THE VIRGINIAN-PILOT
Copyright (c) 1994, Landmark Communications, Inc.
DATE: Monday, July 18, 1994 TAG: 9407180038
SECTION: FRONT PAGE: A1 EDITION: FINAL
SOURCE: BY TOM HOLDEN, STAFF WRITER
LENGTH: Long : 146 lines
A happy baby, Joseph McCarthy sat wobbling on the paper-covered examining table, his great blue eyes staring in wonder at the woman in the white lab coat, a stethoscope draped around her shoulders.
She looked every bit like a pediatrician, but she wasn't.
The woman giving young McCarthy his well-baby checkup at a Virginia Beach Department of Health clinic was Judith N. Cudworth, a certified pediatric nurse practitioner.
Educated at the master's level and sometimes beyond, thousands of practitioners like Cudworth have filled a crucial role in Virginia's health care for more than 20 years - a role experts believe could mushroom in the next decade.
At a time when cost-conscious insurance companies are nudging more people into managed-care plans, nurse practitioners increasingly are seen as a practical way to deliver quality health care at a lower cost.
The reason is simple. Practitioners can provide routine checkups, administer immunizations, treat illness and prescribe many drugs - except controlled substances like barbiturates and narcotics - at a price far lower than demanded by physicians. Doctors typically make at least $120,000 a year, more than double a nurse practitioner's income.
But with growing interest comes a renewed debate about the role of nurse practitioners and whether they should enjoy greater independence from doctors or remain as most are today - employees of doctors.
Listen to two voices in the debate, the first that of the head of a nurse practitioner organization, the second that of an orthopedic surgeon.
``Basically we do the same things as a family physician,'' said Nancy S. Harvey of Roanoke, president of the Virginia Council of Nurse Practitioners. ``We can perform routine checkups, health promotions and follow ups for some chronic illnesses.''
Dr. Michael M. Romash, an orthopedic surgeon in Chesapeake, has concerns.
``If they have no supervision, who takes responsibility for their actions?'' he said. ``If you're not sick, then you don't need to see a doctor, I agree. But I worry about the hidden agenda of practitioners who were trained as physician extenders. Now they want to be independent practitioners and become physicians without going to medical school.''
Nurse Cudworth never had an interest in becoming a doctor. For part of her career, she was more involved in the administrative side of health care and raising her own children. But she returned to school to become a practitioner, opting for the simple joy of working with babies.
``I just love the children,'' she said. ``They're so innocent, but even at their age I get a chance to be a part of their health care, to teach them good habits.''
In the clinic, Cudworth can stress the basics with her patients and their parents, a role she loves. With teenagers, she can weigh in on more urgent subjects like the prevention of sexually transmitted diseases and birth control.
The care provided to baby McCarthy was preventive. Cudworth listened to his breathing, checked his ears and eyes for infection, questioned his mother about home life, and scheduled immunizations.
Tammy McCarthy, the boy's 30-year-old mother, was happy to comply. With no health insurance, she has few health care options.
``I like coming here,'' she said. ``I can't afford a doctor anyhow.''
The public health clinic setting is one of the traditional venues for nurse practitioners, one that Cudworth's supervisor is quick to praise.
``It's a big responsibility and a big help to doctors,'' said Dr. Erlinda R. Ramiscal, a public health pediatrician. ``Nurse practitioners give physicians more time to spend with patients who need more evaluation for complicated diseases.''
Dr. Lisbet M. Hanson, an obstetrician and gynecologist at Virginia Beach Ob/Gyn on First Colonial Road, echoed Ramiscal's sentiments.
``It's sort of like having a medical student around,'' she said of her practitioner.
``She helps us out if we're called away for delivery. She also rounds out what we provide patients and has more time to discuss issues, like breast feeding or dietary concerns, and she is really great with teenagers who might come in for refills on birth control.''
The responsibility is growing.
Five years ago, Virginia registered 1,789 nurse practitioners, according to the Virginia Department of Health Statistics, which licenses all of the state's health professionals. As of June 30, the number had risen to 2,330.
The American Association of Colleges of Nursing estimates that nationwide, 100,000 more primary-care providers will be needed in the next few decades to meet demand, particularly as the number of managed-care programs increases to well over half the total health plans.
The association says that 70,000 of them should be nurse practitioners and certified nurse midwives.
Practitioners in the state are regulated by the Virginia Board of Nursing and can obtain licenses only after becoming registered nurses, completing advanced practice education courses and passing a national certification exam.
While they may feel a close professional kinship to doctors, crucial differences remain - and none so important as the question of independence. Practitioners are almost universally employed by doctors, a fact that gains significance when it comes to money. No matter how much education practitioners have, they cannot bill insurance carriers for their services - a fact that has long angered those in the profession.
``It's a question of territoriality, a market issue,'' said Laurel S. Garzon, the director of the advanced perinatal and neonatal graduate program at Old Dominion University's school of nursing.
``Nurses have suffered restraint of trade. They cannot recover the cost of their care directly through third-party payers. They can do so through a physician.''
The issue is not that nurses want to be treated like doctors, Garzon said, but rather the care they provide has every bit the value offered by doctors.
``There have been studies on top of studies that have demonstrated nurses can do a large majority of what doctors do, and do it well,'' she said. ``Patients are often satisfied with their care.''
The testy subject of pay underscores part of the complex relationship nurses have with doctors, and it's part of the reason that the practitioners recoil from using a common description of their profession: ``physician extenders.''
``Physician extender implies that a nurse practitioner has a role only when a physician is not available,'' said Garzon, who has a doctorate in nursing science. ``We believe they have a legitimate role as an advanced practice nurse in collaboration with physicians. If there is a physician there, a nurse can be, too.
``After all,'' she added, ``the majority of health care provided in this country is done so by nurses. We're taking what they know and expanding upon it.''
Some doctors have voiced concern lest the role of practitioners expand too far, noting the different educational requirements for nurses and doctors.
Romash, the Chesapeake surgeon, agrees that nurse practitioners can deliver basic health care, but says people should be aware of the differences between a nurse practitioner and a physician.
``There is a blurring of these two professions,'' he said. ``In today's world, where there is a high importance placed on truth in labeling, why is the labeling of doctors being blurred with paramedical health care delivery people so that no one knows who they are seeing? Everyone becomes a `provider.'
``The patient who is at risk is the one who is very ill or one who has a subtle disease that the nurse may not appreciate,'' he said.
Of equal importance, he said, is the oversight role that physicians have with nurse practitioners whose decisions - and the responsibility for them - are overseen by the doctors. This traditional arrangement lies at the heart of the reimbursement issue.
If nurses become independent of physicians, their presence could create a new market of low-cost health ``providers'' that insurance companies will want to exploit, he said. ILLUSTRATION: [Color photo] RICHARD L. DUNSTON/Staff
Tammy McCarthy holds son Joseph during a checkup by nurse
practitioner Judith N. Cudworth at a Virginia Beach public clinic.
by CNB