Melissa Knopper

For most of their 40+ years, physician assistants and nurse practitioners have been a uniquely American phenomenon. But now, clinicians are starting to transport their ideas and expertise to all parts of the globe.

Training programs have already been established in parts of Europe and Australia. Now, as countries in the Middle East, Asia, Africa, and Latin America struggle with physician shortages in rural areas, they, too, are eager to bring these highly trained professionals within their borders.

Through international conferences, groups like the International Council of Nursing (ICN) in Geneva (which has NP or APN programs in 78 countries) and the International Academy of Physician Associate Educators (IAPAE) are connecting willing professionals to countries in need.

For clinicians with a sense of adventure, practicing overseas is a wonderful opportunity to delve into a new culture and share ideas and skills. Herein, we profile several PAs and NPs who are already living the international life. Read on, and be inspired!

Saudi Arabia: Welcoming PAs to the Middle East
As an established PA who had worked in emergency medicine for years and who serves on the faculty of the PA program at George Washington University (GWU), Amy Keim, MS, PA-C, is used to having a lot of freedom in her practice. Keim, who is the director of GWU’s International Physician Assistant Development program for the Department of Emergency Medicine, is also no stranger to working overseas.

So when Saudi Arabian government officials approached her department about designing a curriculum for the first PA program in the Middle East, she was thrilled and a little nervous. She wondered how she would be received, both as a PA and as a woman.

“I have worked in Beirut and Abu Dhabi, but Saudi Arabia had this more intimidating feel to it,” Keim says. “We think of it as this romanticized, really exotic locale. People don’t go on vacation to Saudi Arabia, let’s put it that way.”

Keim says she was pleasantly surprised during her first visit, when her Saudi hosts invited her for a wonderful fireside picnic out in the desert. “There was delicious food and music, and the people were very warm and welcoming,” she says. “They were so hospitable, it changed my impression overnight.”

Keim and GWU Program Coordinator Megan Williams both wanted to be sensitive to cultural expectations for women in Saudi Arabia. They learned, sometimes through trial and error, when it was acceptable to wear Western clothes and when they needed to cover their heads or don an abaya (a full-length black robe). Keim and Williams discovered, for example, that when they were shopping in a more westernized mall, they could wear their usual outfits. But if they were invited to an official military ceremony, they would wear an abaya out of respect for the culture.

“I haven’t run into any real difficulties because I’m a woman,” Keim adds. “They have been extremely open to the [program] model and to the leadership.”

The first 25 students started in the Saudi PA program in September. It will last 28 months and will be based on a military model, similar to that of the first PA programs in the United States and Canada. Only male military officers will have the chance to become PAs.

The program will be administered through the Prince Sultan Military College of Health Sciences in the Eastern Province capital of Dhahran. When the students graduate, they will be called “Assistant Physicians,” mainly because the title translates better.

“These highly trained students will not only be the first physician assistants in the Middle East, but will be a critical component to improving access to quality health care in military and civilian communities throughout the country,” Keim says.

Keim feels the Saudi Arabian PA program will serve as a model for other countries with similar health care needs. “I think this trend reflects a general need for this type of provider, with this type of training, to really close some of the gaps,” she says. She has enjoyed having the opportunity to help bring better care to Saudi Arabia, and to learn more about its culture.

Surprisingly, it was on US soil that an accidental cultural misunderstanding occurred, when one of the Saudi Arabian officials visited Washington, DC. Keim was driving him to an event, but needed to stop by the vet first to pick up her beloved Jack Russell terrier. When her colleague started to look uncomfortable in the passenger seat, she asked why. He told her almost no one in Saudi Arabia has a dog, because the Islamic religion considers the animal unclean. Her colleague “toughed it out” for the duration of the trip, but Keim wishes she had recognized the potential problem sooner.

In the end, this new program has been a learning experience for everyone—in more ways than one. It’s those kinds of exchanges with other cultures that make working overseas a joy and a challenge, Keim says: “I reflect back and think this has been a phenomenal career, because it has taken me down paths I never imagined.”

Honduras: Clean Water and Compassion
When Thad Wilson, PhD, RN, FNP-BC, graduated with a BSN from the University of Iowa nursing school, he happened to attend a career fair. One of the booths, way over in a corner, was advertising a primary care nursing position at a clinic in a rural area of Honduras. Wilson, who had been considering the Peace Corps anyway, jumped at the chance for an adventure. “I was going to be the only primary care provider for 5,000 people,” says Wilson (who was 22 and unmarried at the time).

During his first few weeks at La Buena Fe Clinic in a small village by Lake Yajoa, Wilson says he “got really good” at suturing. That’s because so many of his clients came in with machete wounds. One man even had a machete stuck in the back of his neck. Another patient still thanks Wilson every time he sees him, for sewing his thumb back on after he accidentally cut it off while working with a machete.

“This was a great clinic, in the middle of nowhere,” Wilson recalls. “I had no electricity and no running water. I delivered babies by candlelight and boiled water to sterilize my instruments.”

Just about every patient who came to La Buena Fe had gastrointestinal problems. The area was replete with tropical diseases. “I saw every kind of amoeba and worm you could think of,” Wilson says. “Those were my biggest nemesis.”

Upset by seeing toddlers dying of diarrhea, Wilson consulted with some local nonprofit agencies. Eventually, they built a well so the community could have clean water to drink. “Now, we don’t see the number of cases in that area with gastrointestinal problems,” he adds.

Without the fancy diagnostic tools most US nurses take for granted, Wilson says he honed his skills in taking histories and doing physical assessments. “The greatest technology we have is between our eyes and our ears,” he says. When he needed help, he turned on his ham radio and tapped into the expertise of several doctors thousands of miles away, back in the US. Talk about trial by fire… Wilson, who is now Associate Dean of the University of Missouri School of Nursing in Kansas City, recalls those days with fondness.

Thirty years later, Wilson (the Immediate Past President of the American College of Nurse Practitioners) still goes to Honduras on a regular basis. These days, he visits with 12 nursing and pharmacy students from the University of Missouri. He wants them to capture the magic and the intense hands-on experience that he had in his earlier years as a nurse.

The 15-day program gives students a chance to work in rural clinics as well as city hospitals. Part of the goal is to get students thinking about quality of care under different health care systems. For example, in Honduras, patients must make a down payment before they can have surgery in a hospital. “There are people who will die on that bed, waiting for $50,” Wilson says, “whereas in the US, we would do the surgery first and ask for money later.”

Compassion and cultural sensitivity are other byproducts of Wilson’s overseas class. For example, the students begin to understand the importance of family in Latin American culture. Back home, when an entire extended family crowds into their exam room for one family member’s appointment, they won’t mind so much.

Stoicism is another trait they learn about. “In Central America, they come from a culture where pain is just a way of life,” Wilson says. “They are able to improvise and do whatever it takes to survive.” So students realize patients from these areas may not complain much, and it might take a little coaxing to find out what’s wrong.

Wilson is grateful for his time in Honduras. It has offered a life-changing experience—both for him and for his students.

Australia: Digging in Down Under
Al Forde, PA-C, originally from Wyoming, admits he has always had a love affair with Australia. “I’ve always kept an ear to the ground as to how I could get there someday,” he says.

So he felt incredibly lucky to be hired at James Cook University in 2006, when the college decided to launch a pilot PA program. At the time, Forde was teaching in the PA program at the University of Utah in Salt Lake City. Luckily, his wife and 12-year-old daughter were up for the adventure of moving to Queensland.

“The pace of life is much slower here,” Forde says. “I enjoy living in the tropics, with the warm weather, and living near the coast.”

The James Cook PA program is up and running, Forde explains, but graduates can have a hard time finding jobs. That’s because the PA role has not completely caught on yet in Australia.

With such vast rural territory, Australia would seem to be perfectly suited to the skills and expertise PAs could offer. Forde and his colleagues have learned, however, that they must be patient and slowly encourage change within the current health care system. “It’s a matter of persistence,” he adds.

Australia’s health care system, Forde says, has a medical philosophy similar to the British system’s. The government pays for most health care in Australia, so market forces are not shaping the need for PAs the way they did in the US during the 1980s.

Doctors, for example, do only primary care, emergency care, and obstetrics. Specialists are called physicians. “They have different education and different roles,” Forde says.

It’s still unclear where PAs might fit into that system. One thing that is clear is the shortage of providers, particularly in remote and indigenous areas. “The state health departments, especially in the rural areas, are desperate for backup and help and manpower,” Forde says.

Some clinics in Australia are privately run, Forde says, and the doctors who staff them are interested in seeing whether employing PAs can be cost-­effective.

Forde, who now has permanent resident status, is willing to wait and keep promoting the value of PAs. Other than occasional pangs for good Mexican food, he would not want to be living anywhere else.

England: X-rays and Expressions
Physician Assistant Kristen Gipson has worked in emergency medicine for most of her 21-year career. She did her original training at Emory University.

Gipson was glad to be chosen as part of the first pilot group of 12 PAs to travel to the United Kingdom in 2004. She currently works in an emergency room (called Accident and Emergency) in Birmingham, England.

During her first year in the UK, Gipson ran into some unexpected bureaucracy. For example, each time she went to order an x-ray for a patient, she hit roadblocks. In the UK, Gipson explains, a radiographer can refuse to do an x-ray if he or she doesn’t feel it’s justified.

“Initially, we weren’t allowed to order them, but then the PAs in the hospital managed to attend a radiation safety course, which allowed us to request an x-ray,” Gipson explains. Now, most hospital PAs have the right to order x-rays, but PAs providing primary care in other parts of England still cannot order these basic tests.

In Accident and Emergency, Gipson’s daily routine is pretty similar to that in an emergency department in the US. “I see medical trauma, mental health, children, obstetrics, and gynecology,” she says. “I evaluate, diagnose, request tests, and make referrals.” She can discharge and admit patients and arranges for community care. Gipson also is involved in teaching and training medical students.

While four universities currently offer training programs in England, “physician assistant” is not yet an official role in the UK, Gipson says. To be able to officially practice medicine and prescribe, she had to find a physician willing to “delegate” care or treatment to her, under a specific clause in the British Medical Council’s laws. The employer also usually covers the cost of malpractice coverage.

After six years in England, Gipson says she feels pretty well acclimated to British culture. Even though British and American citizens all speak English, subtle language differences can sneak up on you and perhaps put someone’s knickers in a twist. “Both the medical and everyday expressions can be drastically different,” she adds. “Certain words are very differently used and could cause some embarrassment until you learn not to use them in their American context—for example, fanny and pants.”

Scotland: Of Tea Breaks and Trust
Sometimes, while doing rounds as a PA at the Edinburgh Cancer Center in Scotland, Juanita Gardner must stop and wait for her patients to partake in a bit of tea and crumpets. “Tea breaks are a vital part of the workday,” Gardner says. “The oncology wards have a person who will often come around with a cart containing tea, biscuits, and coffee for every patient at no charge.”

Right away, Gardner noticed the pace was different for workers in the Scottish medical system. They have more holidays and time off to be with their families. Unlike many American health care workers, her Scottish counterparts “work to live,” instead of the other way around.

Gardner came to Scotland from the US in 2006, when the National Health Service (NHS) of Scotland launched a pilot PA program. Gardner was among the initial group of 12 American PAs involved. Her assignment was to set up diabetes and COPD clinics at a local primary care health center in Edinburgh.

As in England, the PA profession is not fully recognized in Scotland. PAs do not yet have prescribing privileges. The UK PA association is working on this, but Gardner says she is still in the process of applying for registration. “As you can imagine, there is much red tape and politics involved in such a process,” she says. “Things here move rather slowly.”

Gardner describes her first year in Scotland as “extremely challenging.” For example, the clinic staff refused to give her access to computer programs and medical records that she needed. “I had two wonderful supervising physicians who used their influence to remove all barriers and obstacles in my path,” Gardner says.

