of care and patient satisfaction demonstrated a reduction in wait times.³ Moreover, in a national survey that included a review of the types of visits made to the ED, NPs and PAs were comparable to MDs in terms of reasons for care, diagnosis, and treatment.⁴

Given these results, I again ask: What was the intent of the research by Bai et al?⁵ Surely proper and prompt care is the goal of every ED provider. So the decision to examine only the billing is confounding.

Are the authors suggesting that hospital administrators prefer employing NPs and PAs over MDs? Are we replacing physicians in certain areas or filling voids where the physician workforce is inadequate to meet the community demands? Maybe yes to both. But, if the goal is to improve access, then we should focus on meeting the needs and on the quality of the care, not on who bills for it.

My cynical self says the goal of Bai et al was to establish that NPs and PAs are taking the jobs of ED physicians, and we must be stopped! Am I tilting at windmills with this train of thought? Next week, we’ll conclude our examination and draw our own conclusions! You can join the conversation by writing to NPEditor@mdedge.com.

Nurse practitioners (and PAs, I would submit) have been the most researched group of health care professionals since the inception of the role. Much of that research has focused on evaluating our contributions to primary care. Numerous studies of NP performance in various settings have concluded that we perform as well as physicians with respect to patient outcomes, proper diagnosis, management of specific medical conditions, and patient satisfaction.¹

Over the past 10 years, however, the interest in our roles has shifted from the primary care arena to the emergency department (ED). Even before the introduction of the Affordable Care Act (ACA), two-thirds of all EDs utilized NPs and PAs.² The ACA increased the number of Americans with insurance coverage, resulting in a greater demand for health care services—including ED utilization. Faced with an already strained system, hospital administrators looked for a solution and found one: hiring NPs and PAs to augment the clinician workforce.

This decision to (increasingly) employ NPs and PAs in ED settings was based on a desire to reduce wait times, increase throughput, improve access to care, and control costs. For the most part, these goals have been achieved. A systematic review of the impact of NPs in the ED on quality of care and patient satisfaction demonstrated a reduction in wait times.³ Moreover, in a national survey that included a review of the types of visits made to the ED, NPs and PAs were comparable to MDs in terms of reasons for care, diagnosis, and treatment.⁴

Given these results, I again ask: What was the intent of the research by Bai et al?⁵ Surely proper and prompt care is the goal of every ED provider. So the decision to examine only the billing is confounding.

Are the authors suggesting that hospital administrators prefer employing NPs and PAs over MDs? Are we replacing physicians in certain areas or filling voids where the physician workforce is inadequate to meet the community demands? Maybe yes to both. But, if the goal is to improve access, then we should focus on meeting the needs and on the quality of the care, not on who bills for it.

My cynical self says the goal of Bai et al was to establish that NPs and PAs are taking the jobs of ED physicians, and we must be stopped! Am I tilting at windmills with this train of thought? Next week, we’ll conclude our examination and draw our own conclusions! You can join the conversation by writing to NPEditor@mdedge.com.

In an attempt to understand the data presented by Bai et al regarding independent billing by NPs and PAs in the emergency department (ED), I reached out to several colleagues to get their take on the study.¹ Four of them are ED providers (2 MDs, 1 NP, 1 PA), and another is an experienced data analyst. In short, the analysis was analyzed!

Each member of my “expert panel” had similar comments and concerns, particularly regarding billing versus providing care. These are two different animals, or—as I often say—Bai and colleagues were comparing “oranges and shoes.” Several colleagues questioned the purpose of the article: What were the authors really trying to say?

Both MDs noted the absence of comments related to any consultation between the NP/PA and the ED physician during the patient encounter. They also pointed out the sheer volume of patients in EDs, resulting in the increasing popularity and utilization of NP/PAs to provide timely care to patients in need.

More than one of us initially wondered whether there could be potential “overbilling.” With the implementation of electronic health records (EHRs), the average charge per patient has increased. Maybe the EHR, now so common in EDs, more accurately captures the amount of time the provider spends caring for the patient and allows for more detailed documentation of the visit. This might result in a prima facie higher level of billing without necessarily representing the acuity of the presenting complaint.

One fact not presented in the Bai article is that, in many instances, providers (whether MDs, NPs, or PAs) do not complete the bills submitted to the insurance companies. In many EDs, medical coders extract the patient encounter data from the medical record. The reality is, the acuity of the patient is being decided by the person who is coding the visit—not the provider. And thus, it is potentially flawed thinking to rely on billing data alone to assess an increase in the acuity of patients seen by NPs and PAs in the ED.

Since we know (through data!) that there are more NPs and PAs providing care in EDs across the country, it follows logically that there will be more bills submitted in our names. This leads me to wonder: What was the motivation for Bai and colleagues to perform this study? What point are they actually trying to make?

