Nurse Practitioners and Physician Assistants: Do They Have a Role in Your Practice?

(1)

powerment through communication and access to

knowledge is the goal of House Call. As seen in the

Figure 1, this system provides for patient access to

the latest medical information (Patient

Encyclope-dia), to a self-guided health improvement program

(Health Improvement Program), as well as to a

po-tential linkage-through electronic or voice

mail-with other patients with similar conditions

(Patient-Patient Mail and Public Bulletin Board). When

applied to chronic medical conditions, osteoarthritis

in our pilot, the patient or patient’s parent not only

has instant access to all of these modalities, but also

can communicate with his or her physician on

non-emergent concerns. Asynchronous

communication-messages left through voice mail or electronic mail to

be answered at another time-offers routine,

two-way patient-provider communication. A patient

question or a condition report from a patient can be

left for the medical provider as well as entered into

the medical record for future reference. Likewise, an

inquiry (eg, was there a change in condition after a

medication change?) or a “tickle reminder” from the

doctor can be left for the patient. Manipulation of the

Medical, Health, and Function Database also allows

for customized reports to third-party payers or

med-ical consultants. Aggregation of data has potential

usefulness in outcomes research. In summary, this

communication design allows for better

doctor-patient communication and potential patient

em-powerment through access to knowledge, all in a

convenient and cost-effective manner.

The papers of both Dr Zurhellen and Dr Bergman

provide windows into the future practice of

pediat-rics. Information management offers our greatest

challenge and, in my opinion, our greatest

opportu-nity to improve the health of our patients. In the

future, greater practice efficiency and effectiveness

will be made more attainable through improved

in-formation management.

JoHN B. COOMBS, MD

University of Washington School of Medicine

Seattle, WA

REFERENCE

1. Berwick DM. Controlling variation in health care: a consultation with Walter Skewhart. Med Care. 1991;29:1212-’1225

Nurse

Practitioners

and

Physician

Assistants:

Do

They

Have

a Role

in

Your

Practice?

Elsa L. Stone, MD

ABSTRACT. During the next decade, pediatricians will

confront the difficult challenge of providing quality health care services to more children with more diverse

and difficult problems, and they will have little or no additional funding to accomplish this task. Despite ear-her predictions of surpluses in the pediatric work force, there are now shortages that will worsen if the current trend persists. Pediatric nurse practitioners (PNPs) and some physician assistants are being trained to perform health supervision care and to diagnose and treat the common illnesses of children. Substantial evidence

sug-gests that PNPs provide quality health care services, and

that collaborative teams of pediatricians and PNPs can provide high-quality, cost-effective care to a broader spectrum of children than can be served by either

pro-fessional alone. Pediatrics 199596:844-850.

ABBREVIATIONS. AMA, American Medical Association; AAP, American Academy of Pediatrics; PNP, pediatric nurse practi-tioner; PA, physician assistant; NAPNAP, National Association of Pediatric Nurse Associates and Practitioners; ANA, American Nurses Association; NCBPNP/N, National Certification Board of Pediatric Nurse Practitioners and Nurses; APN, advanced-prac-tice nurse; HMO, health maintenance organization.

Major changes in the delivery of, and payment for,

health care services to children and adolescents

chal-From the Department of Pediatrics, Yale University School of Medicine, New Haven, CT.

lenge pediatricians to reconsider their modes of

prac-lice and their relationships with other health care

professionals. These changes, which seem sudden

and cataclysmic, actually represent a more

evolution-ary change that has its roots in the history of

pedi-atrics and that of other professionals involved with

child health care, but that has been accelerated by

new and disruptive economic forces.