Despite their kindness, Gardner sensed a general lack of trust from the medical community there. “Many seem to feel PAs will take away jobs; others are resistant to change and new ideas,” she says. “Some feel the NHS nurses are equally skilled and trained, so why hire a PA?” In the end, it’s probably a matter of people not understanding the diversity of the PA role and the level of education required, Gardner adds.

When the pilot study ended, Gardner’s employers asked her to stay. Her role blossomed into providing education about the PA role for the NHS. She also helped train nurses and prepare them for clinical exams. Later, she was hired for her current position in the Edinburgh Cancer Center.

It has been an interesting educational experience to work in a socialized medicine system, after having been trained in the US, Gardner says. In some respects, it makes her appreciate what we have in America.

“In Scotland, this system provides patients with limited to no choices in the types of treatment they receive and what doctor they will see,” she says. “They often do not have access to the newest treatments, medications, or facilities, and technology lags.”

Gardner has been surprised by the lack of preventive medicine and patient education programs, despite a nationwide problem with heavy drinking and smoking. “The majority of patients continue to practice unhealthy behaviors, even though they are being treated for cancer,” Gardner says.

Despite these issues, Gardner loves being where she is and feels hopeful that with large enough numbers, PAs will succeed in Scotland.

“The country of Scotland is extremely beautiful and the Scottish people are very friendly, kind, genuine, and humble,” she says. “The PA can be someone who will take the time to listen, show compassion, and go an extra mile for a patient. If used correctly, and enabled to function within his/her full scope of practice, PAs can definitely be cost-effective for the NHS.”

For most of their 40+ years, physician assistants and nurse practitioners have been a uniquely American phenomenon. But now, clinicians are starting to transport their ideas and expertise to all parts of the globe.

Training programs have already been established in parts of Europe and Australia. Now, as countries in the Middle East, Asia, Africa, and Latin America struggle with physician shortages in rural areas, they, too, are eager to bring these highly trained professionals within their borders.

Through international conferences, groups like the International Council of Nursing (ICN) in Geneva (which has NP or APN programs in 78 countries) and the International Academy of Physician Associate Educators (IAPAE) are connecting willing professionals to countries in need.

For clinicians with a sense of adventure, practicing overseas is a wonderful opportunity to delve into a new culture and share ideas and skills. Herein, we profile several PAs and NPs who are already living the international life. Read on, and be inspired!

Saudi Arabia: Welcoming PAs to the Middle East
As an established PA who had worked in emergency medicine for years and who serves on the faculty of the PA program at George Washington University (GWU), Amy Keim, MS, PA-C, is used to having a lot of freedom in her practice. Keim, who is the director of GWU’s International Physician Assistant Development program for the Department of Emergency Medicine, is also no stranger to working overseas.

So when Saudi Arabian government officials approached her department about designing a curriculum for the first PA program in the Middle East, she was thrilled and a little nervous. She wondered how she would be received, both as a PA and as a woman.

“I have worked in Beirut and Abu Dhabi, but Saudi Arabia had this more intimidating feel to it,” Keim says. “We think of it as this romanticized, really exotic locale. People don’t go on vacation to Saudi Arabia, let’s put it that way.”

Keim says she was pleasantly surprised during her first visit, when her Saudi hosts invited her for a wonderful fireside picnic out in the desert. “There was delicious food and music, and the people were very warm and welcoming,” she says. “They were so hospitable, it changed my impression overnight.”

Keim and GWU Program Coordinator Megan Williams both wanted to be sensitive to cultural expectations for women in Saudi Arabia. They learned, sometimes through trial and error, when it was acceptable to wear Western clothes and when they needed to cover their heads or don an abaya (a full-length black robe). Keim and Williams discovered, for example, that when they were shopping in a more westernized mall, they could wear their usual outfits. But if they were invited to an official military ceremony, they would wear an abaya out of respect for the culture.

“I haven’t run into any real difficulties because I’m a woman,” Keim adds. “They have been extremely open to the [program] model and to the leadership.”

The first 25 students started in the Saudi PA program in September. It will last 28 months and will be based on a military model, similar to that of the first PA programs in the United States and Canada. Only male military officers will have the chance to become PAs.

The program will be administered through the Prince Sultan Military College of Health Sciences in the Eastern Province capital of Dhahran. When the students graduate, they will be called “Assistant Physicians,” mainly because the title translates better.

“These highly trained students will not only be the first physician assistants in the Middle East, but will be a critical component to improving access to quality health care in military and civilian communities throughout the country,” Keim says.

Keim feels the Saudi Arabian PA program will serve as a model for other countries with similar health care needs. “I think this trend reflects a general need for this type of provider, with this type of training, to really close some of the gaps,” she says. She has enjoyed having the opportunity to help bring better care to Saudi Arabia, and to learn more about its culture.

Surprisingly, it was on US soil that an accidental cultural misunderstanding occurred, when one of the Saudi Arabian officials visited Washington, DC. Keim was driving him to an event, but needed to stop by the vet first to pick up her beloved Jack Russell terrier. When her colleague started to look uncomfortable in the passenger seat, she asked why. He told her almost no one in Saudi Arabia has a dog, because the Islamic religion considers the animal unclean. Her colleague “toughed it out” for the duration of the trip, but Keim wishes she had recognized the potential problem sooner.

In the end, this new program has been a learning experience for everyone—in more ways than one. It’s those kinds of exchanges with other cultures that make working overseas a joy and a challenge, Keim says: “I reflect back and think this has been a phenomenal career, because it has taken me down paths I never imagined.”

Honduras: Clean Water and Compassion
When Thad Wilson, PhD, RN, FNP-BC, graduated with a BSN from the University of Iowa nursing school, he happened to attend a career fair. One of the booths, way over in a corner, was advertising a primary care nursing position at a clinic in a rural area of Honduras. Wilson, who had been considering the Peace Corps anyway, jumped at the chance for an adventure. “I was going to be the only primary care provider for 5,000 people,” says Wilson (who was 22 and unmarried at the time).

During his first few weeks at La Buena Fe Clinic in a small village by Lake Yajoa, Wilson says he “got really good” at suturing. That’s because so many of his clients came in with machete wounds. One man even had a machete stuck in the back of his neck. Another patient still thanks Wilson every time he sees him, for sewing his thumb back on after he accidentally cut it off while working with a machete.

“This was a great clinic, in the middle of nowhere,” Wilson recalls. “I had no electricity and no running water. I delivered babies by candlelight and boiled water to sterilize my instruments.”

Just about every patient who came to La Buena Fe had gastrointestinal problems. The area was replete with tropical diseases. “I saw every kind of amoeba and worm you could think of,” Wilson says. “Those were my biggest nemesis.”

Upset by seeing toddlers dying of diarrhea, Wilson consulted with some local nonprofit agencies. Eventually, they built a well so the community could have clean water to drink. “Now, we don’t see the number of cases in that area with gastrointestinal problems,” he adds.

Without the fancy diagnostic tools most US nurses take for granted, Wilson says he honed his skills in taking histories and doing physical assessments. “The greatest technology we have is between our eyes and our ears,” he says. When he needed help, he turned on his ham radio and tapped into the expertise of several doctors thousands of miles away, back in the US. Talk about trial by fire… Wilson, who is now Associate Dean of the University of Missouri School of Nursing in Kansas City, recalls those days with fondness.

Thirty years later, Wilson (the Immediate Past President of the American College of Nurse Practitioners) still goes to Honduras on a regular basis. These days, he visits with 12 nursing and pharmacy students from the University of Missouri. He wants them to capture the magic and the intense hands-on experience that he had in his earlier years as a nurse.

The 15-day program gives students a chance to work in rural clinics as well as city hospitals. Part of the goal is to get students thinking about quality of care under different health care systems. For example, in Honduras, patients must make a down payment before they can have surgery in a hospital. “There are people who will die on that bed, waiting for $50,” Wilson says, “whereas in the US, we would do the surgery first and ask for money later.”

Compassion and cultural sensitivity are other byproducts of Wilson’s overseas class. For example, the students begin to understand the importance of family in Latin American culture. Back home, when an entire extended family crowds into their exam room for one family member’s appointment, they won’t mind so much.

Stoicism is another trait they learn about. “In Central America, they come from a culture where pain is just a way of life,” Wilson says. “They are able to improvise and do whatever it takes to survive.” So students realize patients from these areas may not complain much, and it might take a little coaxing to find out what’s wrong.

Wilson is grateful for his time in Honduras. It has offered a life-changing experience—both for him and for his students.

Australia: Digging in Down Under
Al Forde, PA-C, originally from Wyoming, admits he has always had a love affair with Australia. “I’ve always kept an ear to the ground as to how I could get there someday,” he says.

So he felt incredibly lucky to be hired at James Cook University in 2006, when the college decided to launch a pilot PA program. At the time, Forde was teaching in the PA program at the University of Utah in Salt Lake City. Luckily, his wife and 12-year-old daughter were up for the adventure of moving to Queensland.

“The pace of life is much slower here,” Forde says. “I enjoy living in the tropics, with the warm weather, and living near the coast.”

The James Cook PA program is up and running, Forde explains, but graduates can have a hard time finding jobs. That’s because the PA role has not completely caught on yet in Australia.

With such vast rural territory, Australia would seem to be perfectly suited to the skills and expertise PAs could offer. Forde and his colleagues have learned, however, that they must be patient and slowly encourage change within the current health care system. “It’s a matter of persistence,” he adds.

Australia’s health care system, Forde says, has a medical philosophy similar to the British system’s. The government pays for most health care in Australia, so market forces are not shaping the need for PAs the way they did in the US during the 1980s.

Doctors, for example, do only primary care, emergency care, and obstetrics. Specialists are called physicians. “They have different education and different roles,” Forde says.

It’s still unclear where PAs might fit into that system. One thing that is clear is the shortage of providers, particularly in remote and indigenous areas. “The state health departments, especially in the rural areas, are desperate for backup and help and manpower,” Forde says.

Some clinics in Australia are privately run, Forde says, and the doctors who staff them are interested in seeing whether employing PAs can be cost-­effective.

Forde, who now has permanent resident status, is willing to wait and keep promoting the value of PAs. Other than occasional pangs for good Mexican food, he would not want to be living anywhere else.

England: X-rays and Expressions
Physician Assistant Kristen Gipson has worked in emergency medicine for most of her 21-year career. She did her original training at Emory University.

Gipson was glad to be chosen as part of the first pilot group of 12 PAs to travel to the United Kingdom in 2004. She currently works in an emergency room (called Accident and Emergency) in Birmingham, England.

During her first year in the UK, Gipson ran into some unexpected bureaucracy. For example, each time she went to order an x-ray for a patient, she hit roadblocks. In the UK, Gipson explains, a radiographer can refuse to do an x-ray if he or she doesn’t feel it’s justified.

“Initially, we weren’t allowed to order them, but then the PAs in the hospital managed to attend a radiation safety course, which allowed us to request an x-ray,” Gipson explains. Now, most hospital PAs have the right to order x-rays, but PAs providing primary care in other parts of England still cannot order these basic tests.

In Accident and Emergency, Gipson’s daily routine is pretty similar to that in an emergency department in the US. “I see medical trauma, mental health, children, obstetrics, and gynecology,” she says. “I evaluate, diagnose, request tests, and make referrals.” She can discharge and admit patients and arranges for community care. Gipson also is involved in teaching and training medical students.

While four universities currently offer training programs in England, “physician assistant” is not yet an official role in the UK, Gipson says. To be able to officially practice medicine and prescribe, she had to find a physician willing to “delegate” care or treatment to her, under a specific clause in the British Medical Council’s laws. The employer also usually covers the cost of malpractice coverage.

