Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part I: Issues

The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP''s) or physician''s assistants (PA''s). All of these have physician supervision and support. NP''s and PA''s have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician''s assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California''s Medicaid program).Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician''s assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP''s and PA''s will serve an even greater role in rural areas.     

Allocation of health care resources: a challenge for the medical profession.

If current limitations on health care funding continue, medical practitioners will face increasing pressure to conserve scarce resources and to participate in the allocation of funds. This article discusses the ethical and economic aspects of the physician''s role and briefly reviews some efficiency measures that might mitigate the effects of rationing of health care services.     

The Effect of an Individualized Practice-Based CME Program on Physician Performance and Patient Outcomes

The Professional Competence Assurance Program (PROCAP) is an individualized educational program that examines physicians'' performance in ambulatory practice. It uses medical record review to identify deficiencies in the care process that guides development of the educational intervention. Medical care is reassessed one year later. This program was used with 51 private practitioners to assess the care of 1,229 hypertensive patients. The educational program included a computer printout comparing one physician''s performance with that of peers, readings targeted to management problems, and a conference call or group seminar with an expert stressing issues relevant to each physician''s performance. Postintervention assessment showed that physicians prescribed beta-blockers (P<.01) and vasodilators (P<.01) more often. Improvement (P<.05) occurred in the control of diastolic blood pressure (≤90 mm of mercury) and in several other criteria. These results show that well-designed, individualized continuing medical education addressing specific deficiencies can change physicians'' performance and patients'' intermediate outcome.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part II: A Survey

Twenty-six rural California clinics have employed nurse practitioners (NP''s) or physician''s assistants (PA''s) to meet the primary health care needs of local communities. Of the 24 NP''s and 5 PA''s involved, 11 were men and 18 were women. Their average age was 37, and all but five were trained in California. The clinics, with less than 50 percent on-site physician supervision, averaged 19 miles in distance from the nearest physician (ranging up to 63 miles). More than half the clinics were satellites of central, physician-staffed, nonprofit clinics, a third were community-administered and two were private. Half served a whole community, a quarter were established to serve Indians and a quarter to serve Chicanos. Each NP or PA saw an average of 13 patients a day. All nonprivate clinics received subsidies from a variety of local, state and federal funds. Four of the clinics had closed or had no medical staff at the time of our survey.NP/PA clinics are proving to be a feasible and valuable means of offering essential health care needs to remote communities.     

Prevention of psychosocial problems in children with chronic illness.

Children with chronic illness and disability are at considerably increased risk of psychosocial problems, such as neurosis, attention deficit and poor adjustment to school. Health care professionals, especially primary care physicians, can do a great deal to prevent such problems in these children and their families. The approach outlined here is based on an understanding of the transactional model of development, in which the child interacts with--and to some extent creates--the social environment, and on a "noncategorical" concept in which common elements in chronic illness are recognized and emphasized. The physician''s role is to inform the family of the child''s condition as soon as possible, to offer hope, encouragement and guidance, to watch the child''s development, to maintain a shared view of the child and family, and, if possible, to ensure continuity of care.     

Family Planning in the Hospital Setting

Although the availability of oral contraceptives and the development of improved intrauterine contraceptive devices have greatly increased the general utilization of family planning services, there are still great segments of our population which are not yet reached, especially in the economically deprived areas. Since over 98 percent of all obstetrical deliveries now occur in hospitals, it seems logical that it is on hospital maternity services that these deficiencies might often be best overcome. Although this is primarily a medical problem, the use of paramedical personnel can greatly augment the physician''s practice in these areas. Family planning services should be an integral part of comprehensive maternity care, not alone in the physician''s office but also in the hospital setting.     

A new primary care rostering and capitation system in Norway: Lessons for Canada?

