Friday April 25, 2008
Making Room for New Health Care Players
On White Coat, Black Art, we talk a lot about doctors. You might get the sense that doctors are the centre of the health care universe. True, they're important members of the team. But they're no longer the "be all and end all" of staying well and getting better.
This week, on White Coat Black Art, we meet three new players on the health care team. Join me and my co-host, nurse practitioner Michelle Acorn, as we talk about newcomes to the health care sandbox who can help you get better FASTER. Acorn was one of three NPs who delivered primary care in a chronic care hospital without the aid of a physician in 85% of cases.
Jose Araneta is a physician assistant or PA at Concordia Hospital in Winnipeg. In Manitoba, they're also referred to as clinical assistants. The original PAs were medics who treated casualities of war. Some of the PAs who trained with Canadian Forces have found jobs in the civilian health care system. They were brought to Concordia because of long wait times for new hips and knees. PA's like Araneta do things like prepare the patients for surgery, hold the specialized instruments in the operating room, and do some surgical procedures during hip and knee replacements.
Jose Araneta, a physician assistant (pictured right), assists
orthopedic surgeon Dr. David Hedden (pictured left) during knee
replacement surgery. Physician assistants have helped surgeons double
the number of hip and knee replacement operations at Concordia Hospital
The payoff for patients has been astonishing. Since hiring PA's at Concordia, they've been able to more than double the number of hip and knee replacement operations they do each year. That has cut the wait time for new knees and hips by 14 weeks! This fall, the University of Manitoba launches Canada's first civilian masters level PA training program.
From Winnipeg, we travel to Digby Neck, NS, near the Bay of Fundy, where we meet paramedics Wally Howard and Josh Cail. In addition to their usual emergency rescue duties, they make house calls, do blood pressure and blood sugar checks, and even deliver prescriptions, to the residents of Long and Brier Islands. Along with a nurse practitioner, they're part of an innovative program that provides primary care to people who haven't had a family doctor since the last one retired nearly a decade ago.
Paramedics and physician assistants aren't intended to replace doctors but to complement or extend the services that physicians can offer. Nurse practitioners are a different story. From my conversation with Michelle Acorn, you get the sense that NPs are trying to bust through the bureaucratic and regulatory barriers that are holding them back from really strutting their stuff.
Together, all three of them are filling gaps in health care that are left by absent physicians. To me, it's a trend we'll see more and more in the future.
Previous Comments (24)
I would like to be able to see a Nurse, prior to making a appointment with my doctor...so many of my concerns could be addressed, and treated....is there somewhere in the lower mainland, B.C. that there is a "team" clinic?Jean Sheppard, April 28, 2008 2:53 PM
April 28, 08
Dear Jean, you would be best to contact your health authority. As Vancouver coastal has community health centers with primary care clinics. Most of them in the Vancouver area have at least 1 NP. You have to find the community health center that services the district you live in and ask the receptionsit if the NP is taking new patients. I hope this helps.
There are a few clinics in the lower mainland where Nurse Practitioners are currently taking patients:
Pacific Spirit Community Health Centre (CHC)
Raven Song CHC
You can also visit www.bcnpa.org for more info about Nurse Practitioners in BCNatasha Prodan-Bhalla, April 28, 2008 11:26 PM
Just love the show!
Brian, now that you've opened the window on the topic, you might want to follow up today's show with one devoted entirely to the hot topic of interprofessional healthcare education and promoting collaborative practice among health care practitioners.
I would be more than happy to assist in directing your producers to the key players in Canada in the IPE/CP movement. They can also visit the Canadian Interprofessional Health Collaborative at www.cihc.ca as a starting point.
Keep up the great work,
Professor and Coordinator, Interprofessional Education, Faculty of Community Services and Health Sciences, George Brown College, Toronto
I am a newly graduated Nurse Practitioner in BC, and the sad thing is that I cannot find a job as a family practice NP. These jobs are few and far between, and the ones that do exist are mostly filled by the previous graduates.