After six years in England, Gipson says she feels pretty well acclimated to British culture. Even though British and American citizens all speak English, subtle language differences can sneak up on you and perhaps put someone’s knickers in a twist. “Both the medical and everyday expressions can be drastically different,” she adds. “Certain words are very differently used and could cause some embarrassment until you learn not to use them in their American context—for example, fanny and pants.”

Scotland: Of Tea Breaks and Trust
Sometimes, while doing rounds as a PA at the Edinburgh Cancer Center in Scotland, Juanita Gardner must stop and wait for her patients to partake in a bit of tea and crumpets. “Tea breaks are a vital part of the workday,” Gardner says. “The oncology wards have a person who will often come around with a cart containing tea, biscuits, and coffee for every patient at no charge.”

Right away, Gardner noticed the pace was different for workers in the Scottish medical system. They have more holidays and time off to be with their families. Unlike many American health care workers, her Scottish counterparts “work to live,” instead of the other way around.

Gardner came to Scotland from the US in 2006, when the National Health Service (NHS) of Scotland launched a pilot PA program. Gardner was among the initial group of 12 American PAs involved. Her assignment was to set up diabetes and COPD clinics at a local primary care health center in Edinburgh.

As in England, the PA profession is not fully recognized in Scotland. PAs do not yet have prescribing privileges. The UK PA association is working on this, but Gardner says she is still in the process of applying for registration. “As you can imagine, there is much red tape and politics involved in such a process,” she says. “Things here move rather slowly.”

Gardner describes her first year in Scotland as “extremely challenging.” For example, the clinic staff refused to give her access to computer programs and medical records that she needed. “I had two wonderful supervising physicians who used their influence to remove all barriers and obstacles in my path,” Gardner says.

Despite their kindness, Gardner sensed a general lack of trust from the medical community there. “Many seem to feel PAs will take away jobs; others are resistant to change and new ideas,” she says. “Some feel the NHS nurses are equally skilled and trained, so why hire a PA?” In the end, it’s probably a matter of people not understanding the diversity of the PA role and the level of education required, Gardner adds.

When the pilot study ended, Gardner’s employers asked her to stay. Her role blossomed into providing education about the PA role for the NHS. She also helped train nurses and prepare them for clinical exams. Later, she was hired for her current position in the Edinburgh Cancer Center.

It has been an interesting educational experience to work in a socialized medicine system, after having been trained in the US, Gardner says. In some respects, it makes her appreciate what we have in America.

“In Scotland, this system provides patients with limited to no choices in the types of treatment they receive and what doctor they will see,” she says. “They often do not have access to the newest treatments, medications, or facilities, and technology lags.”

Gardner has been surprised by the lack of preventive medicine and patient education programs, despite a nationwide problem with heavy drinking and smoking. “The majority of patients continue to practice unhealthy behaviors, even though they are being treated for cancer,” Gardner says.

Despite these issues, Gardner loves being where she is and feels hopeful that with large enough numbers, PAs will succeed in Scotland.

“The country of Scotland is extremely beautiful and the Scottish people are very friendly, kind, genuine, and humble,” she says. “The PA can be someone who will take the time to listen, show compassion, and go an extra mile for a patient. If used correctly, and enabled to function within his/her full scope of practice, PAs can definitely be cost-effective for the NHS.”

For most of their 40+ years, physician assistants and nurse practitioners have been a uniquely American phenomenon. But now, clinicians are starting to transport their ideas and expertise to all parts of the globe.

Training programs have already been established in parts of Europe and Australia. Now, as countries in the Middle East, Asia, Africa, and Latin America struggle with physician shortages in rural areas, they, too, are eager to bring these highly trained professionals within their borders.

Through international conferences, groups like the International Council of Nursing (ICN) in Geneva (which has NP or APN programs in 78 countries) and the International Academy of Physician Associate Educators (IAPAE) are connecting willing professionals to countries in need.

For clinicians with a sense of adventure, practicing overseas is a wonderful opportunity to delve into a new culture and share ideas and skills. Herein, we profile several PAs and NPs who are already living the international life. Read on, and be inspired!

Saudi Arabia: Welcoming PAs to the Middle East
As an established PA who had worked in emergency medicine for years and who serves on the faculty of the PA program at George Washington University (GWU), Amy Keim, MS, PA-C, is used to having a lot of freedom in her practice. Keim, who is the director of GWU’s International Physician Assistant Development program for the Department of Emergency Medicine, is also no stranger to working overseas.

So when Saudi Arabian government officials approached her department about designing a curriculum for the first PA program in the Middle East, she was thrilled and a little nervous. She wondered how she would be received, both as a PA and as a woman.

“I have worked in Beirut and Abu Dhabi, but Saudi Arabia had this more intimidating feel to it,” Keim says. “We think of it as this romanticized, really exotic locale. People don’t go on vacation to Saudi Arabia, let’s put it that way.”

Keim says she was pleasantly surprised during her first visit, when her Saudi hosts invited her for a wonderful fireside picnic out in the desert. “There was delicious food and music, and the people were very warm and welcoming,” she says. “They were so hospitable, it changed my impression overnight.”

Keim and GWU Program Coordinator Megan Williams both wanted to be sensitive to cultural expectations for women in Saudi Arabia. They learned, sometimes through trial and error, when it was acceptable to wear Western clothes and when they needed to cover their heads or don an abaya (a full-length black robe). Keim and Williams discovered, for example, that when they were shopping in a more westernized mall, they could wear their usual outfits. But if they were invited to an official military ceremony, they would wear an abaya out of respect for the culture.

“I haven’t run into any real difficulties because I’m a woman,” Keim adds. “They have been extremely open to the [program] model and to the leadership.”

The first 25 students started in the Saudi PA program in September. It will last 28 months and will be based on a military model, similar to that of the first PA programs in the United States and Canada. Only male military officers will have the chance to become PAs.

The program will be administered through the Prince Sultan Military College of Health Sciences in the Eastern Province capital of Dhahran. When the students graduate, they will be called “Assistant Physicians,” mainly because the title translates better.

“These highly trained students will not only be the first physician assistants in the Middle East, but will be a critical component to improving access to quality health care in military and civilian communities throughout the country,” Keim says.

Keim feels the Saudi Arabian PA program will serve as a model for other countries with similar health care needs. “I think this trend reflects a general need for this type of provider, with this type of training, to really close some of the gaps,” she says. She has enjoyed having the opportunity to help bring better care to Saudi Arabia, and to learn more about its culture.

Surprisingly, it was on US soil that an accidental cultural misunderstanding occurred, when one of the Saudi Arabian officials visited Washington, DC. Keim was driving him to an event, but needed to stop by the vet first to pick up her beloved Jack Russell terrier. When her colleague started to look uncomfortable in the passenger seat, she asked why. He told her almost no one in Saudi Arabia has a dog, because the Islamic religion considers the animal unclean. Her colleague “toughed it out” for the duration of the trip, but Keim wishes she had recognized the potential problem sooner.

In the end, this new program has been a learning experience for everyone—in more ways than one. It’s those kinds of exchanges with other cultures that make working overseas a joy and a challenge, Keim says: “I reflect back and think this has been a phenomenal career, because it has taken me down paths I never imagined.”

Honduras: Clean Water and Compassion
When Thad Wilson, PhD, RN, FNP-BC, graduated with a BSN from the University of Iowa nursing school, he happened to attend a career fair. One of the booths, way over in a corner, was advertising a primary care nursing position at a clinic in a rural area of Honduras. Wilson, who had been considering the Peace Corps anyway, jumped at the chance for an adventure. “I was going to be the only primary care provider for 5,000 people,” says Wilson (who was 22 and unmarried at the time).

During his first few weeks at La Buena Fe Clinic in a small village by Lake Yajoa, Wilson says he “got really good” at suturing. That’s because so many of his clients came in with machete wounds. One man even had a machete stuck in the back of his neck. Another patient still thanks Wilson every time he sees him, for sewing his thumb back on after he accidentally cut it off while working with a machete.

“This was a great clinic, in the middle of nowhere,” Wilson recalls. “I had no electricity and no running water. I delivered babies by candlelight and boiled water to sterilize my instruments.”

Just about every patient who came to La Buena Fe had gastrointestinal problems. The area was replete with tropical diseases. “I saw every kind of amoeba and worm you could think of,” Wilson says. “Those were my biggest nemesis.”

Upset by seeing toddlers dying of diarrhea, Wilson consulted with some local nonprofit agencies. Eventually, they built a well so the community could have clean water to drink. “Now, we don’t see the number of cases in that area with gastrointestinal problems,” he adds.

Without the fancy diagnostic tools most US nurses take for granted, Wilson says he honed his skills in taking histories and doing physical assessments. “The greatest technology we have is between our eyes and our ears,” he says. When he needed help, he turned on his ham radio and tapped into the expertise of several doctors thousands of miles away, back in the US. Talk about trial by fire… Wilson, who is now Associate Dean of the University of Missouri School of Nursing in Kansas City, recalls those days with fondness.

Thirty years later, Wilson (the Immediate Past President of the American College of Nurse Practitioners) still goes to Honduras on a regular basis. These days, he visits with 12 nursing and pharmacy students from the University of Missouri. He wants them to capture the magic and the intense hands-on experience that he had in his earlier years as a nurse.

The 15-day program gives students a chance to work in rural clinics as well as city hospitals. Part of the goal is to get students thinking about quality of care under different health care systems. For example, in Honduras, patients must make a down payment before they can have surgery in a hospital. “There are people who will die on that bed, waiting for $50,” Wilson says, “whereas in the US, we would do the surgery first and ask for money later.”

Compassion and cultural sensitivity are other byproducts of Wilson’s overseas class. For example, the students begin to understand the importance of family in Latin American culture. Back home, when an entire extended family crowds into their exam room for one family member’s appointment, they won’t mind so much.

Stoicism is another trait they learn about. “In Central America, they come from a culture where pain is just a way of life,” Wilson says. “They are able to improvise and do whatever it takes to survive.” So students realize patients from these areas may not complain much, and it might take a little coaxing to find out what’s wrong.

Wilson is grateful for his time in Honduras. It has offered a life-changing experience—both for him and for his students.

Australia: Digging in Down Under
Al Forde, PA-C, originally from Wyoming, admits he has always had a love affair with Australia. “I’ve always kept an ear to the ground as to how I could get there someday,” he says.

So he felt incredibly lucky to be hired at James Cook University in 2006, when the college decided to launch a pilot PA program. At the time, Forde was teaching in the PA program at the University of Utah in Salt Lake City. Luckily, his wife and 12-year-old daughter were up for the adventure of moving to Queensland.

“The pace of life is much slower here,” Forde says. “I enjoy living in the tropics, with the warm weather, and living near the coast.”

The James Cook PA program is up and running, Forde explains, but graduates can have a hard time finding jobs. That’s because the PA role has not completely caught on yet in Australia.

With such vast rural territory, Australia would seem to be perfectly suited to the skills and expertise PAs could offer. Forde and his colleagues have learned, however, that they must be patient and slowly encourage change within the current health care system. “It’s a matter of persistence,” he adds.

Australia’s health care system, Forde says, has a medical philosophy similar to the British system’s. The government pays for most health care in Australia, so market forces are not shaping the need for PAs the way they did in the US during the 1980s.

Doctors, for example, do only primary care, emergency care, and obstetrics. Specialists are called physicians. “They have different education and different roles,” Forde says.

It’s still unclear where PAs might fit into that system. One thing that is clear is the shortage of providers, particularly in remote and indigenous areas. “The state health departments, especially in the rural areas, are desperate for backup and help and manpower,” Forde says.

Some clinics in Australia are privately run, Forde says, and the doctors who staff them are interested in seeing whether employing PAs can be cost-­effective.

Forde, who now has permanent resident status, is willing to wait and keep promoting the value of PAs. Other than occasional pangs for good Mexican food, he would not want to be living anywhere else.