Pediatrics has always been a profession sensitive

to social and medical issues. In the early 1900s, the

American Pediatric Society and the Pediatric Section

of the American Medical Association (AMA) existed,

but pediatricians and pediatric training programs

were few. Pediatric work was largely consultative;

infectious diseases were the major cause of illness

and death. Preventive health care was limited, and

public health was just beginning, but there was

al-ready a sense that pediatric work went beyond the

immediate patient. Physicians in the Pediatric

Sec-tion of the AMA endorsed a federal maternal and

infant welfare program. This endorsement was

over-ruled by the parent body of the AMA, which

opposed government involvement in health and

wel-fare. Issues arising from this disagreement

contrib-uted to the later formation of the American Academy

of Pediatrics (AAP).1

The 1930s saw an increase in the number of

pedi-atricians and pediatric training programs and an

ex-pansion of the concept of child health care to include

growth, development, and some behavioral

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

(2)

cerns. The 1940s brought knowledge that increased

our ability to help children: penicillin,

corticoste-roids, and immunizations. The physician shortages

caused by the war altered patterns of care:house calls

diminished; group practices began; and solo

practi-tioners joined coverage networks. When the polio

vaccine was discovered in the 1950s, pediatricians

volunteered their time to lead the campaign to

irn-munize all children. At the same time, they were

now spending 40% to 50% of their time performing

preventive care.1 As knowledge grew, pediatric

sub-specialties became well established, and ambulatory

pediatrics became an academic subspecialty in the

1960s.

The impact of the insurance industry began to be

felt in the 1960s, and the AAP began its campaign for

more complete coverage for children, including

health supervision. With the expanding scope of

pe-diatric practice and concern, it became apparent that

there were not enough pediatricians to meet

chil-dren’s needs. With Academy support, programs to

train pediatric nurse practitioners (PNPs) began. The

government increased support for family physician

training programs, and stimulated creation of health

maintenance organizations (HMOs) in the 1970s.

Both of these developments have challenged

pediat-rics. Because the interests of children have been

sub-ordinate to the interests of adults historically, some

thought that family practitioners would have mixed

loyalties when it came to being advocates for

chil-dren. Similarly, FIMOs could, and many did, dictate

health benefits for children that were inadequate to

their needs.

The common thread that runs through this history

and defines the role of the pediatrician is an interest

in the health and well-being of children in all its

manifestations. It means fighting to ensure that

chil-dren will be the beneficiaries of the explosion in

medical knowledge and research, that they will have

access to the finest in pediatric subspecialty care, and

that all children have real access to quality primary

care services, including continuity of care. In 1975,

Haggerty et al coined the term “the new morbidity”

in referring to new and significant problems

affect-ing children.2 (In this issue, he discusses changes

beyond the new morbidity.) Violence is rapidly

be-coming the leading killer in the second half of this

century. Preventive care has become an even more

important component of our direct services to

chil-dren; it is in that context that we can begin to address

the problems of the new morbidity. And in our free

time, we advocate for children locally, state-wide,

and nationally.

If our goals for children are to be achieved, we

must understand the current upheaval in the health

care delivery system. The impetus for change is

eco-nomic and largely unrelated to the mainstream of

pediatric care, but this will not protect children from

feeling the impact of change. American industry has

declared that high health care costs endanger our

economy and our general well-being. Pressure to

keep health care costs down will not only continue, it

will increase, as will new interest in primary care,

which is seen as a means of controlling more costly

secondary and tertiary care. Cost-effective care is the

goal; outcomes research is the means for achieving it.

The sophistication with which these studies are, or

are not, performed and analyzed will have major

impact on the quality of the system that ultimately is

created, as discussed by Dr Bergman in this issue.

Training programs in pediatrics, some of which

are already changing, wifi be dramatically different

in the future. Emphasis on primary care will produce

an increased focus on ambulatory medicine. More

training will occur in nonhospital outpatient settings.

Greater emphasis in the curriculum on

developmen-tal and psychosocial issues, as well as adolescent and

school problems, will be needed.

The challenge in the delivery of health care

ser-vices to children is to maintain quality while the

needs of the children increase and the money

avail-able for services does not. Are there enough

pedia-tricians to meet the current and future needs of

America’s children? If there are not, are PNPs and

physician assistants (PAs) appropriate health

profes-sionals to share in the delivery of quality pediatric

services?