With approx 150 000 orphan patients in BC, I would think that the employment of Nurse Practitioners would be simply "a no brainer".
Instead, NPs are required to taking jobs in specialty areas and acute care instead of what they were trained for in family practice.
Admittedly there are a few jobs in remote locations, however these placements often lack mentorship and the supports required for a new grad. And not all NPs are able to go remote due to community and family obligations.
But whether remote or urban, people in BC need care!
What becomes even more frustrating is the regionalization of the NP jobs within the health authorities. Williams Lake has been unable to get an NP, yet there are thousands of patients in the community without a primary care practitioner. The community is ready, the physicians have written letters of support as has the city council, and various community members have started a petition.
So, my question is, with the lack of primary care practitioners, why can't NPs find primary care jobs in communities that want and need their services?
I feel your pain! Take heart though, here in Ontario this was the situation for many years, until finally the constant lobbying by NP's, Family docs and the public forced the Ministry of Health to listen. There are now more jobs, and not all in remote locations.
Keep putting the pressure on your health authority for more NP's in your area and good luck!Lesley, April 29, 2008 1:07 PM
I would much prefer to see a nurse practitioner than a physician. (You knew that.)
You don't have to deal with the ego. Most NPs are women, as opposed to PAs and physicians (although yes I know that it's about 50/50 now entering). So you also don't have to deal with being patronized and being the recipient of sexist medical care. (You haven't dealt with that Brian. It's a lot more symtemic than a pelvic exam).
I lived in the Arctic for years and watched NPs running the remote health services, mostly women from the U.K., rock the socks off arrogant physicians doing their turn. I've seen a physician go into another room, frantically get a run down on procedure from the NP and then go out and put on a show, while she, with experience that oblitered his, but not with an M.D. and all that carries, played sweep.
I find it extremely sexist that NPs aren't being used, while we create places for men in this already far too patriarchal system.riverein, April 29, 2008 9:43 PM
It's obvious that physicians spend far too much of their time on tasks for which they are over-qualified: it doesn't take a degree plus 4 years of med school plus x years of residency to handle a common cold! It's clear to me that people with different qualifications can handle much of the load, given that they are also very clear on their boundaries. I am pleased to see some first steps being taken in Canada.
One critical point the program overlooked: how are these people being funded? I understand that physicians are paid by the provincial government in accordance with an (inadequate!) fee schedule that must be extremely onerous to modify -- what arrangements have been made -- or are proposed for -- these new health care professionals?
PS. Love the show -- haven't missed one since I learned about podcasting!Scott Campbell, April 30, 2008 4:20 PM
As a recently graduated Nurse Practitioner looking about the province of BC for a job, I have to second my colleague Laura Housden. The jobs are just not there.
In the Health Professions, I have seen strong support for the NP practice from GPs, Specialists, Physios, and Nurses amongst others. More importantly, as a practitioner of a new practice I have to explain my role to every patient I see- and there have been more than a few dubious patients, who by the end of the appointment go out of their way to say they would see me again.
So if the professionals want NPs, and the patients want NPs, and the NPs want to work, and there are so many "orphaned patients".... what is the problem?
It must be the small detail that there is no way to pay us in BC!
The "bottom line" is the problem. Currently NPs in BC are mostly paid with pilot project money. We are not legislated to bill for services like physicians (although we are educated to do them and are legally entitled to do many of the same procedures and diagnoses).
It is summed up in the conversation I had with so many patients during my NP training: "Oh, so you're here to help the doctors?"
With a wink to my doctor-mentor, I would respond, "Nope. We're here to help the patients".
Would that I could!