England: X-rays and Expressions
Physician Assistant Kristen Gipson has worked in emergency medicine for most of her 21-year career. She did her original training at Emory University.

Gipson was glad to be chosen as part of the first pilot group of 12 PAs to travel to the United Kingdom in 2004. She currently works in an emergency room (called Accident and Emergency) in Birmingham, England.

During her first year in the UK, Gipson ran into some unexpected bureaucracy. For example, each time she went to order an x-ray for a patient, she hit roadblocks. In the UK, Gipson explains, a radiographer can refuse to do an x-ray if he or she doesn’t feel it’s justified.

“Initially, we weren’t allowed to order them, but then the PAs in the hospital managed to attend a radiation safety course, which allowed us to request an x-ray,” Gipson explains. Now, most hospital PAs have the right to order x-rays, but PAs providing primary care in other parts of England still cannot order these basic tests.

In Accident and Emergency, Gipson’s daily routine is pretty similar to that in an emergency department in the US. “I see medical trauma, mental health, children, obstetrics, and gynecology,” she says. “I evaluate, diagnose, request tests, and make referrals.” She can discharge and admit patients and arranges for community care. Gipson also is involved in teaching and training medical students.

While four universities currently offer training programs in England, “physician assistant” is not yet an official role in the UK, Gipson says. To be able to officially practice medicine and prescribe, she had to find a physician willing to “delegate” care or treatment to her, under a specific clause in the British Medical Council’s laws. The employer also usually covers the cost of malpractice coverage.

After six years in England, Gipson says she feels pretty well acclimated to British culture. Even though British and American citizens all speak English, subtle language differences can sneak up on you and perhaps put someone’s knickers in a twist. “Both the medical and everyday expressions can be drastically different,” she adds. “Certain words are very differently used and could cause some embarrassment until you learn not to use them in their American context—for example, fanny and pants.”

Scotland: Of Tea Breaks and Trust
Sometimes, while doing rounds as a PA at the Edinburgh Cancer Center in Scotland, Juanita Gardner must stop and wait for her patients to partake in a bit of tea and crumpets. “Tea breaks are a vital part of the workday,” Gardner says. “The oncology wards have a person who will often come around with a cart containing tea, biscuits, and coffee for every patient at no charge.”

Right away, Gardner noticed the pace was different for workers in the Scottish medical system. They have more holidays and time off to be with their families. Unlike many American health care workers, her Scottish counterparts “work to live,” instead of the other way around.

Gardner came to Scotland from the US in 2006, when the National Health Service (NHS) of Scotland launched a pilot PA program. Gardner was among the initial group of 12 American PAs involved. Her assignment was to set up diabetes and COPD clinics at a local primary care health center in Edinburgh.

As in England, the PA profession is not fully recognized in Scotland. PAs do not yet have prescribing privileges. The UK PA association is working on this, but Gardner says she is still in the process of applying for registration. “As you can imagine, there is much red tape and politics involved in such a process,” she says. “Things here move rather slowly.”

Gardner describes her first year in Scotland as “extremely challenging.” For example, the clinic staff refused to give her access to computer programs and medical records that she needed. “I had two wonderful supervising physicians who used their influence to remove all barriers and obstacles in my path,” Gardner says.

Despite their kindness, Gardner sensed a general lack of trust from the medical community there. “Many seem to feel PAs will take away jobs; others are resistant to change and new ideas,” she says. “Some feel the NHS nurses are equally skilled and trained, so why hire a PA?” In the end, it’s probably a matter of people not understanding the diversity of the PA role and the level of education required, Gardner adds.

When the pilot study ended, Gardner’s employers asked her to stay. Her role blossomed into providing education about the PA role for the NHS. She also helped train nurses and prepare them for clinical exams. Later, she was hired for her current position in the Edinburgh Cancer Center.

It has been an interesting educational experience to work in a socialized medicine system, after having been trained in the US, Gardner says. In some respects, it makes her appreciate what we have in America.

“In Scotland, this system provides patients with limited to no choices in the types of treatment they receive and what doctor they will see,” she says. “They often do not have access to the newest treatments, medications, or facilities, and technology lags.”

Gardner has been surprised by the lack of preventive medicine and patient education programs, despite a nationwide problem with heavy drinking and smoking. “The majority of patients continue to practice unhealthy behaviors, even though they are being treated for cancer,” Gardner says.

Despite these issues, Gardner loves being where she is and feels hopeful that with large enough numbers, PAs will succeed in Scotland.

“The country of Scotland is extremely beautiful and the Scottish people are very friendly, kind, genuine, and humble,” she says. “The PA can be someone who will take the time to listen, show compassion, and go an extra mile for a patient. If used correctly, and enabled to function within his/her full scope of practice, PAs can definitely be cost-effective for the NHS.”

Most clinicians who work with children or teenagers already know that the best way to reach them is through a computer screen. As Baby Boomers reach retirement age, this advice now applies to older patients as well. NPs and PAs are seeing more 70-year-olds who spend an hour on Facebook every day, surf the Web, and text with the best of them.

As a result, more clinicians are turning to high-tech devices, such as iPhone apps, video games, and streaming videos, as an effective way to deliver their health promotion messages. Read on to see how providers across the country are tapping into this trend.

Web-Based “Dramas” Promote Safe Sex
Rachel Jones, PhD, RN, FAAN, an associate professor at Rutgers University College of Nursing, hit a roadblock while promoting safe sexual practices with her patients in an urban New Jersey clinic.

“I was seeing these smart, together women and men,” Jones says. “I would talk to them about STDs and HIV, but they were still having unprotected sex.”

Jones realized that the rational, knowledge-based approach to prevention doesn’t really work when it comes to sexual health. “Cognitive-based knowledge is not enough,” she says. “These are intense emotional and relationship issues.”

Once, after having an exam interrupted—yet again!—by a patient taking a cell phone call, Jones realized the phone could be a powerful prevention tool.

She had already been in the midst of making HIV prevention videos, but now will make these compelling dramas available via streaming video on phones with 3G and 4G network service. “We wanted to boost the message between clinic visits, in the comfort of patients’ homes,” Jones says. “We wanted it to be confidential and private.”

To create the story lines for her HIV prevention soap ­operas, Jones brought real women from the community into the studio for focus groups. As a result, her videos are true to life—and very popular. Once patients watch the first video in the series, called “Toni, Mike, and Valerie,” they get hooked and want to continue watching other episodes to find out what happens to the main characters.

“We have found a lot of women carrying both their own phone and our phone,” says Jones, who with grant money was actually able to purchase compatible cell phones and hand them out to patients. “There’s a high interest in the story—it’s not a hard sell.”

The message is built into the story, but it is woven through in a subtle way. The drama includes what Jones calls low-power and high-power women. The low-power women give in to pressure to have unprotected sex as a way to show they’ll do anything for their man, and they trust him completely. The higher-power women, on the other hand, would never even think of having sex without first asking the man to have an HIV test.

“Those women are our heroines,” Jones says. “Strong, powerful women can serve to mentor other women—that’s really what we’re doing with our shows.” When patients identify with the characters emotionally, they understand the consequences of their behavior, and they start to emulate the stronger women, Jones says.

Jones also made a series called “Love, Sex and Choices.” Jones received grants from the National Institutes of Health and the Health Care Foundation of New Jersey, among other sources, to make her prevention videos. Next, she plans to make a video series for men and to market her videos through social media.

“There is tremendous power in this modality,” Jones says.

Her goal is to change attitudes about condoms, so both women and men see them as a symbol of love and protection. “We could completely eradicate HIV in women by using condoms,” Jones says. She hopes more nurses and physician assistants will embrace this multimedia educational approach as an important prevention tool.

As other providers hear about Jones’ videos, requests for copies of the program on DVD (another option, besides the streaming video that can be accessed via Web-capable cell phones) have been pouring in from all over the United States and overseas. Many practitioners are showing the videos while patients sit in the waiting room. They are available at www.stophiv.newark .rutgers.edu.

“Not everybody can go out and make their own movies,” Jones says. “Our goal is to distribute them widely so we can share them with our fellow clinicians.”

Video Games Help Diabetic Kids
Pediatric diabetes is another hot area for high-tech prevention. Several companies have produced interactive video games that educate kids with type 1 diabetes about insulin shots and avoiding sugary foods.

The insulin pump manufacturer Medtronic offers a popular iPhone app starring a cuddly character named Larry the Lion. He helps diabetic children count their carbs to keep their glycemic index in the right zone.

“Larry the Lion is very cute,” says Lois Gilmer, a diabetes educator at the University of Colorado’s Barbara Davis Center for Childhood Diabetes. Since kids like Larry, the app makes eating right a fun game instead of an exercise in self-denial.

Gilmer says the iPhone apps are very popular with their diabetic patients. “A lot of clients I work with do use apps on their Smartphones—that’s useful and we encourage it,” she says.

Other companies, such as Game Equals Life in Norman, Oklahoma, and Bayer, also offer video games that are uniquely tailored to children with diabetes.

Beating Stress and Staying Heart-Healthy
Meanwhile, in Cleveland, prevention experts are using social media and free iPhone apps to appeal to sports fans and reduce their cardiac disease risk. The Cleveland Clinic recently launched a campaign called Let’s Move It!

The Let’s Move It! app, which works with iPhone and iPod Touch, includes a pedometer that helps users keep track of their individual progress. The app also challenges users to participate in different sports-related community walks. For example, they can try to walk the equivalent mileage between Cleveland Browns Stadium and Paul Brown Stadium in Cincinnati. As they participate in the challenge, fellow walkers can cheer them on through Facebook and Twitter. The app even tells them how many steps they would have to take to work off a hot dog, beer, and fries at the stadium.

“Physical inactivity is one of the factors contributing to the escalating chronic disease rate in America,” said Michael Roizen, MD, Chairman of the Cleveland Clinic Wellness Institute, in a statement. “The Let’s Move It! app makes exercise fun by creating friendly competitions among users. Research has shown that people who have access to an interactive, social exercise environment are more likely to actually exercise.”

In other areas of the country, cardiologists are turning their patients on to iPhone apps that help them watch for trends in their blood pressure readings and calculate their risk for a heart attack.

Stress is another factor in heart disease, as well as a host of other conditions, from depression and dementia to fibromyalgia. So the Cleveland Clinic Wellness Institute also offers a free app that leads users through guided meditations. These relaxation apps help people relax their muscles, let go of their anger, and practice mindfulness.

Cleveland Clinic has its own health information Web site. The site, at 360-5.com, is similar to MayoClinic.com, but is more interactive and also sells wellness products. As part of its offerings, it includes an online application that goes with the iPhone app called Stress Free Now. Clinicians at Cleveland Clinic have access to the program for any patient. Others can pay for it for $40 per person. To preview Stress Free Now, visit www.360-5.com/promos.

Thomas Morledge, MD, medical director of the Cleveland Clinic’s Wellness Enterprise, created the eight-week Stress Free Now program and the app. Patients log on daily to read motivational messages from Morledge. Then, they can download an MP3 with breathing techniques, relaxation methods, and positive affirmations. They must set aside about 30 minutes, several times a week, to see results.

“There’s a lot of literature to support these techniques,” Morledge says. “It can help with chronic pain, such as fibromyalgia, and cut down on inflammation. It can reduce the risk of stroke and dementia.” The Cleveland Clinic program is based a great deal on the work of mindfulness expert and University of Massachusetts medical professor Jon Kabat-Zinn.

The clinic currently is enrolling 600 patients in a clinical trial to test the effectiveness of the online program, but so far, anecdotal evidence says it is working. “When people use it, you can see there’s been a change—their color improves, they sleep better, and they have more energy,” Morledge says.

So far, it is the NPs and PAs who have referred the most patients to the Stress Free Now program, he adds. “They seem to have better peripheral vision,” he says. “They have a very patient-centered approach to their care.”