Stay tuned ... There’s more to say next week! (In the meantime, you can share your thoughts by writing to me at NPEditor@mdedge.com.)

In an attempt to understand the data presented by Bai et al regarding independent billing by NPs and PAs in the emergency department (ED), I reached out to several colleagues to get their take on the study.¹ Four of them are ED providers (2 MDs, 1 NP, 1 PA), and another is an experienced data analyst. In short, the analysis was analyzed!

Each member of my “expert panel” had similar comments and concerns, particularly regarding billing versus providing care. These are two different animals, or—as I often say—Bai and colleagues were comparing “oranges and shoes.” Several colleagues questioned the purpose of the article: What were the authors really trying to say?

Both MDs noted the absence of comments related to any consultation between the NP/PA and the ED physician during the patient encounter. They also pointed out the sheer volume of patients in EDs, resulting in the increasing popularity and utilization of NP/PAs to provide timely care to patients in need.

More than one of us initially wondered whether there could be potential “overbilling.” With the implementation of electronic health records (EHRs), the average charge per patient has increased. Maybe the EHR, now so common in EDs, more accurately captures the amount of time the provider spends caring for the patient and allows for more detailed documentation of the visit. This might result in a prima facie higher level of billing without necessarily representing the acuity of the presenting complaint.

One fact not presented in the Bai article is that, in many instances, providers (whether MDs, NPs, or PAs) do not complete the bills submitted to the insurance companies. In many EDs, medical coders extract the patient encounter data from the medical record. The reality is, the acuity of the patient is being decided by the person who is coding the visit—not the provider. And thus, it is potentially flawed thinking to rely on billing data alone to assess an increase in the acuity of patients seen by NPs and PAs in the ED.

Since we know (through data!) that there are more NPs and PAs providing care in EDs across the country, it follows logically that there will be more bills submitted in our names. This leads me to wonder: What was the motivation for Bai and colleagues to perform this study? What point are they actually trying to make?

Stay tuned ... There’s more to say next week! (In the meantime, you can share your thoughts by writing to me at NPEditor@mdedge.com.)

In an attempt to understand the data presented by Bai et al regarding independent billing by NPs and PAs in the emergency department (ED), I reached out to several colleagues to get their take on the study.¹ Four of them are ED providers (2 MDs, 1 NP, 1 PA), and another is an experienced data analyst. In short, the analysis was analyzed!

Each member of my “expert panel” had similar comments and concerns, particularly regarding billing versus providing care. These are two different animals, or—as I often say—Bai and colleagues were comparing “oranges and shoes.” Several colleagues questioned the purpose of the article: What were the authors really trying to say?

Both MDs noted the absence of comments related to any consultation between the NP/PA and the ED physician during the patient encounter. They also pointed out the sheer volume of patients in EDs, resulting in the increasing popularity and utilization of NP/PAs to provide timely care to patients in need.

More than one of us initially wondered whether there could be potential “overbilling.” With the implementation of electronic health records (EHRs), the average charge per patient has increased. Maybe the EHR, now so common in EDs, more accurately captures the amount of time the provider spends caring for the patient and allows for more detailed documentation of the visit. This might result in a prima facie higher level of billing without necessarily representing the acuity of the presenting complaint.

One fact not presented in the Bai article is that, in many instances, providers (whether MDs, NPs, or PAs) do not complete the bills submitted to the insurance companies. In many EDs, medical coders extract the patient encounter data from the medical record. The reality is, the acuity of the patient is being decided by the person who is coding the visit—not the provider. And thus, it is potentially flawed thinking to rely on billing data alone to assess an increase in the acuity of patients seen by NPs and PAs in the ED.

Since we know (through data!) that there are more NPs and PAs providing care in EDs across the country, it follows logically that there will be more bills submitted in our names. This leads me to wonder: What was the motivation for Bai and colleagues to perform this study? What point are they actually trying to make?

Stay tuned ... There’s more to say next week! (In the meantime, you can share your thoughts by writing to me at NPEditor@mdedge.com.)

Recently, my colleague Randy D. Danielsen, PhD, DFAAPA, PA-C Emeritus, shared a study from the American Journal of Emergency Medicine that focused on “the involvement of NPs and PAs who billed independently” in emergency departments (EDs).¹ In casual conversation, several of us agreed the findings didn’t “pass the sniff test,” so I decided to do some investigating.

The context: Data from 2006-2009 indicate that in two-thirds of all EDs, NPs and PAs are involved in the care of 13.7% of all patients.² Further analysis of Medicare Public Use Files from 2014 reveal that of 58,641 unique emergency medicine clinicians, 14,360 (24.5%) are advanced practice providers.³ All interesting statistics.

