So often, physicians seem to garner headlines in NP/PA-themed publications by making bombastic statements impugning PAs’ and NPs’ ability to safely provide patient care or by obstructing efforts, at the state or national level, to expand the scope of practice for nonphysician health care providers. Yet most Clinician Reviews editorial board members and contributors have incredibly strong relationships with their supervising/collaborating MDs. These NPs and PAs provide evidence of the notion that health care is a “team sport.”
In this issue, Randy Danielsen, PhD, PA-C, DFAAPA, discusses whether interprofessional team care actually works and whether it will, indeed, be the future of health care. And we decided to profile two physicians who truly understand and value what PAs and NPs contribute to the health care team, in the hope that readers will be inspired to share their stories with us as well.
ROBERT A. VIGERSKY, MD
In 2000, when Robert A. Vigersky, MD, a Colonel in the Medical Corps, was establishing the Diabetes Institute at what is now Walter Reed National Military Medical Center in Maryland, he was looking for experts in disease management to staff it. With available funding, he was able to hire four nurse practitioners initially and two more within another two years. Why did he choose NPs?
“To do disease management, you have to bring to bear a lot of skills—you have to be able to not only care for the patient but you have to have the time to care for the patient, and then you have to be detail-oriented,” he explains. “These are attributes I’ve encountered in NPs as a group. And they also have a more holistic approach to the patients. They’ve extended themselves beyond just looking at numbers, to treating the whole patient and the patient’s family and environment, addressing all the psychosocial issues that come up with diabetes. I think physicians are less likely to deal with that—not because they don’t care; they just are less skilled in it.”
Of the original six NPs, three are still working with Vigersky at the Diabetes Institute; the other three NPs who currently work there have been with the Institute for at least five years. Four of the six NPs work at satellite primary care clinics in the Washington, DC, area. Everyone gathers at the Endocrinology Clinic at Walter Reed on Fridays for presentation and review of case studies, which serve as an opportunity for the NPs to get feedback on difficult cases but also for the residents and fellows to learn from them as well.
“Through their experience and presentation of cases and discussion of complex management issues,” Vigersky says, “the NPs have been able to educate other individuals in our department—other physicians—as well as educating the people in their individual clinics, who are generally primary care providers.”
It is the combination of respect for their expertise and the balance between autonomy and collaboration that earns Vigersky praise from his NP colleagues. “Several of us work at some distance from him, but he is always available to us whenever we want to ‘pick his brain’ on a clinical/medical issue,” says Christine Kessler, RN, MN, CNS, ANP, BC-ADM. “That said, he gives us full autonomy; we make our own medical decisions. He never looks over our shoulders.”
Vigersky’s faith in his NP colleagues is such that when he has not been available to serve on an expert panel for the FDA, he has sent Kessler to represent him. “Not any of the other fine endocrinologists he works with,” she notes. “That says a lot about what he thinks of NPs and what he feels we can offer in terms of our expertise.”
That expertise has been honed through years of working with diabetic patients day in and day out. “The NPs are regarded with the highest esteem as subject-matter experts,” Vigersky says. “Their outcomes are better than the other providers’ in their respective clinics and better than the institution’s as a whole.”
Praise from an esteemed physician colleague—Vigersky is a Past President of the Endocrine Society, as well as an internationally renowned speaker and researcher—carries a great deal of weight. While pointing out that the military is free from issues such as title and turf wars, Vigersky notes that in his 15 years in private practice, his endocrinology group always had one or two NPs on staff because “they made the practice more accessible to patients who needed to be seen.”
On the subject of titles in the clinical setting, Vigersky says, “I think it’s important that the patient comes first. As long as providers have a certain competency level, I don’t think it matters what degree is after your name—as long as you can take care of that problem and extend a high level of care.”
DANIEL EINHORN, MD, FACP, FACE
Daniel Einhorn, MD, FACP, FACE, an endocrinologist in La Jolla, California, was familiar with hospital-based physician assistants—he had seen how they effectively “ran everything” after a surgical procedure and took charge of very sick patients—but his experience with outpatient PAs began with a single colleague, Chris Sadler, MA, PA-C, CDE.
Sadler, who worked at a diabetes center where Einhorn was director, had a master’s in exercise physiology and was certified as a diabetes educator when he approached Einhorn with the idea of returning to school to become a PA. Einhorn told him if he received the training, Einhorn would love to work with him. And the rest is history; they have been such an outstanding team for the past 16 years that in 2011 they were honored with AAPA’s Physician-PA Partnership Award.
“Chris is essentially another endocrinologist in the practice,” says Einhorn, adding that accommodating each other’s personalities and professional styles has been part of the key to their success. “He is very methodical and will typically go through various steps of the exam, where I might jump to a conclusion sooner. By sharing patients, Chris may pick up on something that I’ve missed and vice versa. I think we’ve each taught the other to embrace whatever our differences are and to take advantage of them.”
“Dr. Einhorn treats me as an equal and promotes me to our patients by telling them they will get the best possible care from me,” Sadler says. “As a PA, you feel fortunate when you find a physician as a competent supervisor, or a wise mentor, or a trusted colleague and maybe even a good friend. You are truly blessed if you find all of those, as I have with Dr. Einhorn.”
The respect Sadler and Einhorn have for one another translates into opportunities for consultation, which can only improve patient care. “You have a constant second opinion, which is very important,” says Einhorn. “I think when people practice all by themselves, they start to believe their press releases. You just have people thanking you all day; I think having critical eyes look at our work makes us better.”
Einhorn, who is both a Past President and the current President-Elect of the American Association of Clinical Endocrinologists, has sat at many a table with his physician colleagues and heard similar stories of how indispensible PAs (and NPs) are. In his viewpoint, PAs are often the experts in a specific aspect of care: In some endocrinology practices, the PAs might focus on diabetes; in others, they may handle all the technology, such as continuous glucose monitoring and carotid or thyroid ultrasound.
“There are certain skill sets that individuals bring or develop that you might not have in the practice otherwise,” he observes.
Not all of Einhorn’s physician colleagues, however, are as welcoming of nonphysician providers. “Some feel protective of their specialty and concerned that all their years of training and focus will be somehow demeaned by someone of lesser years of training providing ostensibly the same service,” he says. “Those of us who, I think, are part of the future embrace the idea of a team. Anything that someone else can do as well as I can, I want them to do it so I can go and do something else.”
As far as professional titles are concerned, Einhorn says they are “certainly not irrelevant,” but he points out that at the level of direct patient care, it may be an RN who has the most insight into a hospitalized patient and is able to teach the medical team something about that patient and his/her course.
“I do think the many years involved in graduate medical education add to your ability to diagnose and to analyze new information,” he says. “There is value to the added years of training, but in terms of active patient care day in and day out, other qualities—quality of training, quality of character, and quality of attentiveness—are far more important.
“The future is working in a team. I don’t think there’s anybody who thinks otherwise.”