Stress remains an overlooked component of health, even though, as Morledge says, “The impact of stress is probably as great as [that of] obesity.”

By reaching out to patients with MP3s, iPhone apps, and online coaching, Cleveland Clinic is on the leading edge of an important trend in prevention. Programs like Stress Free Now can help spread the word to thousands of people—more than any single clinician could reach from a typical medical office.

Most clinicians who work with children or teenagers already know that the best way to reach them is through a computer screen. As Baby Boomers reach retirement age, this advice now applies to older patients as well. NPs and PAs are seeing more 70-year-olds who spend an hour on Facebook every day, surf the Web, and text with the best of them.

As a result, more clinicians are turning to high-tech devices, such as iPhone apps, video games, and streaming videos, as an effective way to deliver their health promotion messages. Read on to see how providers across the country are tapping into this trend.

Web-Based “Dramas” Promote Safe Sex
Rachel Jones, PhD, RN, FAAN, an associate professor at Rutgers University College of Nursing, hit a roadblock while promoting safe sexual practices with her patients in an urban New Jersey clinic.

“I was seeing these smart, together women and men,” Jones says. “I would talk to them about STDs and HIV, but they were still having unprotected sex.”

Jones realized that the rational, knowledge-based approach to prevention doesn’t really work when it comes to sexual health. “Cognitive-based knowledge is not enough,” she says. “These are intense emotional and relationship issues.”

Once, after having an exam interrupted—yet again!—by a patient taking a cell phone call, Jones realized the phone could be a powerful prevention tool.

She had already been in the midst of making HIV prevention videos, but now will make these compelling dramas available via streaming video on phones with 3G and 4G network service. “We wanted to boost the message between clinic visits, in the comfort of patients’ homes,” Jones says. “We wanted it to be confidential and private.”

To create the story lines for her HIV prevention soap ­operas, Jones brought real women from the community into the studio for focus groups. As a result, her videos are true to life—and very popular. Once patients watch the first video in the series, called “Toni, Mike, and Valerie,” they get hooked and want to continue watching other episodes to find out what happens to the main characters.

“We have found a lot of women carrying both their own phone and our phone,” says Jones, who with grant money was actually able to purchase compatible cell phones and hand them out to patients. “There’s a high interest in the story—it’s not a hard sell.”

The message is built into the story, but it is woven through in a subtle way. The drama includes what Jones calls low-power and high-power women. The low-power women give in to pressure to have unprotected sex as a way to show they’ll do anything for their man, and they trust him completely. The higher-power women, on the other hand, would never even think of having sex without first asking the man to have an HIV test.

“Those women are our heroines,” Jones says. “Strong, powerful women can serve to mentor other women—that’s really what we’re doing with our shows.” When patients identify with the characters emotionally, they understand the consequences of their behavior, and they start to emulate the stronger women, Jones says.

Jones also made a series called “Love, Sex and Choices.” Jones received grants from the National Institutes of Health and the Health Care Foundation of New Jersey, among other sources, to make her prevention videos. Next, she plans to make a video series for men and to market her videos through social media.

“There is tremendous power in this modality,” Jones says.

Her goal is to change attitudes about condoms, so both women and men see them as a symbol of love and protection. “We could completely eradicate HIV in women by using condoms,” Jones says. She hopes more nurses and physician assistants will embrace this multimedia educational approach as an important prevention tool.

As other providers hear about Jones’ videos, requests for copies of the program on DVD (another option, besides the streaming video that can be accessed via Web-capable cell phones) have been pouring in from all over the United States and overseas. Many practitioners are showing the videos while patients sit in the waiting room. They are available at www.stophiv.newark .rutgers.edu.

“Not everybody can go out and make their own movies,” Jones says. “Our goal is to distribute them widely so we can share them with our fellow clinicians.”

Video Games Help Diabetic Kids
Pediatric diabetes is another hot area for high-tech prevention. Several companies have produced interactive video games that educate kids with type 1 diabetes about insulin shots and avoiding sugary foods.

The insulin pump manufacturer Medtronic offers a popular iPhone app starring a cuddly character named Larry the Lion. He helps diabetic children count their carbs to keep their glycemic index in the right zone.

“Larry the Lion is very cute,” says Lois Gilmer, a diabetes educator at the University of Colorado’s Barbara Davis Center for Childhood Diabetes. Since kids like Larry, the app makes eating right a fun game instead of an exercise in self-denial.

Gilmer says the iPhone apps are very popular with their diabetic patients. “A lot of clients I work with do use apps on their Smartphones—that’s useful and we encourage it,” she says.

Other companies, such as Game Equals Life in Norman, Oklahoma, and Bayer, also offer video games that are uniquely tailored to children with diabetes.

Beating Stress and Staying Heart-Healthy
Meanwhile, in Cleveland, prevention experts are using social media and free iPhone apps to appeal to sports fans and reduce their cardiac disease risk. The Cleveland Clinic recently launched a campaign called Let’s Move It!

The Let’s Move It! app, which works with iPhone and iPod Touch, includes a pedometer that helps users keep track of their individual progress. The app also challenges users to participate in different sports-related community walks. For example, they can try to walk the equivalent mileage between Cleveland Browns Stadium and Paul Brown Stadium in Cincinnati. As they participate in the challenge, fellow walkers can cheer them on through Facebook and Twitter. The app even tells them how many steps they would have to take to work off a hot dog, beer, and fries at the stadium.

“Physical inactivity is one of the factors contributing to the escalating chronic disease rate in America,” said Michael Roizen, MD, Chairman of the Cleveland Clinic Wellness Institute, in a statement. “The Let’s Move It! app makes exercise fun by creating friendly competitions among users. Research has shown that people who have access to an interactive, social exercise environment are more likely to actually exercise.”

In other areas of the country, cardiologists are turning their patients on to iPhone apps that help them watch for trends in their blood pressure readings and calculate their risk for a heart attack.

Stress is another factor in heart disease, as well as a host of other conditions, from depression and dementia to fibromyalgia. So the Cleveland Clinic Wellness Institute also offers a free app that leads users through guided meditations. These relaxation apps help people relax their muscles, let go of their anger, and practice mindfulness.

Cleveland Clinic has its own health information Web site. The site, at 360-5.com, is similar to MayoClinic.com, but is more interactive and also sells wellness products. As part of its offerings, it includes an online application that goes with the iPhone app called Stress Free Now. Clinicians at Cleveland Clinic have access to the program for any patient. Others can pay for it for $40 per person. To preview Stress Free Now, visit www.360-5.com/promos.

Thomas Morledge, MD, medical director of the Cleveland Clinic’s Wellness Enterprise, created the eight-week Stress Free Now program and the app. Patients log on daily to read motivational messages from Morledge. Then, they can download an MP3 with breathing techniques, relaxation methods, and positive affirmations. They must set aside about 30 minutes, several times a week, to see results.

“There’s a lot of literature to support these techniques,” Morledge says. “It can help with chronic pain, such as fibromyalgia, and cut down on inflammation. It can reduce the risk of stroke and dementia.” The Cleveland Clinic program is based a great deal on the work of mindfulness expert and University of Massachusetts medical professor Jon Kabat-Zinn.

The clinic currently is enrolling 600 patients in a clinical trial to test the effectiveness of the online program, but so far, anecdotal evidence says it is working. “When people use it, you can see there’s been a change—their color improves, they sleep better, and they have more energy,” Morledge says.

So far, it is the NPs and PAs who have referred the most patients to the Stress Free Now program, he adds. “They seem to have better peripheral vision,” he says. “They have a very patient-centered approach to their care.”

Stress remains an overlooked component of health, even though, as Morledge says, “The impact of stress is probably as great as [that of] obesity.”

By reaching out to patients with MP3s, iPhone apps, and online coaching, Cleveland Clinic is on the leading edge of an important trend in prevention. Programs like Stress Free Now can help spread the word to thousands of people—more than any single clinician could reach from a typical medical office.

Most clinicians who work with children or teenagers already know that the best way to reach them is through a computer screen. As Baby Boomers reach retirement age, this advice now applies to older patients as well. NPs and PAs are seeing more 70-year-olds who spend an hour on Facebook every day, surf the Web, and text with the best of them.

As a result, more clinicians are turning to high-tech devices, such as iPhone apps, video games, and streaming videos, as an effective way to deliver their health promotion messages. Read on to see how providers across the country are tapping into this trend.

Web-Based “Dramas” Promote Safe Sex
Rachel Jones, PhD, RN, FAAN, an associate professor at Rutgers University College of Nursing, hit a roadblock while promoting safe sexual practices with her patients in an urban New Jersey clinic.

“I was seeing these smart, together women and men,” Jones says. “I would talk to them about STDs and HIV, but they were still having unprotected sex.”

Jones realized that the rational, knowledge-based approach to prevention doesn’t really work when it comes to sexual health. “Cognitive-based knowledge is not enough,” she says. “These are intense emotional and relationship issues.”

Once, after having an exam interrupted—yet again!—by a patient taking a cell phone call, Jones realized the phone could be a powerful prevention tool.

She had already been in the midst of making HIV prevention videos, but now will make these compelling dramas available via streaming video on phones with 3G and 4G network service. “We wanted to boost the message between clinic visits, in the comfort of patients’ homes,” Jones says. “We wanted it to be confidential and private.”

To create the story lines for her HIV prevention soap ­operas, Jones brought real women from the community into the studio for focus groups. As a result, her videos are true to life—and very popular. Once patients watch the first video in the series, called “Toni, Mike, and Valerie,” they get hooked and want to continue watching other episodes to find out what happens to the main characters.

“We have found a lot of women carrying both their own phone and our phone,” says Jones, who with grant money was actually able to purchase compatible cell phones and hand them out to patients. “There’s a high interest in the story—it’s not a hard sell.”

The message is built into the story, but it is woven through in a subtle way. The drama includes what Jones calls low-power and high-power women. The low-power women give in to pressure to have unprotected sex as a way to show they’ll do anything for their man, and they trust him completely. The higher-power women, on the other hand, would never even think of having sex without first asking the man to have an HIV test.

“Those women are our heroines,” Jones says. “Strong, powerful women can serve to mentor other women—that’s really what we’re doing with our shows.” When patients identify with the characters emotionally, they understand the consequences of their behavior, and they start to emulate the stronger women, Jones says.

Jones also made a series called “Love, Sex and Choices.” Jones received grants from the National Institutes of Health and the Health Care Foundation of New Jersey, among other sources, to make her prevention videos. Next, she plans to make a video series for men and to market her videos through social media.

“There is tremendous power in this modality,” Jones says.

Her goal is to change attitudes about condoms, so both women and men see them as a symbol of love and protection. “We could completely eradicate HIV in women by using condoms,” Jones says. She hopes more nurses and physician assistants will embrace this multimedia educational approach as an important prevention tool.

As other providers hear about Jones’ videos, requests for copies of the program on DVD (another option, besides the streaming video that can be accessed via Web-capable cell phones) have been pouring in from all over the United States and overseas. Many practitioners are showing the videos while patients sit in the waiting room. They are available at www.stophiv.newark .rutgers.edu.

“Not everybody can go out and make their own movies,” Jones says. “Our goal is to distribute them widely so we can share them with our fellow clinicians.”

Video Games Help Diabetic Kids
Pediatric diabetes is another hot area for high-tech prevention. Several companies have produced interactive video games that educate kids with type 1 diabetes about insulin shots and avoiding sugary foods.

The insulin pump manufacturer Medtronic offers a popular iPhone app starring a cuddly character named Larry the Lion. He helps diabetic children count their carbs to keep their glycemic index in the right zone.

“Larry the Lion is very cute,” says Lois Gilmer, a diabetes educator at the University of Colorado’s Barbara Davis Center for Childhood Diabetes. Since kids like Larry, the app makes eating right a fun game instead of an exercise in self-denial.