The American Journal of Emergency Medicine article, however, gave me (and several colleagues) pause. In it, the authors presented their analysis of Medicare provider utilization and payment data from 2012-2016.¹ The researchers documented billing increases of 65% for NPs and 35% for PAs.

But what stopped me in my tracks was that the researchers emphasized an increase—from 18% to 24%—in NP/PA treatment of patients with the highest severity illness or injury (CPT code 99285).¹ I discussed this finding with ED-based colleagues, and they too questioned its accuracy.

In fact, the more we parsed this study, the more questions we had … and the higher our eyebrows raised. What were the researchers examining and drawing conclusions on— independent billing by NPs and PAs, or independent practice? These are two very different measures. Were the authors in fact grousing about the increase in NP/PA providers in EDs? 

There is a paucity of research on billing by NPs and PAs, and the discussion surrounding this particular study will undoubtedly prompt additional questions. Over the next 3 weeks, we invite you to join us on Thursdays as we continue our examination of this data—and encourage you to share your thoughts with us along the way!

Recently, my colleague Randy D. Danielsen, PhD, DFAAPA, PA-C Emeritus, shared a study from the American Journal of Emergency Medicine that focused on “the involvement of NPs and PAs who billed independently” in emergency departments (EDs).¹ In casual conversation, several of us agreed the findings didn’t “pass the sniff test,” so I decided to do some investigating.

The context: Data from 2006-2009 indicate that in two-thirds of all EDs, NPs and PAs are involved in the care of 13.7% of all patients.² Further analysis of Medicare Public Use Files from 2014 reveal that of 58,641 unique emergency medicine clinicians, 14,360 (24.5%) are advanced practice providers.³ All interesting statistics.

The American Journal of Emergency Medicine article, however, gave me (and several colleagues) pause. In it, the authors presented their analysis of Medicare provider utilization and payment data from 2012-2016.¹ The researchers documented billing increases of 65% for NPs and 35% for PAs.

But what stopped me in my tracks was that the researchers emphasized an increase—from 18% to 24%—in NP/PA treatment of patients with the highest severity illness or injury (CPT code 99285).¹ I discussed this finding with ED-based colleagues, and they too questioned its accuracy.

In fact, the more we parsed this study, the more questions we had … and the higher our eyebrows raised. What were the researchers examining and drawing conclusions on— independent billing by NPs and PAs, or independent practice? These are two very different measures. Were the authors in fact grousing about the increase in NP/PA providers in EDs? 

There is a paucity of research on billing by NPs and PAs, and the discussion surrounding this particular study will undoubtedly prompt additional questions. Over the next 3 weeks, we invite you to join us on Thursdays as we continue our examination of this data—and encourage you to share your thoughts with us along the way!

Recently, my colleague Randy D. Danielsen, PhD, DFAAPA, PA-C Emeritus, shared a study from the American Journal of Emergency Medicine that focused on “the involvement of NPs and PAs who billed independently” in emergency departments (EDs).¹ In casual conversation, several of us agreed the findings didn’t “pass the sniff test,” so I decided to do some investigating.

The context: Data from 2006-2009 indicate that in two-thirds of all EDs, NPs and PAs are involved in the care of 13.7% of all patients.² Further analysis of Medicare Public Use Files from 2014 reveal that of 58,641 unique emergency medicine clinicians, 14,360 (24.5%) are advanced practice providers.³ All interesting statistics.

The American Journal of Emergency Medicine article, however, gave me (and several colleagues) pause. In it, the authors presented their analysis of Medicare provider utilization and payment data from 2012-2016.¹ The researchers documented billing increases of 65% for NPs and 35% for PAs.

But what stopped me in my tracks was that the researchers emphasized an increase—from 18% to 24%—in NP/PA treatment of patients with the highest severity illness or injury (CPT code 99285).¹ I discussed this finding with ED-based colleagues, and they too questioned its accuracy.

In fact, the more we parsed this study, the more questions we had … and the higher our eyebrows raised. What were the researchers examining and drawing conclusions on— independent billing by NPs and PAs, or independent practice? These are two very different measures. Were the authors in fact grousing about the increase in NP/PA providers in EDs? 

There is a paucity of research on billing by NPs and PAs, and the discussion surrounding this particular study will undoubtedly prompt additional questions. Over the next 3 weeks, we invite you to join us on Thursdays as we continue our examination of this data—and encourage you to share your thoughts with us along the way!

Every year, thousands of us vow to “get in shape” by eating right and exercising. (Whether we keep that resolution is another story.) But while we view physical exercise as a way to lose or maintain weight, reduce stress, or even hone athletic skills, we seldom think about exercising one of the most important muscles in our body: the brain.