Love your show and recommend it to each new group of students that i work with. I work with foreign trained physicians who are looking to find alternate careers in the health sector. As you know only a few of the International MD's get a residency place even after passing all the qualifying exams. Physican Assistants would be a great fit for them. I hope the pilot project for PA's in Ontario is successful. We are wasting resources at the very time when we are suffering medical shortages. You should do a show on these Foreign doctors. Maybe it would help advocate for change. These are great people, hard working, skilled and eager to help.sheila hellier, April 30, 2008 10:40 PM
The NP is a core concept of primary health care reform. According to Romanow (2002) “Primary health care reform goes against entrenched practices in the prevailing culture of our health care system and it sometimes runs into powerful interests and long-standing privileges” (p. 119).
Awareness and critical examination of how elements such as power operates in our health care system is important to understand how this then shapes peoples’ health status, opportunities for health, and access to resources (e.g., FNP services). Maika Mclorie MN-NP(c).
I am lucky to have a caring family doctor.I feel for those who don't.
I apreciate my doctor's knowledge base. She works with a physician assistant who helps me organize my medications, monitor my blood sugars and organize which issues need to addressed at each visit. This works very well for me as a patient. I know my doctor is able to see more patients in a day because of her assistant. I however, given a choice, do not want a nurse practitioner diagnosing my medical conditions. I personally think there is a reason that doctors are trained for at least 6 years after their undergraduate degrees and think the depth and breadth of their knowledge is necessary.My doctor diagnosed my lymphoma when all I thought I had was the common cold with a sore throat.
I have to wonder; given some of the comments made on the web posts and during the show, especially Michelle Acorn stating that she can replace family physicians(stating that the only thing limiting her clinical work is legislation and not training)...why do we even need medical schools if that is the case?; Family doctors are being shot down from pretty much everyone including their fellow health care providers. I can bet if a doctor came on your program and stated in such certainty that they could easily take over another health care provider's job that they would be mocked as arrogant. I found Michelle Acorn to be arrogant. This type of attitude is likely the reason why nurse practitioners haven't been more widely used.
I agreed with the segment on physician assistants especially in the operating room. It seems a good way to introduce foreign medical doctors(there are a lot not utilized in Canada)back into the system and then hopefully into full medical practice.(freeing up family physicians who currently help in the operating room to attend to patients-again more doctors) If wait times for major joint surgery are reduced then there will be less doctors visits for pain medication and a whole lot of stress taken off the system.
I have numerous friends who are nurses and work in both community health and the hospital: their traditional roles have been pushed away from them mostly due to budget restraints and nursing shortage - their main duties given to LPN's- this has lead to one RN supervising a whole floor of lpn's. They hate this type of care as often medication errors lead to worsened patient outcomes. Also bedside assessments are not done in the way they should be. This leads to my friends being very stressed, burned out, and worried about patient care. Nurses are important and their roles are needed especially in the hospital as the primary caregiver. This is a role that is meant to work in conjunction with all the health care providers. We need more nurses to do the amazing jobs that they were trained to do. We need less managers and more primary nursing at the bedside and community.
Having more NP will not address the issue that we still need more doctors.Joaquina Amaral, May 2, 2008 11:54 PM
There are jobs in the IHA for family NP in Family practice settings. These are great jobs, full scope and a great place to gain experince and build confidence as a new HC provider.
If we don't fill these jobs there will not be others created. So for you new NP's looking for work in PHC setting check out the opportunities in IH.
I also suggest you work with you CNO team to develop a framework for implementation so the jobs move from acute care to the family practice/PHC settings.
On another note. I want to thank the CBC for finally giving a little air time to the NP. The time is now to move this important role in health care forward.
Thanks for presenting this program. I have always wondered why doctors are the only "gatekeepers" for other services. I am a social worker with an MSW, and have worked in mental health and addictions for many years. I can make suitable referrals to local psychiatrists, yet some only want an MD referral. Apparently this is because the psychiatrist gets paid more for an MD referral. As others have said, I do believe related health professionals can help take the load off the medical system.