Gilmer says the iPhone apps are very popular with their diabetic patients. “A lot of clients I work with do use apps on their Smartphones—that’s useful and we encourage it,” she says.

Other companies, such as Game Equals Life in Norman, Oklahoma, and Bayer, also offer video games that are uniquely tailored to children with diabetes.

Beating Stress and Staying Heart-Healthy
Meanwhile, in Cleveland, prevention experts are using social media and free iPhone apps to appeal to sports fans and reduce their cardiac disease risk. The Cleveland Clinic recently launched a campaign called Let’s Move It!

The Let’s Move It! app, which works with iPhone and iPod Touch, includes a pedometer that helps users keep track of their individual progress. The app also challenges users to participate in different sports-related community walks. For example, they can try to walk the equivalent mileage between Cleveland Browns Stadium and Paul Brown Stadium in Cincinnati. As they participate in the challenge, fellow walkers can cheer them on through Facebook and Twitter. The app even tells them how many steps they would have to take to work off a hot dog, beer, and fries at the stadium.

“Physical inactivity is one of the factors contributing to the escalating chronic disease rate in America,” said Michael Roizen, MD, Chairman of the Cleveland Clinic Wellness Institute, in a statement. “The Let’s Move It! app makes exercise fun by creating friendly competitions among users. Research has shown that people who have access to an interactive, social exercise environment are more likely to actually exercise.”

In other areas of the country, cardiologists are turning their patients on to iPhone apps that help them watch for trends in their blood pressure readings and calculate their risk for a heart attack.

Stress is another factor in heart disease, as well as a host of other conditions, from depression and dementia to fibromyalgia. So the Cleveland Clinic Wellness Institute also offers a free app that leads users through guided meditations. These relaxation apps help people relax their muscles, let go of their anger, and practice mindfulness.

Cleveland Clinic has its own health information Web site. The site, at 360-5.com, is similar to MayoClinic.com, but is more interactive and also sells wellness products. As part of its offerings, it includes an online application that goes with the iPhone app called Stress Free Now. Clinicians at Cleveland Clinic have access to the program for any patient. Others can pay for it for $40 per person. To preview Stress Free Now, visit www.360-5.com/promos.

Thomas Morledge, MD, medical director of the Cleveland Clinic’s Wellness Enterprise, created the eight-week Stress Free Now program and the app. Patients log on daily to read motivational messages from Morledge. Then, they can download an MP3 with breathing techniques, relaxation methods, and positive affirmations. They must set aside about 30 minutes, several times a week, to see results.

“There’s a lot of literature to support these techniques,” Morledge says. “It can help with chronic pain, such as fibromyalgia, and cut down on inflammation. It can reduce the risk of stroke and dementia.” The Cleveland Clinic program is based a great deal on the work of mindfulness expert and University of Massachusetts medical professor Jon Kabat-Zinn.

The clinic currently is enrolling 600 patients in a clinical trial to test the effectiveness of the online program, but so far, anecdotal evidence says it is working. “When people use it, you can see there’s been a change—their color improves, they sleep better, and they have more energy,” Morledge says.

So far, it is the NPs and PAs who have referred the most patients to the Stress Free Now program, he adds. “They seem to have better peripheral vision,” he says. “They have a very patient-centered approach to their care.”

Stress remains an overlooked component of health, even though, as Morledge says, “The impact of stress is probably as great as [that of] obesity.”

By reaching out to patients with MP3s, iPhone apps, and online coaching, Cleveland Clinic is on the leading edge of an important trend in prevention. Programs like Stress Free Now can help spread the word to thousands of people—more than any single clinician could reach from a typical medical office.

Stephen Kimmel, MD, noticed a trend in his cardiology clinic: Patients who use anticoagulants, such as warfarin, seemed to have difficulty taking their medication consistently and correctly.

“Each time that happens, it costs $50 for an office visit,” explains Kimmel, a professor at the University of Pennsylvania. “If their anticoagulant goes out of whack, it costs $100 to $150 every time that happens.”

As Kimmel watched this happen on a regular basis, he started searching for ways to help these patients improve compliance. He tried reminder clocks that buzz when it’s time to take a pill, actual phone calls from the clinic, and support groups. But nothing has proven to be as effective as the power of the dollar.

A Small Price to Pay
These days, Kimmel’s research focuses on financial incentives. “Maybe what we need to do is come up with simpler solutions that can work without time and training—something that could be cost-effective,” Kimmel says. “It has to be something that’s ­doable.”

While some programs hand patients money up front or offer lower co-pays for prescription medications, Kimmel uses a lottery system. Each day, patients have a chance to win a small amount of money ($90) if they can prove they have faithfully taken their pills. (They use a computerized pillbox that keeps track.)

“Hopefully, through the fun of being involved in the daily process, we are helping them change their long-term behavior,” Kimmel says. “The goal of our program is to give people something that will help them help themselves through positive incentives.”

Kimmel, who is conducting an ongoing study for the NIH, says he has preliminary data that show these financial incentives do, in fact, work. He chose patients who take anticoagulants for his study because they must be very consistent and precise about the way they take their medication, and there is a lot at stake if they don’t follow through—namely, blood clots and strokes.

“It’s a complex problem, and it’s hard to solve,” he says. “Pretty much anything is on the table.”

Insurance companies, such as Aetna, are collaborating with researchers like Kimmel because they feel these kinds of financial incentives might be a great solution to rising health care costs. Kimmel argues it’s much more cost-effective to give away $90 in a lottery than it is to spend more than $100,000 to hospitalize a patient who has had a stroke due to a medication error.

Changing Behavior
Research shows that financial incentive programs are a cost-effective measure. One study estimated that for every dollar spent on incentives, the per-patient savings could be $7 for those with diabetes, $4 for those with high blood pressure, and $5 for those with high cholesterol.

Several articles in the Journal of Medical Ethics, however, raise questions about whether financial incentives could mislead patients or even be construed as coercion. Furthermore, some ask whether it is fair to pay noncompliant patients to take their medications, while those who take their medications as directed get no reward for their “good behavior” (other than, of course, presumably improved health). Others wonder if patients would go so far as to start faking noncompliance just to qualify for an incentive.

But Aetna executive Ed Pezalla, MD, MPH, says he feels incentives are a valuable tool to help patients develop more consistent habits and, as a result, enjoy better health.

Poor compliance is an issue not just for cardiology patients, but for people with many different chronic diseases. Anyone with a chronic condition, from epilepsy to mental illness, would be a good candidate for financial incentives, experts say.

Noncompliance adds up to $177 billion a year in extra health care costs, according to the National Council on Patient Information and Education. Studies show one-quarter of all prescriptions written by a clinician are never filled, and patients with chronic diseases like diabetes only take their medication properly half the time.

“As the nation looks for ways to reduce [health care] spending, we need to improve patient compliance,” said Troyen Brennan, MD, executive vice president of CVS Caremark, in a statement.

Like Aetna, CVS Caremark has also partnered with researchers from such institutions as Brigham and Women’s Hospital, Carnegie Mellon University, and Dartmouth College to find ways to improve medication compliance. Financial incentives are one of the options they are exploring.

“This research will help us understand the reasons why patients do not take their medications as prescribed. We will use this information to develop effective, evidence-based approaches to improve prescription adherence,” said William Shrank, MD, of Brigham and Women’s Hospital, in a statement. “We hope this research will help us create strategies to promote wellness in our patients.”

What You Can Do Now
While the results of these studies won’t be available for several years, Kimmel argues that clinicians can still take certain steps right now in their own practice settings, even if they work in a small medical office or a rural town. All it takes is good communication, he says.

“When we do an exam, we should ask patients how it’s going with their meds,” Kimmel explains. “Ask them, ‘What can I do to help you take your medication?’”

Often, patients will admit they are confused about when to take their pills, or they may not be able to fill the prescription. “If they do tell you, that gives you an opportunity to do something at the moment,” he says.

Sometimes it only takes a simple solution, such as asking an adult child to supervise an elderly parent while filling his or her seven-day pillbox. If cost is an issue, patients could switch to a generic alternative that would be more affordable.

“This is about more than just writing a prescription and handing it to the patient,” Kimmel says. “It’s not going to help them if they’re not taking it.”

Stephen Kimmel, MD, noticed a trend in his cardiology clinic: Patients who use anticoagulants, such as warfarin, seemed to have difficulty taking their medication consistently and correctly.

“Each time that happens, it costs $50 for an office visit,” explains Kimmel, a professor at the University of Pennsylvania. “If their anticoagulant goes out of whack, it costs $100 to $150 every time that happens.”

As Kimmel watched this happen on a regular basis, he started searching for ways to help these patients improve compliance. He tried reminder clocks that buzz when it’s time to take a pill, actual phone calls from the clinic, and support groups. But nothing has proven to be as effective as the power of the dollar.

A Small Price to Pay
These days, Kimmel’s research focuses on financial incentives. “Maybe what we need to do is come up with simpler solutions that can work without time and training—something that could be cost-effective,” Kimmel says. “It has to be something that’s ­doable.”

While some programs hand patients money up front or offer lower co-pays for prescription medications, Kimmel uses a lottery system. Each day, patients have a chance to win a small amount of money ($90) if they can prove they have faithfully taken their pills. (They use a computerized pillbox that keeps track.)

“Hopefully, through the fun of being involved in the daily process, we are helping them change their long-term behavior,” Kimmel says. “The goal of our program is to give people something that will help them help themselves through positive incentives.”

Kimmel, who is conducting an ongoing study for the NIH, says he has preliminary data that show these financial incentives do, in fact, work. He chose patients who take anticoagulants for his study because they must be very consistent and precise about the way they take their medication, and there is a lot at stake if they don’t follow through—namely, blood clots and strokes.

“It’s a complex problem, and it’s hard to solve,” he says. “Pretty much anything is on the table.”

Insurance companies, such as Aetna, are collaborating with researchers like Kimmel because they feel these kinds of financial incentives might be a great solution to rising health care costs. Kimmel argues it’s much more cost-effective to give away $90 in a lottery than it is to spend more than $100,000 to hospitalize a patient who has had a stroke due to a medication error.

Changing Behavior
Research shows that financial incentive programs are a cost-effective measure. One study estimated that for every dollar spent on incentives, the per-patient savings could be $7 for those with diabetes, $4 for those with high blood pressure, and $5 for those with high cholesterol.

Several articles in the Journal of Medical Ethics, however, raise questions about whether financial incentives could mislead patients or even be construed as coercion. Furthermore, some ask whether it is fair to pay noncompliant patients to take their medications, while those who take their medications as directed get no reward for their “good behavior” (other than, of course, presumably improved health). Others wonder if patients would go so far as to start faking noncompliance just to qualify for an incentive.

But Aetna executive Ed Pezalla, MD, MPH, says he feels incentives are a valuable tool to help patients develop more consistent habits and, as a result, enjoy better health.

Poor compliance is an issue not just for cardiology patients, but for people with many different chronic diseases. Anyone with a chronic condition, from epilepsy to mental illness, would be a good candidate for financial incentives, experts say.

Noncompliance adds up to $177 billion a year in extra health care costs, according to the National Council on Patient Information and Education. Studies show one-quarter of all prescriptions written by a clinician are never filled, and patients with chronic diseases like diabetes only take their medication properly half the time.

“As the nation looks for ways to reduce [health care] spending, we need to improve patient compliance,” said Troyen Brennan, MD, executive vice president of CVS Caremark, in a statement.

Like Aetna, CVS Caremark has also partnered with researchers from such institutions as Brigham and Women’s Hospital, Carnegie Mellon University, and Dartmouth College to find ways to improve medication compliance. Financial incentives are one of the options they are exploring.

“This research will help us understand the reasons why patients do not take their medications as prescribed. We will use this information to develop effective, evidence-based approaches to improve prescription adherence,” said William Shrank, MD, of Brigham and Women’s Hospital, in a statement. “We hope this research will help us create strategies to promote wellness in our patients.”