“What?” you say. “The brain is not like other muscles.” No, it’s not … and yet, it isn’t as different as we used to think. Historically (maybe histologically?), it was believed that if nerve cells in the adult brain were damaged or had died, they, unlike other cells in the body, were not replaced. Longstanding scientific belief was that while the brain compensated for damage by making new connections to undamaged nerve cells, it could not regenerate because it does not contain stem cells.¹

But since the late 1990s, scientists have been debunking the negative myths about our brains as we age. They are not as static and unable to change as we have been led to fear! In fact, in 1998, American and Swedish scientists demonstrated that adult humans can generate new brain cells.^1,2 Moreover, the brain does replicate neurons in the hippocampus, the area in our brains that is central to learning and memory. Neurons continue to grow and change beyond the first years of development and well into adulthood.

So learning (and teaching) movements to encourage the rebuilding of our neurons is key to keeping our minds sharp. In his work, Ratey found that “our physical movements can directly influence our ability to learn, think, and remember.”³ He also tells us that exercise enhances circulation to the brain, “priming it for improved function, including mental health as well as cognitive ability.”⁴

No, you can’t put your brain on a treadmill to get, and help keep, it “in shape.” But you can do something to maintain mental sharpness and delay decline in mental agility. And these exercises don’t require a health club membership or special equipment. They can be done anytime, anywhere … and no one knows you are doing them!

I’m talking about neurobics, a term coined to describe exercises that keep us mentally fit.⁵ The purpose of these activities is to work our brains in nonroutine or unexpected ways, using all of our senses to experience, or re-experience, a common activity.

Not sure what that means? Here are some examples:

Spend time in a new environment. Go to a different park or a new store. Travel, by the way, seems to slow age-related mental decline.

Continue to: Smell new odors in the morning

Smell new odors in the morning. Have new scents, like a bottle of mint extract, ready to smell first thing in the morning, to “wake up” your brain.

Take a shower with your eyes closed. Other senses become more active when you cannot see, and a shower engages several.

Try brushing your teeth with your nondominant hand. This may be difficult for some of us—and it definitely requires full attention the first time you try it!

Learn to read braille. This is a tough one, but learning to read with your fingers definitely involves one of your senses in a new context. Or, you could try learning American Sign Language, which also uses your fingers to communicate.

Respond to a situation differently. Catch yourself in a normal, unconscious response to a situation, and choose to respond in an alternate (and preferably better) way.

Continue to: Find a new route to work

Find a new route to work. It doesn’t have to be longer, just different. You may even find a faster way to work once you break your routine.

Act confidently. In a situation you are unsure about, choose to act confidently. You’ll notice that your mind gets very active once you adopt the assumption that you will know what to do.

Distinguish coins using only your sense of touch. This brain exercise can be used to kill time while waiting for an appointment. If you really want a challenge, see if you can distinguish paper currency denominations by touch.

Leave the lights off in the house. Get around your home by memory and feel. This certainly fully engages your attention—but be careful, of course!

If you give neurobics a try, let me know what you think! Or if you have other tips for staying mentally “fit,” please share them. I can be reached at npeditor@mdedge.com. And thank you to my friend Gail, who suggested this topic to me!

Every year, thousands of us vow to “get in shape” by eating right and exercising. (Whether we keep that resolution is another story.) But while we view physical exercise as a way to lose or maintain weight, reduce stress, or even hone athletic skills, we seldom think about exercising one of the most important muscles in our body: the brain.

“What?” you say. “The brain is not like other muscles.” No, it’s not … and yet, it isn’t as different as we used to think. Historically (maybe histologically?), it was believed that if nerve cells in the adult brain were damaged or had died, they, unlike other cells in the body, were not replaced. Longstanding scientific belief was that while the brain compensated for damage by making new connections to undamaged nerve cells, it could not regenerate because it does not contain stem cells.¹

But since the late 1990s, scientists have been debunking the negative myths about our brains as we age. They are not as static and unable to change as we have been led to fear! In fact, in 1998, American and Swedish scientists demonstrated that adult humans can generate new brain cells.^1,2 Moreover, the brain does replicate neurons in the hippocampus, the area in our brains that is central to learning and memory. Neurons continue to grow and change beyond the first years of development and well into adulthood.

So learning (and teaching) movements to encourage the rebuilding of our neurons is key to keeping our minds sharp. In his work, Ratey found that “our physical movements can directly influence our ability to learn, think, and remember.”³ He also tells us that exercise enhances circulation to the brain, “priming it for improved function, including mental health as well as cognitive ability.”⁴

No, you can’t put your brain on a treadmill to get, and help keep, it “in shape.” But you can do something to maintain mental sharpness and delay decline in mental agility. And these exercises don’t require a health club membership or special equipment. They can be done anytime, anywhere … and no one knows you are doing them!