DEMOGRAPHY OF PEDIATRIC PRACTICE

In 1992, of the 44 881 pediatricians in the United

States, the main professional activity of 90% was

patient care in office- and hospital-based settings.3

Forty-three percent were younger than 44 years of

age, and 40% of all pediatricians were women,

corn-pared with 21% of internists and 18% of all

physi-cians.3 The number of international medical

gradu-ates entering pediatrics has been rising rapidly, and

in 1992 they constituted 29% of pediatricians,

com-pared with 22% of all physicians.3

A 1989 analysis of the pediatric marketplace

re-vealed that the number of births is expected to

con-tinue to rise at about I % annually. The baby boom

population of children younger than 5 years of age

peaked in 1990; the adolescent population will peak

in 2005. Pediatricians are steadily capturing more of

the market of children younger than 19 years of age,

and particularly of children 0 to 2 years of age (Table

1). Young children generate the largest number of

pediatric office visits (Table 2). Thus, demand for

pediatric services is increasing.

Considerable controversy has surrounded the

ap-propriate size of the pediatric work force. In 1980, the

Graduate Medical Education National Advisory

Committee reported that there would be an excess of

4950 pediatricians by 1990. In 1990, Abt Associates,

engaged by the Council on Graduate Medical

Edu-cation to do a reexamination, reported an even

TABLE I. Pediatrician Market Share (%)*

Age (y) 1976-1977 1983-1984 1985-1986 1987

0-2 65.0 67.5 68.6 71.8

3-9 47.4 52.4 52.8 55.4

10-19 15.6 21.3 20.9 24.4

Total 38.3 45.5 46.3 49.8

* Defined as number of office-based patient visits to pediatricians

divided by the total number of all same age patient visits to a physician (x 100). (Adapted from Martinez and Ryan.4)

(3)

higher projected surplus of pediatricians, 7289 rather

than 4950 for 1990, with surpluses of 12 931 in 2000

and 18 462 in 2010.6 This projected glut has yet to be

realized.7 Although the number of pediatricians has

increased at a rate faster than the population of

chil-dren, pediatricians do not seem to be working less

(Table 3). Pediatricians are seeing patients who

pre-viously had been seen by other physicians, and they

are providing care for patients with more diverse

problems. In 1990, 96% of residents completing their

pediatric training found immediate employment,

which strongly refutes those studies that projected

pediatric surpluses beginning in 19907 On the

con-trary, these data suggest a current shortage of

pedi-atricians, even without health care reform and

im-provements in access to care for the uninsured and

underinsured.

In 1992, 15% of children-9.8 million-had no

pri-vate or public health insurance.8 Of these children,

63% had at least one parent who was employed

year-round, either full- or part-time.8 Another 16

mil-lion children received Medicaid assistance providing

limited access to medical care.

Despite the recent failure of the federal

govern-ment to pass a health care reform initiative, health

care reform is not dead. The Academy’s concept of

“children first,” as put forth in the Dodd bill, is likely

to be picked up again in the current Congress.

Nu-rnerous state legislatures are also actively working

on health care reform proposals. During the next 10

years, the barriers that limit access to care for these 26

million children are likely to be removed. Pediatric

resources will be insufficient to meet this increased

demand.

Several factors compound this anticipated problem.

The rapid increase in numbers of women entering

pediatrics is a relatively new phenomenon. Although

the productive work life of women physicians is

comparable to that of their male counterparts, the

distribution of their work years may differ. Many

women will work part-time or not at all during their

child-bearing and child-rearing years, but they will

work to an older age.

In recent years the pediatric work force has relied

heavily on international medical graduates, who

now constitute 29% of all pediatricians.

Governmen-tal reform to control the number of physicians and to

decrease the number of specialists has proposed

him-iting residency slots to 105% to 110% of the number

of American medical school graduates. Thus, the

shortage of pediatricians is likely to increase, at least

in the short run.

