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.
PEDIATRICS (ISSN 0031 4005). Copyright © 1995 by the American Acad-emy of Pediatrics.
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
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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)
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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
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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
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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
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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.
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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
PEDIATRIcS (ISSN 0031 4005). Copyright © 1995 by the American Acad-emy of Pediatrics.
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1995;96;844
Pediatrics
Elsa L. Stone
Nurse Practitioners and Physician Assistants: Do They Have a Role in Your Practice?
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1995;96;844
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Elsa L. Stone
Nurse Practitioners and Physician Assistants: Do They Have a Role in Your Practice?
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