I’m talking about neurobics, a term coined to describe exercises that keep us mentally fit.⁵ The purpose of these activities is to work our brains in nonroutine or unexpected ways, using all of our senses to experience, or re-experience, a common activity.

Not sure what that means? Here are some examples:

Spend time in a new environment. Go to a different park or a new store. Travel, by the way, seems to slow age-related mental decline.

Continue to: Smell new odors in the morning

Smell new odors in the morning. Have new scents, like a bottle of mint extract, ready to smell first thing in the morning, to “wake up” your brain.

Take a shower with your eyes closed. Other senses become more active when you cannot see, and a shower engages several.

Try brushing your teeth with your nondominant hand. This may be difficult for some of us—and it definitely requires full attention the first time you try it!

Learn to read braille. This is a tough one, but learning to read with your fingers definitely involves one of your senses in a new context. Or, you could try learning American Sign Language, which also uses your fingers to communicate.

Respond to a situation differently. Catch yourself in a normal, unconscious response to a situation, and choose to respond in an alternate (and preferably better) way.

Continue to: Find a new route to work

Find a new route to work. It doesn’t have to be longer, just different. You may even find a faster way to work once you break your routine.

Act confidently. In a situation you are unsure about, choose to act confidently. You’ll notice that your mind gets very active once you adopt the assumption that you will know what to do.

Distinguish coins using only your sense of touch. This brain exercise can be used to kill time while waiting for an appointment. If you really want a challenge, see if you can distinguish paper currency denominations by touch.

Leave the lights off in the house. Get around your home by memory and feel. This certainly fully engages your attention—but be careful, of course!

If you give neurobics a try, let me know what you think! Or if you have other tips for staying mentally “fit,” please share them. I can be reached at npeditor@mdedge.com. And thank you to my friend Gail, who suggested this topic to me!

Every year, thousands of us vow to “get in shape” by eating right and exercising. (Whether we keep that resolution is another story.) But while we view physical exercise as a way to lose or maintain weight, reduce stress, or even hone athletic skills, we seldom think about exercising one of the most important muscles in our body: the brain.

“What?” you say. “The brain is not like other muscles.” No, it’s not … and yet, it isn’t as different as we used to think. Historically (maybe histologically?), it was believed that if nerve cells in the adult brain were damaged or had died, they, unlike other cells in the body, were not replaced. Longstanding scientific belief was that while the brain compensated for damage by making new connections to undamaged nerve cells, it could not regenerate because it does not contain stem cells.¹

But since the late 1990s, scientists have been debunking the negative myths about our brains as we age. They are not as static and unable to change as we have been led to fear! In fact, in 1998, American and Swedish scientists demonstrated that adult humans can generate new brain cells.^1,2 Moreover, the brain does replicate neurons in the hippocampus, the area in our brains that is central to learning and memory. Neurons continue to grow and change beyond the first years of development and well into adulthood.

So learning (and teaching) movements to encourage the rebuilding of our neurons is key to keeping our minds sharp. In his work, Ratey found that “our physical movements can directly influence our ability to learn, think, and remember.”³ He also tells us that exercise enhances circulation to the brain, “priming it for improved function, including mental health as well as cognitive ability.”⁴

No, you can’t put your brain on a treadmill to get, and help keep, it “in shape.” But you can do something to maintain mental sharpness and delay decline in mental agility. And these exercises don’t require a health club membership or special equipment. They can be done anytime, anywhere … and no one knows you are doing them!

I’m talking about neurobics, a term coined to describe exercises that keep us mentally fit.⁵ The purpose of these activities is to work our brains in nonroutine or unexpected ways, using all of our senses to experience, or re-experience, a common activity.

Not sure what that means? Here are some examples:

Spend time in a new environment. Go to a different park or a new store. Travel, by the way, seems to slow age-related mental decline.

Continue to: Smell new odors in the morning

Smell new odors in the morning. Have new scents, like a bottle of mint extract, ready to smell first thing in the morning, to “wake up” your brain.

Take a shower with your eyes closed. Other senses become more active when you cannot see, and a shower engages several.

Try brushing your teeth with your nondominant hand. This may be difficult for some of us—and it definitely requires full attention the first time you try it!

Learn to read braille. This is a tough one, but learning to read with your fingers definitely involves one of your senses in a new context. Or, you could try learning American Sign Language, which also uses your fingers to communicate.

Respond to a situation differently. Catch yourself in a normal, unconscious response to a situation, and choose to respond in an alternate (and preferably better) way.