I am very lucky to have a family physician who I like. I am not sure I would want to actually replace him with an NP or other health professional. I would happily use the services of one of these other professionals as part of a team. In fact, I believe that other health professionals may indeed be better at assessing needs than family doctors, perhaps mostly because they do have more time. I am a little concerned about the idea of actually replacing docs with NPs in these days of "bottom line" measurements in healthcare. I would not want to see thses services put into place because they are more cost effective. I want them to be there because they are a way to provide better healthcare. I know that I have been able to do my work best when part of an interdisciplinary team.Kathryn, May 5, 2008 1:02 PM
My thanks to everyone involved in producing this very interesting show.
www.thefirstcanadianhealthcareconference.ca is a national online platform showcasing Canadian healthcare: the people, the organizations; their ideas, their work and their achievements. We are interested in talking to the paramedics in Digby Neck Nova Scotia about supporting them to further promote their innovative work. We would appreciate your help in putting us in touch.
Many thanks.Gloria Lattanzio, May 8, 2008 3:18 PM
Another great show. I remember, when pregnant with my first child in 1979, midwives were fighting for accreditation. This past December, my daughter gave birth to a lovely girl with the help of the midwife. The services were spectacular. Since she was 2 weeks early the midwife was most attentive and visited every day. She was knowledgeable about breast feeding and ensured success. The midwife managed to have a hospital test done and the results back quickly.
This has supported OB/GYNs and given them more time to devote to high-risk pregnancies. It is time that we extended this option to other health care recipients.
I am a Nurse Practitioner from Saskatchewan. I am proud of my profession and good at what I do. I find it offensive, however, when NPs or others suggest that we can replace family physicians. I do not, nor have I ever, wanted to be a physician. I have great respect for many family physicians, and some are very dear friends. There are important and significant differences in our roles and in our education. I have met Drs that were threatened by me and others that welcomed me with open arms into their practise. I also know nurses who are threatened by LPNs, PAs other NPs (Master's vs. BSN). My belief is that if you are good at what you do and practise safely and compassionately then you are likely the right person for the job. Thanks for the forum.connie, May 31, 2008 8:11 PM
I agree with Joaquina Amaral in regards to her comment about NPs and the over all shortage of bedside RNs!
RNs play a pivotal role in the health care system that cannot be replaced. I work in health care and see the amaxing work and the necessity that RNs are to patient management, however the basic role of being a nurse seems to be lost! There are so many executive/managerial/advanced roles for RNs, that bedside nurses are virtually being taken away from the bedside! I do believe that everyone has the right to advancement and further development, I do though find it hard to encourage a population so pivotal to health care to expand their role, where they don't have enough resources to cover the very basis of what their profession entails-bedside care! The amount of overtime that is paid out due to lack of nurses working at the bedside (their fundemantal role) is astonashing!
I do think that there is an overall shortage of healthcare providers and the introduction of new professions like PAs is very excitting. Being in health care myself, I find it hard to find areas, and support, to advance or excel in your profession unless you carry the title of RN behind your name. Advanced Practice Nurses are in almost every program within the hospital I work in, no other health care profession has that ability. So seeing the introduction of a new prosefession like PAs is a fresh alternative. I think a lot of people get involved in nursing b/c they want to be involved in advanced roles, and not do bedside care, its nice to see that there could now be that avenue available. It seems that PAs offer the ability of an advanced practioner that does not require someone to be an RN first, and will keep RNs where they are needed most and thats at the bedside!Marc , June 2, 2008 2:06 PM
I have to agree with the statements made by Joaquina Amaral (May 2). Indeed Nurse Practitioners are medical professionals, but i also feel it is arrogant to state that the level of expertise and training is the same. I have the utmost respect for physicians and the education and training they endure to practice medicine. As an Advanced Care Paramedic and RNBN, i can say that my nursing education in no way was as extensive as a medical degree- there is a different focus of care, and the scientific background was lacking. Based on my experience as an RN and as a Paramedic i am choosing to pursue a PA program instead of an NP program. I may offend fellow nurses, but one cannot disocunt the years of education and clinical experience an MD posesses. I do not feel an NP should be endeavoring to take over the role of an MD, but rather complement. After all, if one wished to be am MD, there is always medical school.Sandy , July 2, 2008 3:48 PM
The comments on nurse practitioners and their changing role in what (to use the American term) is now known as 'primary health care' are excellent examples of why there is no future in 'family medicine' and why any Canadian medical graduate should avoid primary health care like the proverbial plague.