Providing every patient with a personal primary care physician or, from the physician''s perspective, establishing a stable roster or list of patients is currently being actively debated in Canada. Norway''s system of primary care medicine, similar to Canada''s, faces many of the same problems. In 1992 a trial rostering system with blended funding (capitation, fee-for-service and user fees) was established in 4 Norwegian municipalities. After 3 years of close monitoring, the results of system evaluations have attracted strong interest. This article reports on the benefits and problems encountered with the new rostering system in Norway. If Canada is moving in the same direction, some of the lessons learned may be helpful.     

Managing uncertainty in family practice.

Because patients present in the early stages of undifferentiated problems, the family physician often faces uncertainty, especially in diagnosis and management. The physician''s uncertainty may be unacceptable to the patient and may lead to inappropriate use of diagnostic procedures. The problem is intensified by the physician''s hospital training, which emphasizes mastery of available knowledge and decision-making based on certainty. Strategies by which a physician may manage uncertainty include (a) a more open doctor-patient relationship, (b) understanding the patient''s reason for attending the office, (c) a thorough assessment of the problem, (d) a commitment to reassessment and (e) appropriate consultation.     

Patient Attitudes Toward Physician's Assistants

A study was conducted in urban Los Angeles to assess patient acceptance of the use of physician''s assistants. Data collection was facilitated by the development of an attitude scale and responses were analyzed to determine differences between various socioeconomic stratifications. With a few exceptions, acceptance was highest among non-married middle-class respondents who have had some exposure to college. As to the perceived complexity of procedures a physician''s assistant might perform, 91 percent of all respondents would not object to injections administered by a physician''s assistant, but this tolerance diminishes to 34 percent in the case of first examination of a patient by a physician''s assistant if there appeared to be a serious head injury.     

Do physicians have an ethical obligation to care for patients with AIDS?

This paper responds to the question: Do physicians have an ethical obligation to care for patients with acquired immunodeficiency syndrome (AIDS)? First, the social and political milieu in which this question arises is sampled. Here physicians as well as other members of the community are found declaring an unwillingness to be exposed to people with AIDS. Next, laws, regulations, ethical codes and principles, and the history of the practice of medicine are examined, and the literature as it pertains to these areas is reviewed. The obligation to care for patients with AIDS, however, cannot be located in an orientation to morality defined in rules and codes and an appeal to legalistic fairness. By turning to the orientation to morality that emerges naturally from connection and is defined in caring, the physicians'' ethical obligation to care for patients with AIDS is found. Through an exploration of the writings of modern medical ethicists, it is clear that the purpose of the practice of medicine is healing, which can only be accomplished in relationship to the patient. It is in relationship to patients that the physician has the opportunity for self-realization. In fact, the physician is physician in relationship to patients and only to the extent that he or she acts virtuously by being morally responsible for and to those patients. Not to do so diminishes the physician''s ethical ideal, a vision of the physician as good physician, which has consequences for the physician''s capacity to care and for the practice of medicine.     

A Taxonomy of Continuing Medical Education Endeavour

Five basic forms of continuing educational endeavour by physicians are listed in rank order. These components constitute an indivisible unit bound together by self-learning. The scholarly habit of planned daily reading and study in a home library-sanctuary as an integral part of a physician''s workday heads the list. Day-to-day informal and formal colleague-association in patient care in the community and teaching hospital, in group practice and by consultation is the present major form of continuing educational endeavour. Emphasized is the sabbatical return every three to five years for three months at least to the teaching hospital to reinforce scholarly motivation and attitudes and to acquire new skills and knowledge. Attendance at scientific sessions of learned professional societies and short courses should be accompanied by presession and post-session guided reading to be undertaken in the physician''s home library-sanctuary.     

Motor neurone disease: towards better care.

Even in the most severe forms of motor neurone disease--progressive bulbar palsy and amyotrophic lateral sclerosis--the symptoms and disabilities from progressive paralysis may be relieved in many patients by various symptomatic treatments. Quality of life may be improved even in the terminal stage, when narcotic administration should be considered. The physician''s proper role is to offer and carefully supervise these treatments, not withhold them. Home care is recommended even for the most severely paralysed, though hospice care may be a good alternative. The underlying principle--to alleviate symptoms--applies to the management of all progressive incurable diseases.     