Costs of American medical education have risen

alarmingly. Graduates, many of whom now have

debts in excess of $70 000, will find it increasingly

difficult to enter pediatrics-almost the lowest paid

specialty-without some form of loan forgiveness or

increased remuneration for their work.

Finally, the scope of general pediatric practice has

expanded to include problems of great complexity,

problems that are killing, scarring, and handicapping

a large number of children. These problems are no

less a challenge and no less appropriate a challenge

to pediatricians now than infectious diseases were in

the 1930s.

Clearly, if our goal is to meet the increased needs

of an increasing number of children, we will need

help. This need, which was documented 25 years

ago, is no less real now. In a survey conducted in

1970 by the Academy, 60% of more than 4000

respon-dents considered as very serious the lack of trained

allied health workers with whom they could share

patient care tasks.9 If an adequately trained allied

health professional were available, 63% indicated

they would hire him or her on a full- or part-time

basis. Results of this survey led the AAP, with the

implicit approval of its membership as evidenced by

this survey, to support actively the development of

PNP programs nationwide.

When the first PA programs began in 1961 at Duke

University, they attracted many hospital corpsmen

and combat medics returning from Vietnam. The

first PNP program was begun in Denver by Dr

Henry Silver and Dr Loretta Ford, a nurse, in the

mid-1960s, and similar programs rapidly began to

appear nationwide. Although both PAs and PNPs

have been finding a place in the care of children,

these two professional groups have many

differ-ences. Conceptually, PAs define their role in relation

to physicians; they are assistants, trained to perform

certain functions for physicians. Their training

pro-grams require 2 years of undergraduate studies

con-sisting of 9 to 12 months of didactic preparation and

9 to 15 months of clinical training under physician

supervision.1#{176} Most programs have limited pediatric

content in the core curriculum. Only 3% of PAs

prac-tice in pediatrics, according to the 1991 General

Cen-sus Data Survey on PAs. Consequently, the

remain-der of this article will be limited to a discussion of

PNPs.

PNPs have their roots in the nursing profession

while having close ties with pediatrics. In 1973, they

formed the National Association of Pediatric Nurse

Associates and Practitioners (NAPNAP) and decided

to remain independent of the American Nurses

As-sociation (ANA) but to consider association with the

AAP.1’ In 1975, the NAPNAP and AAP collaborated

to form the National Board of Pediatric Nurse

Prac-titioners and Associates. Its goals were to establish

and to maintain standards of competence for PNPs,

to develop a National Qualifying Examination for

PNPs, and to participate in the establishment and

maintenance of standards for their educational

pro-grams. Fundamental to the creation of this

organiza-lion was the belief that, as PNP functions extend

beyond traditional nursing and into the province of

medicine, both nursing and medicine should share in

certification. The Association of Nursing Faculties

later became an equal partner, and the board was

renamed the National Certification Board of

Pediat-ric Nurse Practitioners and Nurses (NCBPNP/N).

The Executive Committee has two representatives

from each of the three parent organizations.

PNP programs must meet the standards set by the

NCBPNP/N for their graduates to sit for the

certifi-cation examination. All entrants must have a

bacca-laureate degree, and they receive a master’s degree

(4)

TABLE 2. Pediatric Office Visits by Age

Age (y) Percent of Total Office Visits

0-2 49

3-9 33

10-19 18

TABLE 3. Utilization Comparison for Pediatricians, 1982 and 1990

1982 1990*

Weeks worked/y 47.2 47.4

Hours of patient care/wk 50.3 52.4

Patient visits/wk 134.4 134.0

Appointment delay for new patients, d 5.0 9.2

* 1989 data. (Adapted from Eaton and Flint.7)

on completion of the course of study, usually 2 years.

Most entrants also are registered nurses, although

some programs offer a third year of study for

non-nurses, conferring both a master’s degree and a

nurs-ing certificate. PNP training programs are entirely

focused on children: health promotion, nutrition,

growth and development, and diagnosis and

treat-ment of common disorders. Students must have a

minimum of 500 clinical hours of supervision; many

programs provide two or three times this amount.