What You Can Do Now
While the results of these studies won’t be available for several years, Kimmel argues that clinicians can still take certain steps right now in their own practice settings, even if they work in a small medical office or a rural town. All it takes is good communication, he says.

“When we do an exam, we should ask patients how it’s going with their meds,” Kimmel explains. “Ask them, ‘What can I do to help you take your medication?’”

Often, patients will admit they are confused about when to take their pills, or they may not be able to fill the prescription. “If they do tell you, that gives you an opportunity to do something at the moment,” he says.

Sometimes it only takes a simple solution, such as asking an adult child to supervise an elderly parent while filling his or her seven-day pillbox. If cost is an issue, patients could switch to a generic alternative that would be more affordable.

“This is about more than just writing a prescription and handing it to the patient,” Kimmel says. “It’s not going to help them if they’re not taking it.”

Stephen Kimmel, MD, noticed a trend in his cardiology clinic: Patients who use anticoagulants, such as warfarin, seemed to have difficulty taking their medication consistently and correctly.

“Each time that happens, it costs $50 for an office visit,” explains Kimmel, a professor at the University of Pennsylvania. “If their anticoagulant goes out of whack, it costs $100 to $150 every time that happens.”

As Kimmel watched this happen on a regular basis, he started searching for ways to help these patients improve compliance. He tried reminder clocks that buzz when it’s time to take a pill, actual phone calls from the clinic, and support groups. But nothing has proven to be as effective as the power of the dollar.

A Small Price to Pay
These days, Kimmel’s research focuses on financial incentives. “Maybe what we need to do is come up with simpler solutions that can work without time and training—something that could be cost-effective,” Kimmel says. “It has to be something that’s ­doable.”

While some programs hand patients money up front or offer lower co-pays for prescription medications, Kimmel uses a lottery system. Each day, patients have a chance to win a small amount of money ($90) if they can prove they have faithfully taken their pills. (They use a computerized pillbox that keeps track.)

“Hopefully, through the fun of being involved in the daily process, we are helping them change their long-term behavior,” Kimmel says. “The goal of our program is to give people something that will help them help themselves through positive incentives.”

Kimmel, who is conducting an ongoing study for the NIH, says he has preliminary data that show these financial incentives do, in fact, work. He chose patients who take anticoagulants for his study because they must be very consistent and precise about the way they take their medication, and there is a lot at stake if they don’t follow through—namely, blood clots and strokes.

“It’s a complex problem, and it’s hard to solve,” he says. “Pretty much anything is on the table.”

Insurance companies, such as Aetna, are collaborating with researchers like Kimmel because they feel these kinds of financial incentives might be a great solution to rising health care costs. Kimmel argues it’s much more cost-effective to give away $90 in a lottery than it is to spend more than $100,000 to hospitalize a patient who has had a stroke due to a medication error.

Changing Behavior
Research shows that financial incentive programs are a cost-effective measure. One study estimated that for every dollar spent on incentives, the per-patient savings could be $7 for those with diabetes, $4 for those with high blood pressure, and $5 for those with high cholesterol.

Several articles in the Journal of Medical Ethics, however, raise questions about whether financial incentives could mislead patients or even be construed as coercion. Furthermore, some ask whether it is fair to pay noncompliant patients to take their medications, while those who take their medications as directed get no reward for their “good behavior” (other than, of course, presumably improved health). Others wonder if patients would go so far as to start faking noncompliance just to qualify for an incentive.

But Aetna executive Ed Pezalla, MD, MPH, says he feels incentives are a valuable tool to help patients develop more consistent habits and, as a result, enjoy better health.

Poor compliance is an issue not just for cardiology patients, but for people with many different chronic diseases. Anyone with a chronic condition, from epilepsy to mental illness, would be a good candidate for financial incentives, experts say.

Noncompliance adds up to $177 billion a year in extra health care costs, according to the National Council on Patient Information and Education. Studies show one-quarter of all prescriptions written by a clinician are never filled, and patients with chronic diseases like diabetes only take their medication properly half the time.

“As the nation looks for ways to reduce [health care] spending, we need to improve patient compliance,” said Troyen Brennan, MD, executive vice president of CVS Caremark, in a statement.

Like Aetna, CVS Caremark has also partnered with researchers from such institutions as Brigham and Women’s Hospital, Carnegie Mellon University, and Dartmouth College to find ways to improve medication compliance. Financial incentives are one of the options they are exploring.

“This research will help us understand the reasons why patients do not take their medications as prescribed. We will use this information to develop effective, evidence-based approaches to improve prescription adherence,” said William Shrank, MD, of Brigham and Women’s Hospital, in a statement. “We hope this research will help us create strategies to promote wellness in our patients.”

What You Can Do Now
While the results of these studies won’t be available for several years, Kimmel argues that clinicians can still take certain steps right now in their own practice settings, even if they work in a small medical office or a rural town. All it takes is good communication, he says.

“When we do an exam, we should ask patients how it’s going with their meds,” Kimmel explains. “Ask them, ‘What can I do to help you take your medication?’”

Often, patients will admit they are confused about when to take their pills, or they may not be able to fill the prescription. “If they do tell you, that gives you an opportunity to do something at the moment,” he says.

Sometimes it only takes a simple solution, such as asking an adult child to supervise an elderly parent while filling his or her seven-day pillbox. If cost is an issue, patients could switch to a generic alternative that would be more affordable.

“This is about more than just writing a prescription and handing it to the patient,” Kimmel says. “It’s not going to help them if they’re not taking it.”

When Chris Ruge, FNP-BC, a nurse practitioner in rural New Mexico, thinks of his biggest success stories, a particular patient comes to mind. She’s a mom who underwent several different surgeries and in the process became hooked on pain medication. Over time, she was dealing with a full-blown addiction.

Since patients who live in this part of New Mexico have to drive three hours each way to receive treatment at the University of New Mexico (UNM) in Albuquerque, most never make the trip. Project ECHO, an innovative program at the UNM School of Medicine, has changed all that by knocking down rural barriers to access.

Ruge is a participant in this unique telemedicine program. He presented his patient’s case to a panel of addiction experts at UNM via a remote hook-up. They guided him as he treated her dependence on pain meds. Gradually, she recovered and started to find more energy for positive things in her life, such as coaching her kids’ sports teams.

During a routine follow-up visit, the woman brought her 11-year-old daughter with her. “Oh, thank you,” the girl said to Ruge. “Now I have my mom back.”

SPECIALTY CARE, NEAR AND FAR
Thanks to Project ECHO (Extension for Community Healthcare Outcomes), founded by Dr. Sanjeev Arora in 2003, clinicians across New Mexico can point to many similar success stories. “It started as a way to increase access to care for hepatitis C,” says Karla Thornton, MD, associate medical director of Project ECHO and a UNM professor in infectious disease. “The model works so well, it’s been expanded to include a lot of different diseases.”

The program—which has won many awards, including one from the Robert Wood Johnson Foundation—relies heavily on nurse practitioners, like Ruge, and physician assistants. “They become specialists,” Thornton says, “so they can provide care for their patients in their own community.”

Through the ECHO program, Ruge can share patients’ labs and medical information with a panel of experts at UNM, including Arora, who is a hepatologist. After consulting with the group, he returns to the patient and carries out a specialized treatment plan—in the local clinic close to the patient’s home.

Another clinician in the ECHO network, Debra Newman, PA-C, MPAS, MPH, admits that when she first signed on with the ECHO program, she was a little intimidated by the technology, but she got the hang of it. Basically, all it takes is a computer, a Web cam, and the right software. Every Wednesday, Newman plugs in an IP address and suddenly, the UNM group appears on her screen, sitting around a big conference table. Then providers from other rural clinics also pop up on her screen in a series of smaller boxes.

Each rural provider presents a case, then gets feedback from the UNM multidisciplinary team of experts. “It’s almost like in medical school,” Thornton explains, “where you present the patient to the attending physician.”

Ruge participates in several ECHO program clinics, including those for addiction, hepatitis C, and diabetes. With his background as a small-business owner, Ruge says, he likes the sense of autonomy the program gives him. He also likes the way the UNM team treats clinicians with courtesy, as fellow professionals.

“It allows me to create my own kind of program here, with Project ECHO giving it structure,” Ruge says. “How I coordinate the program, that comes from me.”

KEEPING UP TO DATE
When Ruge started working in rural New Mexico, he had a strong background in addiction medicine but didn’t know as much about how to manage diabetes. He received quite an education by joining the ECHO program’s diabetes clinic. In particular, he appreciates the way other clinicians share their tips for helping diabetic patients with lifestyle changes, such as diet and exercise.

When he logs on to the virtual clinic, there will be, say, an endocrinologist sitting at the table, along with a diabetes educator and several nurse care managers. “When you present, it really is just as if the patient has gone to an endocrinology expert, and you’re sitting there talking about it afterward,” Ruge says. “I’ve learned so much by working with them.”

He also appreciates the support and education ECHO provides. “With hepatitis C, it’s similar to AIDS care about 15 years ago,” Ruge says. “The treatments we have are not always as effective as we would like them to be. It’s kind of like frontier medicine—you need to feel like someone has your back so you can push that envelope.”

Participation in the ECHO program’s hepatitis C clinic also gives clinicians access to the latest drugs and research, since the panel shares information about up-and-coming clinical trials. Ruge can share the latest data about his patients through a sophisticated electronic medical record system.

“They are really going the extra mile to get good data and good labs,” Ruge says of the specialists at the other end of the program.

A BLESSING FOR PATIENTS
The patient Newman will always remember is a man who had started using drugs, including heroin, as a young teenager. He had been incarcerated several times. Newman started giving him suboxone for opiate replacement therapy.

“He became stable, he stopped smoking, and we got some counseling in place,” Newman says. “Then we started hepatitis C treatment.”

Newman was thrilled to get the news that this young man, who is now in his 20s, has been cured of his hepatitis C. “He is planning to move to Colorado and start a whole new life,” she says, with pride. “Without the ECHO program, there would be so many people like him who would not be able to get treatment. It’s such a blessing.”

This is a sentiment Ruge echoes. During his first year and a half with the ECHO program, Ruge started 19 patients on treatment for hepatitis C. “I can honestly say probably half of them would not have been treated within the next five years, if at all,” he surmises, “because the hurdles are too great.”

Many of his patients have very low incomes, so the $30 to $40 it would cost in gas to make the trip to Albuquerque would be a barrier for them, Ruge explains. Others don’t even own a car. If any of them tried to make the trip but were delayed by a snowstorm and had to postpone their appointment, they might never reschedule, he adds.

Because of the ability to help so many, the ECHO program has made Newman feel great about her work. “I’m really happy I landed in this,” she says. “This is like a dream job.”

GREAT OPPORTUNITY FOR PAs, NPs
PAs and NPs are well suited to this unique program, according to Newman. “Generally speaking, we’re given a little bit more time to talk to patients,” she says. “We tend to do more of the education piece, so I think it’s a good fit.”

Another plus: Clinicians who participate in the ECHO program can receive continuing medical education credit. And each clinic has a weekly education session or didactic presentation. “I love to learn,” Newman says. “I love having that available to me all the time. It just makes my job that much more enjoyable.”

Clinicians in other states may eventually have similar opportunities. The UNM model has been so successful at improving access to care that many other medical centers—such as the University of Chicago and the University of Washington—are taking Arora’s idea and adopting a similar system.

“It sort of spread in a way he never imagined,” Thornton says. “It’s really a great program. It provides care for people who couldn’t otherwise have it.”

For more information about the ECHO program, visit echo.unm.edu or send an e-mail to [email protected].

When Chris Ruge, FNP-BC, a nurse practitioner in rural New Mexico, thinks of his biggest success stories, a particular patient comes to mind. She’s a mom who underwent several different surgeries and in the process became hooked on pain medication. Over time, she was dealing with a full-blown addiction.