Continue to: Find a new route to work

Find a new route to work. It doesn’t have to be longer, just different. You may even find a faster way to work once you break your routine.

Act confidently. In a situation you are unsure about, choose to act confidently. You’ll notice that your mind gets very active once you adopt the assumption that you will know what to do.

Distinguish coins using only your sense of touch. This brain exercise can be used to kill time while waiting for an appointment. If you really want a challenge, see if you can distinguish paper currency denominations by touch.

Leave the lights off in the house. Get around your home by memory and feel. This certainly fully engages your attention—but be careful, of course!

If you give neurobics a try, let me know what you think! Or if you have other tips for staying mentally “fit,” please share them. I can be reached at npeditor@mdedge.com. And thank you to my friend Gail, who suggested this topic to me!

In 1992, then-governor of Massachusetts William F. Weld signed a bill into law legalizing the use of marijuana for glaucoma, cancer therapy, and certain asthmatic disorders under a limited Department of Public Health (DPH) research program. In 1996, the legislature gave DPH the power to approve any Massachusetts patient to “possess and use pot” legally for relief of symptoms.¹ In my position as Health Policy Coordinator with DPH, those two acts were my introduction to the controversy of medical marijuana.

Since then, the popularity of—or rather, the shift in public sentiment regarding—marijuana (cannabis/cannabinoid) use has changed. There has been significant interest in the use of marijuana as an adjunct to treating chronic and/or debilitating medical conditions. There is also increasing interest in the potential therapeutic uses of marijuana and other cannabinoid compounds.

In recent years, we’ve seen significant momentum on this front. Point in fact, in fiscal year 2017, the National Institutes of Health supported projects on cannabinoid research totaling almost $140 million.² More than 30 US jurisdictions have passed legislation to legalize marijuana for medical use (while a few have legalized its use, period).³ All of which has prompted quite the debate not only among the public but also among health care providers.

A review of the history of cannabis use is very interesting—specifically, that the use of cannabis as a therapeutic modality predates recorded history. Cannabis was very popular in ancient China, India, and Greece as a medicine to alleviate pain or cure a variety of ailments.^4,5 In the early 1900s, cannabis was available OTC and commonly used for a variety of illnesses in the US. The first law regarding marijuana was enacted in 1619 at Jamestown Colony, Virginia; it “ordered” all farmers to grow Indian hempseed.⁶

But by 1906, cannabis was labeled as a poison in many states, and by the 1920s absolute prohibitions began. The Controlled Substances Act of 1970 outlawed cannabis for any use. Despite that ban, marijuana is the most common illegal drug used in the US today.⁷

Marijuana, not a completely benign substance, occupies a unique position in our society. On the one hand, it is a recreational compound, used to attain pleasant euphoria and a sense of relaxation. On the other, it has been used as a therapeutic compound, relieving nausea and anorexia from chemotherapy. In the former, it is viewed by many as a dangerous drug that can lead to madness (as depicted in the film Reefer Madness).⁸ In the latter, its use as an effective analgesic and appetite stimulant has been supported by people who have realized a therapeutic benefit.

The potential medicinal benefits of marijuana and its components have been the subject of research and ongoing heated debates. Decades of anecdotal evidence regarding the effectiveness of marijuana on the aforementioned symptoms have been documented. There are also numerous studies on marijuana as a therapeutic agent for multiple conditions, using the plant itself or extracts derived from it.^9-11

Continue to: Perhaps most interesting...

Perhaps most interesting, emerging data suggest that use and abuse of prescription drugs may be decreasing in states where medical cannabis is legal.¹² Two recent studies examining cannabis laws and prescription of opioids found that “medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population,” concluding that the potential for marijuana to decrease opioid use in the Medicaid population deserves consideration during policy discussions about marijuana reform and the opioid epidemic.^{13, 14}

The support for policy changes in states that have legalized marijuana for medical use suggests it is gaining greater acceptance in our society. The increase in jurisdictions that have approved marijuana for medical use requires that we, as health care providers, understand the implications for our practice and educate ourselves on the laws and regulations in our respective states.

Recent guidelines from the National Council of State Boards of Nursing (NCSBN) identify six principles of essential knowledge for NPs (that could apply to PAs, as well) who care for patients who qualify to participate in a Medical Marijuana Program (MMP). These include principles of safe and knowledgeable practice for clinicians when qualifying a patient for an MMP.³ Note that I said qualifying a patient and not prescribing marijuana. Federal law still classifies cannabis as a Schedule I controlled substance, thus prohibiting the actual prescription of marijuana, and prohibits pharmacies from dispensing cannabis. Quite a contradiction!