Both pediatricians and PNPs act as preceptors in the

clinical training of PNP students, and an increasing

number of programs have PNP students and

pediat-ric residents learning together in outpatient settings,

an ideal training model for promoting mutual

under-standing of the different roles and for developing

styles of collaboration. Certified PNPs must be

recer-tified every 6 years through a series of continuing

education courses and self-assessment tests or by

retaking the formal certification examination. The

ANA also offers certification tests for nurse

practi-tioners, but it does not certify training programs, and

only a few PNPs take this pediatric examination.

DEMOGRAPHY OF PNP PRACTICE

Approximately 6000 PNPs are active in the United

States, and more than haif belong to the NAPNAP.12

As of March 1993, the NAPNAP had a membership

of 3500; 98.8% were women, and 77% were between

30 and 50 years of age.13 Fifty-five percent possessed

at least a master’s degree, and 78% were certified by

the NCBPNP/N.’3 Most earned between $30 000 and

$60 000 per year in 1992, a large increase over a 1988

survey. The highest earnings occurred in the

south-west and mid-Atlantic states, and the lowest

earn-ings in the northeastern, southeastern, and Pacific

northwestern states.13 Sixty-two percent of NAPNAP

members work in urban areas with populations

more than 100 000. The settings in which they work

are shown in Table 4#{149}14

Primary care services constitute the majority of

care provided by PNPs (Table 5). They see an

aver-age of 14 patients per day.14 Many patients are from

poor, underserved families, for whom NPs provide

much-needed access to care.14

All but 26% of NAPNAP members have some

prescriptive authority, although for many these

priv-TABLE 4. Practice Sites for PNPs (%)*

Hospital clinic 33

Private practice 23

Health department 13

School health 11

Community clinic 10

HMO 10%

* Adapted from Dunn)

TABLE 5. NPs Sell-Report of Services Provided (% of respon-dents)*

Health Care Service Provided Very Often or Often

Seldom or Never

Health education, individual 94 6

History and physical examination 92 8

Anticipatory guidance 90 10

Support and nurturing 91 9

Medical treatment of common 19 81

illness of problem

Screening 78 12

Follow-up care 80 20

Client advocacy 50 50

Referral to physician 47 53

Crisis intervention 20 80

Program design and development 16 84

Community outreach 11 89

Home visits 5 95

* 1992 NAPNAP Membership Survey, Dunn.’4

ileges are limited. One third of surveyed members

thought that lack of prescriptive authority was a

barrier to their practice, and 94% thought that PNPs

should have this authority.14 Only 23% of members

have hospital privileges, mostly limited, but most

did not think that this interfered with their practices.

An additional issue of importance is third-party

re-imbursement. Few NAPNAP members can bill

inde-pendently, but they plus those who can bill through

the physician or agency with whom they work

corn-prise 53% of the membership.’4

BARRIERS TO PNP PRACTICE

The three areas most commonly thought by nurse

practitioners to be problematic in their efforts to

practice fully are legal authority, prescriptive

author-ity, and reimbursement parity. Indeed, state practice

environments favorable to nurse practitioners in

these terms are associated positively with the supply

of NPs.’5

Scopes of practice for physicians and nurses is

legally defined by Medical and Nurse Practice Acts.

In most states, the practice of medicine and surgery

has been very broadly defined to include all acts of

diagnosing, treating, prescribing, or curing.’6 Nurse

practice acts have defined nursing as supervising

patients, observing for symptoms and reactions,

accurate recording of facts, and carrying out

treat-ments, medications, and medical orders as

pre-scribed by a licensed physician.’6 This narrow

defi-nition hampers advanced-practice nurses (APNs) in

using their diagnostic and therapeutic skills. In the

same year, Idaho became the first state to include

diagnosis and treatment in the scope of practice for

APNs; regulatory authority was assigned jointly to

its state Board of Nursing and Board of Medicine)6

(5)

Whether the functions of APNs should be governed

by nursing or medical boards has continued to be

controversial. Currently, most states have revised

their Nurse Practice Acts to recognize APNs (Table 6)

and have made significant revisions in law

govern-ing the ability to prescribe medications (Table 7).