The difference between what nurse practitioners do (or more accurately, are allowed to do) and family physicians is for the most part entirely artificial and can easily be changed by appropriate legislation. One can, with absolute accuracy, predict that nurse practitioners and physician assistants will in the not very distant future usurp almost completely the role of the primary health care physician. Evidence from the US very strongly suggests that there is no difference in outcome or in patient satisfaction between primary care patients treated by nurse practitioners/physician assistants or by primary care physicians. The key point is knowing when to refer to the appropriate specialist.
So why would any medical graduate with any sense whatever even think about going into a seudo-specialty which will be increasingly dominated by nurse practitioners
and others doing essentially exactly the same thing? Which is maybe why family practice in the USA gets very little respect from specialists and is at the very bottom of both the physician income and status scales. And which is almost certainly the route that Canadian medical graduates (and especially male Canadian medical graduates) will follow. Like it or not, from a medical viewpoint primary care medicine as a field of medical practice is in its death throes.
I heard the rebroadcast of this episode on the 28th of July. It was very interesting to hear of the new and developing roles in healthcare across the country.
I am often disappointed however, when listening to the primary care debate that my own profession - physiotherapy - is left out of the discussion on primary care reform. There are numerous examples in the United States, the United Kingdom, and here in Canada where physiotherapists have taken on a greater role in the care of patients with musculoskeletal problems. Even with these great examples physiotherapists are often overlooked when it comes to remodelling primary care. Physiotherapists with expanded responsibilities (e.g ordering x-rays) could be a great asset in primary care settings to deal with the numerous patients with musculoskeletal complaints. Physiotherapists working alongside physicians as Nurse Practitioners do could allow patients with musculoskeletal problems get the help they need without having to wait for a referral to the already overtaxed orthopaedic surgeons.
The primary care discussion needs to include all of the regulated health professionals whose services could help enhance patient care. To many of these discussion focuss on physicians and Nurse Practitioners.
Stephen Patton, PhysiotherapistStephen Patton, July 29, 2008 1:41 PM
I listened to your programme this morning and someone mentioned that a G.P. was a good source for women having babies. I am well past that age myself, thank goodness! I do not say that because I would not want more babies but I am appalled to think that if I did choose to use my G.P. I would be one of 3,500 patients and my chances of having a doctor at my side would be slim indeed. That actually happened to me once and a sample of the cord blood was missed. I am RH negative and in those days it was a dangerous condition. Fortunately all was well and my six children have all grown to be lovely healthy adults.
I do not even call my doctor for an appointment. I use the nurse practitioner and she uses the doctor for consultation and mostly for signing off on some medications. Catherine is wonderful and shows me results and charts on the computer. The doctor is also very nice and tells wonderful tales of her family life. She is also compassionate and listens to my tales as well but I see her about twice a year. In my opinion we would be better off with lots of nurse practitioners and specialists and clinics. G.P.s are pretty well obsolete as far as I can see. which are open all the time as they are in Spain for example, even Christmas Day as well as all night.
Thanks for your programme. It is very good.
Glenna L. will
I was listening to your show regarding physician burn out. Why is it so hard to solve this problem of lack of doctors, lack of nurses, lack of human bodies to fill these jobs? I just can't understand why it’s so hard to hire more health professionals. Why can't we immigrate health professionals that are schooled and have worked in other countries (that have similar schooling and credentials to our country). Is it government bureaucracy, job protectionism, greed? What is it that's stopping us from solving this problem? There will always be a need for health care professionals. More bodies would surely take some of the pressure off of our health care system and the people who currently work in this environment?Rachel, November 17, 2008 3:02 PM
Very interesting site, Hope it will always be alive!propecia, May 25, 2009 4:22 AM