Working as a nurse in one of the busiest cardiac catheterization labs in the country for the last year and a half, Courtney Nahigian spent a lot of time thinking about the preventability of many of her patients’ heart problems.
Kyle Jahner/MEDILL NEWS SERVICE
Kate Dillon and Jason Buchenhorst, both registered nurses, monitor a patient’s progress. Nurses have become more active in health care, and higher levels of education have increasingly been called for in the profession.
“How do people get to this point?” she would wonder.
She has decided to do something about it.
This fall she will leave Washington (D.C.) Hospital Center to start working on her doctorate at George Mason University to become a nurse practitioner. When she started as a nurse, she knew she wanted graduate education but didn’t know what she wanted to do with it.
Now, she aims to work in a free clinic-type setting to get preventative care to groups underserved by the current medical industry. She hopes her work will keep her new patients away from her old lab.
“I think it’s a unique time in health care,” said Nahaigian, who previously earned a political management master’s from George Washington University and helped manage finances for Sen. John McCain, R-Ariz. “I think primary care is really where the need is.”
Courtesy photo
Courtney Nahagian
Nahigian represents a small part of a new evolution of health care delivery. Between already high costs and the anticipated influx of demand from an aging population and health care reform, the catalysts for major changes have already begun to shift paradigms, both transforming traditional care settings and creating new ones.
“We don’t really think of ourselves as a hospital. We’re a health care system,” Janis Orlowski, chief of medicine at Washington Hospital Center.
The hospital has looked to people like Nahigian to take pressure off doctors. A new physician’s assistant track, greater use of nurse midwives in the delivery ward, and structures utilizing nurse practitioners more all leverage her staff’s medical knowledge, she said.
She said the hospital also plans to take advantage of many of health reform’s new pilot programs, such as Accountable Care Organizations, and implementing its own ideas for restructuring the organization of health professionals. Like many health care experts, she supports the reform bill in general as a flawed but important step forward, and said that if even some of the innovations prove successful, the efforts could be worthwhile.
“We are looking at a different care model, again, all in the hope of improving quality, decreasing length of stay, decreasing dollars,” she said.
In your average visit to the doctor’s office or hospital, actual time with the doctor is often limited. Whether primary care or emergency care, specialist or surgeon, doctors aren’t the only ones that treat patients. With other professionals taking increasingly active roles, it helps to know who they are. After all, patients typically spend more time with them than doctors.
Advanced Practice Clinicians: The general term for professionals with graduate degrees. They can include nurse midwives, nurse practitioners and physician assistants. With more medical training than nurses, they can provide a variety of services, and often spend more time with patients than doctors. Many organizations, such as Washington Hospital Center, use them in teams, with a doctor overseeing a group. Able to deal with many issues, the doctor is only consulted when a problem arises that goes beyond their training.
Nurse Practitioner: A registered nurse can go on to graduate school to become a nurse practitioner. Formally Advanced Practice Registered Nurses, NPs have master’s degrees traditionally, though there is a push to have an increasing number of NPs earn doctorates. With specialties in a variety of areas, NPs can provide primary care for an array of health care consumers, young and old.
According to the American Academy for Nurse Practitioners: “NPs diagnose and treat a wide range of health problems. They have a unique approach and stress both care and cure. Besides clinical care, NPs focus on health promotion, disease prevention, health education and counseling. They help patients make wise health and lifestyle choices.”
Nurse Midwives: Nurse Midwives emphasize pregnancy, delivery and reproductive health, but technically they provide care for women from adolescence to menopause. Like NPs, they can be primary care sources, and also emphasize advising healthy lifestyles and patient education. They also perform physical examinations and diagnostic tests.
Physician Assistant: PAs practice medicine under the supervision of a physician or surgeon. Another primary care access point, PAs can work in situations where the doctor is only present one or two days a week in rural and inner-city clinics, examining and treating patients and monitoring medical histories. They can prescribe some medications, as can nurse practitioner. They can suture, splint and cast injuries, order and carry out therapy, and instruct and council patients. They also sometimes take on managerial roles, supervising technicians and assistants and ordering supplies.
They also often make house calls or visit nursing homes and hospitals. They must report back to their doctor with progress updates to keep them informed. Like Nurse Practitioners, the extent of their ability to prescribe medication and act independently vary by state. More medically trained than NPs, PAs generally have passed through master’s degree programs that include a wide array of science, diagnostic training, pharmacology, and medical ethics.
Away from the big hospitals, new options have also begun to expand their reach. Retail health care centers, home care, and care in the office providing ways to reach more people directly, and hopefully before the little problems become big one. In many cases, nurse practitioners and physician assistants represent the primary contact for patients. Information technology also continues to be developed.
But it’s all a work in progress.
“The health care system hasn’t caught up to the health care needs of society,” said Melanie Dreher, dean at Rush University’s nursing school.
Dreher sees the elderly in particular as a source of growth in the nursing industry, where doctors aren’t necessarily required for all health problems.
“There’s enormous opportunity. Nurses are really good at managing chronic illness. The advances of medicine have been great, but they’ve created a lot of chronically-ill people,” Dreher said.
Home-based care has become a growth industry in particular, especially for the elderly. An October 2009 Journal of American Medical Association study concluded that home visits proved effective compared to nursing homes, and even lowered mortality rates among those in the study under the age of 80.
The costs are substantially lower. Orlowski’s hospital is one of many that has expanded its reach to include some home-based care programs.
The non-elderly have increased options as well. The first retail clinics opened in 2000, and the Convenient Care Association counts about 1,200 nationwide. Typically relying on nurse practitioners and physician, the clinics mostly treat common illness such as colds and flus as well as provide immunizations and blood pressure tests.
Though controversial as they are almost never staffed by a doctor, 2009 study by RAND Health found the treatment to be 30-40 percent less costly with no apparent drop-off in effectiveness in quality of care or preventative care.
That speaks to another problem facing advanced care that can save major dollars down the road; making it available is one thing, having people use it is another. Orlowski said she supports the Affordable Care Act as it addresses problems long overlooked, but added that it isn’t perfect. Asked about the idea of universal insurance leading to more preventative care, she bristled.
“Do you believe that?” she asked. “I’m not sure. That’s the theory. And it’s a great theory. The question is, where’s the practice.”
She pointed out that Massachusetts created health reform with similar guarantees of insurance. But there was not wide-spread access to primary care doctors, so people were going to emergency rooms, the most expensive of options. In addition, she worries about programs like Medicaid that don’t pay well, forcing hospitals into tough business decisions. AAMC federal affairs director Christiane Mitchell said half of those newly insured under health care reform are expected to rely on Medicaid.
Connor O’Brien, between his third and fourth year of medical school at Columbia, pointed out that many have a distrust of doctors – some going so far as believing doctors will deceitfully harvest organs, he said – which adds to the problem.
“People are very averse to allowing intervention in their life when they are not sick,” O’Brien said. “That’s their right, but the end result is that it is very hard to change the systemic problems.”