Reimbursement for services rendered is obviously

an important issue. In 49 states, APNs received direct

Medicaid reimbursement; in 39 of them,

reimburse-ment is at 80% to 100% of a physician’s level. In

addition, APNs receive third-party reimbursement

in 34 states, although it is very limited in 10 states.’7

Currently, at least 12 states are considering further

legislation that would increase prescriptive

author-ity, alter requirements for physician supervision or

collaboration, or both.

PNPs AND PRIVATE PEDIATRIC PRACTICE

PNPs perform a variety of functions in private

pediatric practice. They are employed in all private

settings: solo practices, small and large groups, and

HMOS. PNPs usually are allotted more time with

patients and therefore see fewer children per day

than pediatricians. Typically, PNPs will consult with

ped iatricians about diagnosis or treatment of more

complicated problems. One study demonstrated that

PNPs were able to manage 67% of patient visits

without consultation.’8

In some offices, PNPs provide newborn follow-up

care and teach new parents. Some PNPs have

be-come expert in the art and science of breast feeding.

Because health promotion, nutrition, and lifestyle

education are all aspects of PNP training, PNPs are

ideal health and illness educators in the office.

Teach-ing children with asthma and their parents-how to

assess severity or when and how to use

medica-tion-is an example of an important educational task

that often requires more time than pediatricians are

able to provide. PNPs actively can help address

obe-sity, another increasingly important problem in

childhood and adolescence.’9 Similarly, PNPs can be

effective in the management of other adolescent

problems, which often require considerable time to

explore.

In some practices, PNPs share night and weekend

call with pediatrician back-ups. Because of the

pos-sibility of collaborative practice with PNPs,

pediatri-cians have been attracted to otherwise unattractive

rural areas.2#{176}In addition, PNPs have demonstrated

TABLE 6. Summary of Advanced Practice Legislation*

Nursing (APN)

Type of Legislation No. of States

APN title protection, Board of Nursing 16 sole authority, APN scope of practice,

no physician supervision or collaboration

APN title protection, Board of Nursing 24 sole authority, APN scope of practice,

physician supervision or collaboration.

APN title protection, scope of practice 4 authorized by both Board of Nursing and

Board of Medicine.

No APN title protection, board Nurse Practice Act. 7

* Adapted from Pearson.’7

their effectiveness as primary care providers and

case managers for chronically ill children at home.2’

QUALITY OF CARE

Numerous studies attest to the high quality of care

provided by NPs. A 1993 ANA metaanalysis of 53

studies of NPs and certified nurse-midwives (CNMs)

found that NPs provided more health promotion

activities than did physicians and also scored higher

on quality-of-care measures that involved diagnostic

accuracy and/or completeness of the care process,

such as taking a comprehensive medical history.

Nurses achieved equivalent clinical outcomes, and

their patients demonstrated equivalent or greater

satisfaction with their health care provides,

compli-ance with health promotion and treatment

recom-mendations, and knowledge of their health status

and treatment recommendations.

Results of this recent study should not have been

surprising given the results of much earlier work. An

analysis of 21 quality-of-care studies published

be-tween 1969 and 1979 concluded that “these studies

show that NPs and PAs provide office-based care

that is indistinguishable from physician care.”Th The

report emphasized that results of these studies,

which were of limited scope, should not be

general-ized to care that was unsupervised or given outside

the office. Similarly, a major report in 1986 by the

Office of Technology Assessment concluded that

“the quality of care provided by NPs, PAs, and

CNMs within their areas of competence is equivalent

to the quality of comparable services provided by

physicians.”24

An excellent randomized study of 1598 Canadian

families in 1974 demonstrated the safety and

effec-tiveness of the work of NPs.’8 The health status of

patients assigned to NPs was compared with that of

patients assigned to family physicians. No

differ-ences were found in mortality or in “physical

func-tional capacity, social function or emotional function.