All of that said, it is incumbent upon each of us to understand the complexities of the MMP in our state. Each has its own specifications as to the qualifying conditions or symptoms, as well as the requirements to become an approved provider. And each is as diverse as the opinions on marijuana use.

Without doubt, the debate and dichotomy about medical marijuana will ensue for years. What we as health care providers must do is keep current on the laws and regulations not only in our state, but also at the federal level. As a primer on the status of MMPs and provider approval, I encourage all to review the NCSBN document.³

As always, you can share your thoughts with me via NPeditor@mdedge.com.

In 1992, then-governor of Massachusetts William F. Weld signed a bill into law legalizing the use of marijuana for glaucoma, cancer therapy, and certain asthmatic disorders under a limited Department of Public Health (DPH) research program. In 1996, the legislature gave DPH the power to approve any Massachusetts patient to “possess and use pot” legally for relief of symptoms.¹ In my position as Health Policy Coordinator with DPH, those two acts were my introduction to the controversy of medical marijuana.

Since then, the popularity of—or rather, the shift in public sentiment regarding—marijuana (cannabis/cannabinoid) use has changed. There has been significant interest in the use of marijuana as an adjunct to treating chronic and/or debilitating medical conditions. There is also increasing interest in the potential therapeutic uses of marijuana and other cannabinoid compounds.

In recent years, we’ve seen significant momentum on this front. Point in fact, in fiscal year 2017, the National Institutes of Health supported projects on cannabinoid research totaling almost $140 million.² More than 30 US jurisdictions have passed legislation to legalize marijuana for medical use (while a few have legalized its use, period).³ All of which has prompted quite the debate not only among the public but also among health care providers.

A review of the history of cannabis use is very interesting—specifically, that the use of cannabis as a therapeutic modality predates recorded history. Cannabis was very popular in ancient China, India, and Greece as a medicine to alleviate pain or cure a variety of ailments.^4,5 In the early 1900s, cannabis was available OTC and commonly used for a variety of illnesses in the US. The first law regarding marijuana was enacted in 1619 at Jamestown Colony, Virginia; it “ordered” all farmers to grow Indian hempseed.⁶

But by 1906, cannabis was labeled as a poison in many states, and by the 1920s absolute prohibitions began. The Controlled Substances Act of 1970 outlawed cannabis for any use. Despite that ban, marijuana is the most common illegal drug used in the US today.⁷

Marijuana, not a completely benign substance, occupies a unique position in our society. On the one hand, it is a recreational compound, used to attain pleasant euphoria and a sense of relaxation. On the other, it has been used as a therapeutic compound, relieving nausea and anorexia from chemotherapy. In the former, it is viewed by many as a dangerous drug that can lead to madness (as depicted in the film Reefer Madness).⁸ In the latter, its use as an effective analgesic and appetite stimulant has been supported by people who have realized a therapeutic benefit.

The potential medicinal benefits of marijuana and its components have been the subject of research and ongoing heated debates. Decades of anecdotal evidence regarding the effectiveness of marijuana on the aforementioned symptoms have been documented. There are also numerous studies on marijuana as a therapeutic agent for multiple conditions, using the plant itself or extracts derived from it.^9-11

Continue to: Perhaps most interesting...

Perhaps most interesting, emerging data suggest that use and abuse of prescription drugs may be decreasing in states where medical cannabis is legal.¹² Two recent studies examining cannabis laws and prescription of opioids found that “medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population,” concluding that the potential for marijuana to decrease opioid use in the Medicaid population deserves consideration during policy discussions about marijuana reform and the opioid epidemic.^{13, 14}

The support for policy changes in states that have legalized marijuana for medical use suggests it is gaining greater acceptance in our society. The increase in jurisdictions that have approved marijuana for medical use requires that we, as health care providers, understand the implications for our practice and educate ourselves on the laws and regulations in our respective states.

Recent guidelines from the National Council of State Boards of Nursing (NCSBN) identify six principles of essential knowledge for NPs (that could apply to PAs, as well) who care for patients who qualify to participate in a Medical Marijuana Program (MMP). These include principles of safe and knowledgeable practice for clinicians when qualifying a patient for an MMP.³ Note that I said qualifying a patient and not prescribing marijuana. Federal law still classifies cannabis as a Schedule I controlled substance, thus prohibiting the actual prescription of marijuana, and prohibits pharmacies from dispensing cannabis. Quite a contradiction!

All of that said, it is incumbent upon each of us to understand the complexities of the MMP in our state. Each has its own specifications as to the qualifying conditions or symptoms, as well as the requirements to become an approved provider. And each is as diverse as the opinions on marijuana use.