Community participation in primary health care.

A two and a half year''s experience of a community participation group has shown that this can have a valuable role in suggesting practicable improvements in a group practice. Topics discussed by the group (which is composed of one representative from every known organization in the area) have included problems of receptionists; the role of the individual ancillary worker; and teaching in general practice. The high attendance rate at the group''s meetings testifies to the community''s interest in primary health care services.     

Housing,health, and illness.

Cases referred to a community physician in his role as medical adviser to a housing authority were reviewed. A new system of classifying health problems was devised because conventional diagnostic classification was found to be inappropriate. The effectiveness of medical intervention was apparently low, since only 29 out of 612 (4.7%) applications for rehousing on medical grounds were successful. The effectiveness of the community physician''s role was limited by the available resources and the number of cases he could take before the housing committee. It is proposed that the use of medical resources for intervention in such cases is acceptably efficient, though this proposal is based on value judgement rather than on economic grounds. Doctors should be concerned in improving housing conditions, which are still unacceptably poor in many parts of Britain, in the interests of improving general standards of public health.     

Antihypertensive Pharmacology

Although drug treatment of hypertension is associated with improved survival and decreased vascular complications, drug compliance is a major problem in the control of hypertension. All antihypertensive medications are associated with side effects; thus, it is a physician''s responsibility to explain to each patient the side effects of the drugs he prescribes to treat hypertension, and to instill in the patient a sense of necessity for the treatment of hypertension. The choice of antihypertensive drug should be made based on each patient''s lifestyle, overall health and ability to tolerate the drug. Ideally, the antihypertensive regimen should be simple, effective, convenient to take and have very few side effects.     

The emerging role of the physician in genetic counselling and testing for heritable breast,ovarian and colon cancer.

As a genetic testing for susceptibility to breast, ovarian and colon cancer becomes more readily available, physicians are faced with an increasing demand for information about inherited cancer risk. Because advances in treatment have not kept pace with advances in predictive testing, the provision of genetic counselling and testing marks a departure from the traditional role of the physician. A systematic framework is needed within which the physician''s emerging role in predictive testing for heritable cancer can be delineated. The development of such a framework will require collaboration among professionals in a range of scientific disciplines, as well as the suspension of traditional assumptions about the physicians role.     

THE HIGH SCHOOL FOOTBALL TEAM PHYSICIAN

Mutual confidence is necessary between the football coach and the team physician. The physician''s decision in the matter of a boy''s condition must always be final. The coach should also consider the physician''s advice in shaping his psychological appeals to the players in before-game and between-halves talks. The physician should be on his way to a man injured on the field as soon as the play is ended. It is up to him and not the trainer or coach to make the diagnosis. The physician must have the ability to make an immediate evaluation of the extent of injury and use appropriate measures to get the player off the field. To see a semi-conscious man with dangling head being half dragged off the field is far worse from the patient''s standpoint and from the spectator''s standpoint than removal by stretcher.     

A patient's guide to choosing unconventional therapies

Unconventional therapies (UTs) are therapies not usually provided by Canadian physicians or other conventionally trained health care providers. Examples of common UTs available in Canada are herbal preparations, reflexology, acupuncture and traditional Chinese medicine. UTs may be used along with conventional therapies (complementary) or instead of conventional therapies (alternative). Surveys have shown that many Canadians use UTs, usually as complementary therapies, for a wide range of diseases and conditions. Reliable information about UTs is often difficult to find. Your doctor may be unable to give you specific advice or recommendations, since UTs are often not in a physician''s area of expertise. However, he or she will usually be able to provide some general advice and help supervise your progress. For your own health and safety, it is important to keep your doctor informed of the choices you make. This document is intended to (a) provide you with questions to consider when making your treatment choices, (b) help you find information about UTs, (c) help you decide whether a specific UT is right for you, and (d) provide tips to help you evaluate the information you find.