The quality of care rendered to the two groups

seemed similar.” This study found NPs able to treat

67% of patients without physician consultation. In

1971, the earliest group of PNPs-pediatric nurses

who had received only an additional 4 months of

intensive pediatric training-were shown to be

highly competent, compared with pediatricians, in

assessing normal and abnormal physical findings in

children?

TABLE 7. Prescriptive Authority of APN5*

Type of Authority No. of States

Full independent authority, including controlled drugs

Full independent authority, excluding controlled drugs

Full authority, including controlled drugs, but dependent on physician supervision and collaboration

Full authority, excluding controlled drugs, but dependent on physician supervision and collaboration

Limited dispensing authority

3

2

24

16

8

* Adapted from Pearson.’7

(6)

NPs also have scored well compared with

pedia-tricians when the content of patient interactions was

examined. Foye et al in 1977 compared the content

and emphasis of health supervision visits conducted

by experienced NPs with those conducted by

expe-rienced pediatricians.26 The NPs “discussed

develop-mental and child behavioral topics in significantly

more depth, asked more open-ended questions,

made more specific recommendations, provided

more maternal support,” and “spent more time

lis-tening than talking.” They also averaged 8 minutes

more per visit. A small subgroup of pediatricians

scored as well as the nurses and in less time. Another

controlled study in 1976 looked at preventive care

provided by PNPs in two Kaiser-Perrnanente

medi-cal centers in California.27 In this study, which

in-volved 1152 preschool children, PNPs were “entirely

competent in maintaining the health of their patients,

and were generally accepted by the parents.”

An integral component of pediatric practice is the

assessment and treatment of ifiness using the

tele-phone. In a 1978 study conducted by Perrin and

Goodman, NPs scored highest in their telephone

management of acute pediatric illness.28 House

offic-ers scored less well, and practicing pediatricians

scored least well. Criteria for scoring were history

taking, disposition, and interviewing skills.

PNPs are also effective teachers of first-year

med-ical students and role models for students and

resi-dents.29 Students exposed to PNP teaching of

preven-tive care scored higher on cognitive testing and on

videotapes of patient encounters than students who

did not receive this additional instruction. Clearly,

PNPs have demonstrated that they can make

mean-ingful contributions at multiple levels of the health

care system. The attitudes of physicians who work or

train together with NPs reflect an appreciation of

their skills and a willing acceptance of their role in

helping meet the health care needs of children)#{176}’’

CONTROVERSIES

Recently, numerous issues that have created

ani-mosity between pediatricians and PNPs have

become barriers to greater mutual acceptance and

collaboration. In the current climate of cost

con-sciousness, pediatricians are concerned that the

pur-chasers of health care services, insurance companies,

will look to replace them with what seems to be a

comparable but less expensive alternative. NPs are

concerned that they will not have full professional

recognition if their activities are contingent on

phy-sician supervision and if they are unable to be

re-imbursed directly for their services. The extremists

in both professions do the children of America a

disservice.

Many children do not receive pediatric services

from either a PNP or a pediatrician. In 1992, when

there were nearly 45 000 pediatricians, 6000 PNPs

and 700 PAs were working in pediatrics. On

num-bers alone, PNPs and PAs cannot supplant

pediatri-cians in the foreseeable future. In states having a

climate for practice that is favorable for all, the

sup-ply of generalist physicians and the supply of PNPs

and PAs are positively associated. The states having

more than the national average of PNPs and PAs are

those that have a relatively favorable environment

for them, compared with other states, and a shortage

of primary care physicians.3’

Analyses regarding cost effectiveness conflict.

DeAngelis argues that, although PNPs earn half the

salary of physicians, the cost per patient visit is

corn-parable, because PNPs spend more time per patient

visit and work fewer hours than physicians.32 Others,

who challenge the validity of this measure of

pro-ductivity,’6 would substitute for cost per patient visit

“episodes of care,” the number of visits related to a

given illness.33 By this measure, one study found NPs

to be 20% more efficient.33 In reality, comparisons are

difficult if not impossible, because very few PNPs

practice truly independently, because, although

scopes of practice overlap, they are not identical.