Without doubt, the debate and dichotomy about medical marijuana will ensue for years. What we as health care providers must do is keep current on the laws and regulations not only in our state, but also at the federal level. As a primer on the status of MMPs and provider approval, I encourage all to review the NCSBN document.³

As always, you can share your thoughts with me via NPeditor@mdedge.com.

In 1992, then-governor of Massachusetts William F. Weld signed a bill into law legalizing the use of marijuana for glaucoma, cancer therapy, and certain asthmatic disorders under a limited Department of Public Health (DPH) research program. In 1996, the legislature gave DPH the power to approve any Massachusetts patient to “possess and use pot” legally for relief of symptoms.¹ In my position as Health Policy Coordinator with DPH, those two acts were my introduction to the controversy of medical marijuana.

Since then, the popularity of—or rather, the shift in public sentiment regarding—marijuana (cannabis/cannabinoid) use has changed. There has been significant interest in the use of marijuana as an adjunct to treating chronic and/or debilitating medical conditions. There is also increasing interest in the potential therapeutic uses of marijuana and other cannabinoid compounds.

In recent years, we’ve seen significant momentum on this front. Point in fact, in fiscal year 2017, the National Institutes of Health supported projects on cannabinoid research totaling almost $140 million.² More than 30 US jurisdictions have passed legislation to legalize marijuana for medical use (while a few have legalized its use, period).³ All of which has prompted quite the debate not only among the public but also among health care providers.

A review of the history of cannabis use is very interesting—specifically, that the use of cannabis as a therapeutic modality predates recorded history. Cannabis was very popular in ancient China, India, and Greece as a medicine to alleviate pain or cure a variety of ailments.^4,5 In the early 1900s, cannabis was available OTC and commonly used for a variety of illnesses in the US. The first law regarding marijuana was enacted in 1619 at Jamestown Colony, Virginia; it “ordered” all farmers to grow Indian hempseed.⁶

But by 1906, cannabis was labeled as a poison in many states, and by the 1920s absolute prohibitions began. The Controlled Substances Act of 1970 outlawed cannabis for any use. Despite that ban, marijuana is the most common illegal drug used in the US today.⁷

Marijuana, not a completely benign substance, occupies a unique position in our society. On the one hand, it is a recreational compound, used to attain pleasant euphoria and a sense of relaxation. On the other, it has been used as a therapeutic compound, relieving nausea and anorexia from chemotherapy. In the former, it is viewed by many as a dangerous drug that can lead to madness (as depicted in the film Reefer Madness).⁸ In the latter, its use as an effective analgesic and appetite stimulant has been supported by people who have realized a therapeutic benefit.

The potential medicinal benefits of marijuana and its components have been the subject of research and ongoing heated debates. Decades of anecdotal evidence regarding the effectiveness of marijuana on the aforementioned symptoms have been documented. There are also numerous studies on marijuana as a therapeutic agent for multiple conditions, using the plant itself or extracts derived from it.^9-11

Continue to: Perhaps most interesting...

Perhaps most interesting, emerging data suggest that use and abuse of prescription drugs may be decreasing in states where medical cannabis is legal.¹² Two recent studies examining cannabis laws and prescription of opioids found that “medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population,” concluding that the potential for marijuana to decrease opioid use in the Medicaid population deserves consideration during policy discussions about marijuana reform and the opioid epidemic.^{13, 14}

The support for policy changes in states that have legalized marijuana for medical use suggests it is gaining greater acceptance in our society. The increase in jurisdictions that have approved marijuana for medical use requires that we, as health care providers, understand the implications for our practice and educate ourselves on the laws and regulations in our respective states.

Recent guidelines from the National Council of State Boards of Nursing (NCSBN) identify six principles of essential knowledge for NPs (that could apply to PAs, as well) who care for patients who qualify to participate in a Medical Marijuana Program (MMP). These include principles of safe and knowledgeable practice for clinicians when qualifying a patient for an MMP.³ Note that I said qualifying a patient and not prescribing marijuana. Federal law still classifies cannabis as a Schedule I controlled substance, thus prohibiting the actual prescription of marijuana, and prohibits pharmacies from dispensing cannabis. Quite a contradiction!

All of that said, it is incumbent upon each of us to understand the complexities of the MMP in our state. Each has its own specifications as to the qualifying conditions or symptoms, as well as the requirements to become an approved provider. And each is as diverse as the opinions on marijuana use.

Without doubt, the debate and dichotomy about medical marijuana will ensue for years. What we as health care providers must do is keep current on the laws and regulations not only in our state, but also at the federal level. As a primer on the status of MMPs and provider approval, I encourage all to review the NCSBN document.³

As always, you can share your thoughts with me via NPeditor@mdedge.com.