Furthermore, although the cost of training PNPs is

significantly lower than the cost of training

pediatri-cians, the cited costs usually do not include the

on-the-job training that occurs in the early years of

collaborative practice.

Comparisons such as these only confuse the issues.

PNPs are legitimate child health care professionals

trained in health promotion, health supervision, and

the diagnosis and treatment of common childhood

illnesses. Pediatricians are physicians concerned

with the health and well-being of children, trained in

depth in the diagnosis and treatment of the illnesses

of children. Overlap is significant; children need both

the health promotion and educational services of the

PNP and the depth and breadth of knowledge of the

pediatrician. Critics of NPs often cite their brief

train-ing as evidence of their inability to provide quality

health care services. Any deficiencies created by the

brevity of their training seem to be compensated for

by the collaborative practice style of the vast majority

of PNPs.

The AAP encouraged the development of

ad-vanced training for nurses and continues to endorse

the role of PNPs. In its most recent policy statement,

it called for “an interdependent relationship . . . and

a clear understanding between both parties of the

roles of each.” The Academy’s belief that

pediatri-cians should “supervise” the work of PNPs

antago-nized many reasonable PNPs and their organization,

the NAPNAP. In fact, if pediatricians and PNPs

work together in teams as coprofessionals, such

su-pervision is unwarranted and unnecessary. Using

the care of an inpatient as the model, the physician

and nurse are team members, and both are essential

to the recovery of the patient, but the physician does

not supervise the nurse.

On the other extreme, some PNPs seek to practice

completely independently. The Academy is strongly

opposed on the grounds that such a practice would

not represent the highest quality of care for children.

Most quality-of-care studies were conducted in

set-tings in which PNPs work with pediatricians, and

the results have been excellent. Few data on the

quality of independent PNP practice are available,

and, in any case, the trend in health care delivery is

moving away from small independent practices of

any sort.

(7)

Direct reimbursement is another potentially

divi-sive issue, symbolizing for both PNPs and

pediatri-cians the issue of independent practice. In the future,

both pediatricians and PNPs are likely to be salaried

professionals in large groups and probably capitated,

making this issue largely moot, but to the extent that

it represents for PNPs a sense of professional dignity,

direct reimbursement is not an issue to be taken

lightly.

CONCLUSION

Children may be our nation’s greatest resource,

but their needs have never been this nation’s highest

priority. At a time when society is reexamining

health care expenditures and when the needs of

chil-dren have escalated with the complexities of modern

life, there is great danger that children will suffer a

disproportionately high loss of health care services.

We must help each other adapt to the expanded

needs of children and the changing health care

cli-mate. We must learn to reach children in settings

other than our offices. We must forge affiances with

other child health professionals, particularly PNPs

and PAs, if our goal is for every child to receive

quality health care in a cost-effective manner. The

breadth of services and the potential for flexibility in

the delivery of services that can be offered by

pedi-atrician-PNP teams far surpasses that which either

professional can deliver alone.

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Response

to Dr

Stone

Dr Elsa Stone, in her usual organized and lucid

fashion, has presented the case for inclusion of

pedi-atric nurse practitioners (PNPs) in private pediatric

practices. She bases her conclusions on her nearly 10

years of positive experience with a PNP in her own

practice in Connecticut. Dr Stone describes the PNP

population and demography, describes the training

curriculum of PNPs, and discusses the scope of work

of these individuals. She concludes that “there is

substantial evidence that PNPs provide quality

health care and that collaborative teams of

pediatri-cians and PNPs can provide high-quality,

cost-effec-tive care to a broader spectrum of children than can

be served by either profession alone.”

The American Academy of Pediatrics (AAP) has

(8)

1995;96;844

Pediatrics

Elsa L. Stone