Since patients who live in this part of New Mexico have to drive three hours each way to receive treatment at the University of New Mexico (UNM) in Albuquerque, most never make the trip. Project ECHO, an innovative program at the UNM School of Medicine, has changed all that by knocking down rural barriers to access.

Ruge is a participant in this unique telemedicine program. He presented his patient’s case to a panel of addiction experts at UNM via a remote hook-up. They guided him as he treated her dependence on pain meds. Gradually, she recovered and started to find more energy for positive things in her life, such as coaching her kids’ sports teams.

During a routine follow-up visit, the woman brought her 11-year-old daughter with her. “Oh, thank you,” the girl said to Ruge. “Now I have my mom back.”

SPECIALTY CARE, NEAR AND FAR
Thanks to Project ECHO (Extension for Community Healthcare Outcomes), founded by Dr. Sanjeev Arora in 2003, clinicians across New Mexico can point to many similar success stories. “It started as a way to increase access to care for hepatitis C,” says Karla Thornton, MD, associate medical director of Project ECHO and a UNM professor in infectious disease. “The model works so well, it’s been expanded to include a lot of different diseases.”

The program—which has won many awards, including one from the Robert Wood Johnson Foundation—relies heavily on nurse practitioners, like Ruge, and physician assistants. “They become specialists,” Thornton says, “so they can provide care for their patients in their own community.”

Through the ECHO program, Ruge can share patients’ labs and medical information with a panel of experts at UNM, including Arora, who is a hepatologist. After consulting with the group, he returns to the patient and carries out a specialized treatment plan—in the local clinic close to the patient’s home.

Another clinician in the ECHO network, Debra Newman, PA-C, MPAS, MPH, admits that when she first signed on with the ECHO program, she was a little intimidated by the technology, but she got the hang of it. Basically, all it takes is a computer, a Web cam, and the right software. Every Wednesday, Newman plugs in an IP address and suddenly, the UNM group appears on her screen, sitting around a big conference table. Then providers from other rural clinics also pop up on her screen in a series of smaller boxes.

Each rural provider presents a case, then gets feedback from the UNM multidisciplinary team of experts. “It’s almost like in medical school,” Thornton explains, “where you present the patient to the attending physician.”

Ruge participates in several ECHO program clinics, including those for addiction, hepatitis C, and diabetes. With his background as a small-business owner, Ruge says, he likes the sense of autonomy the program gives him. He also likes the way the UNM team treats clinicians with courtesy, as fellow professionals.

“It allows me to create my own kind of program here, with Project ECHO giving it structure,” Ruge says. “How I coordinate the program, that comes from me.”

KEEPING UP TO DATE
When Ruge started working in rural New Mexico, he had a strong background in addiction medicine but didn’t know as much about how to manage diabetes. He received quite an education by joining the ECHO program’s diabetes clinic. In particular, he appreciates the way other clinicians share their tips for helping diabetic patients with lifestyle changes, such as diet and exercise.

When he logs on to the virtual clinic, there will be, say, an endocrinologist sitting at the table, along with a diabetes educator and several nurse care managers. “When you present, it really is just as if the patient has gone to an endocrinology expert, and you’re sitting there talking about it afterward,” Ruge says. “I’ve learned so much by working with them.”

He also appreciates the support and education ECHO provides. “With hepatitis C, it’s similar to AIDS care about 15 years ago,” Ruge says. “The treatments we have are not always as effective as we would like them to be. It’s kind of like frontier medicine—you need to feel like someone has your back so you can push that envelope.”

Participation in the ECHO program’s hepatitis C clinic also gives clinicians access to the latest drugs and research, since the panel shares information about up-and-coming clinical trials. Ruge can share the latest data about his patients through a sophisticated electronic medical record system.

“They are really going the extra mile to get good data and good labs,” Ruge says of the specialists at the other end of the program.

A BLESSING FOR PATIENTS
The patient Newman will always remember is a man who had started using drugs, including heroin, as a young teenager. He had been incarcerated several times. Newman started giving him suboxone for opiate replacement therapy.

“He became stable, he stopped smoking, and we got some counseling in place,” Newman says. “Then we started hepatitis C treatment.”

Newman was thrilled to get the news that this young man, who is now in his 20s, has been cured of his hepatitis C. “He is planning to move to Colorado and start a whole new life,” she says, with pride. “Without the ECHO program, there would be so many people like him who would not be able to get treatment. It’s such a blessing.”

This is a sentiment Ruge echoes. During his first year and a half with the ECHO program, Ruge started 19 patients on treatment for hepatitis C. “I can honestly say probably half of them would not have been treated within the next five years, if at all,” he surmises, “because the hurdles are too great.”

Many of his patients have very low incomes, so the $30 to $40 it would cost in gas to make the trip to Albuquerque would be a barrier for them, Ruge explains. Others don’t even own a car. If any of them tried to make the trip but were delayed by a snowstorm and had to postpone their appointment, they might never reschedule, he adds.

Because of the ability to help so many, the ECHO program has made Newman feel great about her work. “I’m really happy I landed in this,” she says. “This is like a dream job.”

GREAT OPPORTUNITY FOR PAs, NPs
PAs and NPs are well suited to this unique program, according to Newman. “Generally speaking, we’re given a little bit more time to talk to patients,” she says. “We tend to do more of the education piece, so I think it’s a good fit.”

Another plus: Clinicians who participate in the ECHO program can receive continuing medical education credit. And each clinic has a weekly education session or didactic presentation. “I love to learn,” Newman says. “I love having that available to me all the time. It just makes my job that much more enjoyable.”

Clinicians in other states may eventually have similar opportunities. The UNM model has been so successful at improving access to care that many other medical centers—such as the University of Chicago and the University of Washington—are taking Arora’s idea and adopting a similar system.

“It sort of spread in a way he never imagined,” Thornton says. “It’s really a great program. It provides care for people who couldn’t otherwise have it.”

For more information about the ECHO program, visit echo.unm.edu or send an e-mail to [email protected].

When Chris Ruge, FNP-BC, a nurse practitioner in rural New Mexico, thinks of his biggest success stories, a particular patient comes to mind. She’s a mom who underwent several different surgeries and in the process became hooked on pain medication. Over time, she was dealing with a full-blown addiction.

Since patients who live in this part of New Mexico have to drive three hours each way to receive treatment at the University of New Mexico (UNM) in Albuquerque, most never make the trip. Project ECHO, an innovative program at the UNM School of Medicine, has changed all that by knocking down rural barriers to access.

Ruge is a participant in this unique telemedicine program. He presented his patient’s case to a panel of addiction experts at UNM via a remote hook-up. They guided him as he treated her dependence on pain meds. Gradually, she recovered and started to find more energy for positive things in her life, such as coaching her kids’ sports teams.

During a routine follow-up visit, the woman brought her 11-year-old daughter with her. “Oh, thank you,” the girl said to Ruge. “Now I have my mom back.”

SPECIALTY CARE, NEAR AND FAR
Thanks to Project ECHO (Extension for Community Healthcare Outcomes), founded by Dr. Sanjeev Arora in 2003, clinicians across New Mexico can point to many similar success stories. “It started as a way to increase access to care for hepatitis C,” says Karla Thornton, MD, associate medical director of Project ECHO and a UNM professor in infectious disease. “The model works so well, it’s been expanded to include a lot of different diseases.”

The program—which has won many awards, including one from the Robert Wood Johnson Foundation—relies heavily on nurse practitioners, like Ruge, and physician assistants. “They become specialists,” Thornton says, “so they can provide care for their patients in their own community.”

Through the ECHO program, Ruge can share patients’ labs and medical information with a panel of experts at UNM, including Arora, who is a hepatologist. After consulting with the group, he returns to the patient and carries out a specialized treatment plan—in the local clinic close to the patient’s home.

Another clinician in the ECHO network, Debra Newman, PA-C, MPAS, MPH, admits that when she first signed on with the ECHO program, she was a little intimidated by the technology, but she got the hang of it. Basically, all it takes is a computer, a Web cam, and the right software. Every Wednesday, Newman plugs in an IP address and suddenly, the UNM group appears on her screen, sitting around a big conference table. Then providers from other rural clinics also pop up on her screen in a series of smaller boxes.

Each rural provider presents a case, then gets feedback from the UNM multidisciplinary team of experts. “It’s almost like in medical school,” Thornton explains, “where you present the patient to the attending physician.”

Ruge participates in several ECHO program clinics, including those for addiction, hepatitis C, and diabetes. With his background as a small-business owner, Ruge says, he likes the sense of autonomy the program gives him. He also likes the way the UNM team treats clinicians with courtesy, as fellow professionals.

“It allows me to create my own kind of program here, with Project ECHO giving it structure,” Ruge says. “How I coordinate the program, that comes from me.”

KEEPING UP TO DATE
When Ruge started working in rural New Mexico, he had a strong background in addiction medicine but didn’t know as much about how to manage diabetes. He received quite an education by joining the ECHO program’s diabetes clinic. In particular, he appreciates the way other clinicians share their tips for helping diabetic patients with lifestyle changes, such as diet and exercise.

When he logs on to the virtual clinic, there will be, say, an endocrinologist sitting at the table, along with a diabetes educator and several nurse care managers. “When you present, it really is just as if the patient has gone to an endocrinology expert, and you’re sitting there talking about it afterward,” Ruge says. “I’ve learned so much by working with them.”

He also appreciates the support and education ECHO provides. “With hepatitis C, it’s similar to AIDS care about 15 years ago,” Ruge says. “The treatments we have are not always as effective as we would like them to be. It’s kind of like frontier medicine—you need to feel like someone has your back so you can push that envelope.”

Participation in the ECHO program’s hepatitis C clinic also gives clinicians access to the latest drugs and research, since the panel shares information about up-and-coming clinical trials. Ruge can share the latest data about his patients through a sophisticated electronic medical record system.

“They are really going the extra mile to get good data and good labs,” Ruge says of the specialists at the other end of the program.

A BLESSING FOR PATIENTS
The patient Newman will always remember is a man who had started using drugs, including heroin, as a young teenager. He had been incarcerated several times. Newman started giving him suboxone for opiate replacement therapy.

“He became stable, he stopped smoking, and we got some counseling in place,” Newman says. “Then we started hepatitis C treatment.”

Newman was thrilled to get the news that this young man, who is now in his 20s, has been cured of his hepatitis C. “He is planning to move to Colorado and start a whole new life,” she says, with pride. “Without the ECHO program, there would be so many people like him who would not be able to get treatment. It’s such a blessing.”

This is a sentiment Ruge echoes. During his first year and a half with the ECHO program, Ruge started 19 patients on treatment for hepatitis C. “I can honestly say probably half of them would not have been treated within the next five years, if at all,” he surmises, “because the hurdles are too great.”

Many of his patients have very low incomes, so the $30 to $40 it would cost in gas to make the trip to Albuquerque would be a barrier for them, Ruge explains. Others don’t even own a car. If any of them tried to make the trip but were delayed by a snowstorm and had to postpone their appointment, they might never reschedule, he adds.

Because of the ability to help so many, the ECHO program has made Newman feel great about her work. “I’m really happy I landed in this,” she says. “This is like a dream job.”

GREAT OPPORTUNITY FOR PAs, NPs
PAs and NPs are well suited to this unique program, according to Newman. “Generally speaking, we’re given a little bit more time to talk to patients,” she says. “We tend to do more of the education piece, so I think it’s a good fit.”

Another plus: Clinicians who participate in the ECHO program can receive continuing medical education credit. And each clinic has a weekly education session or didactic presentation. “I love to learn,” Newman says. “I love having that available to me all the time. It just makes my job that much more enjoyable.”

Clinicians in other states may eventually have similar opportunities. The UNM model has been so successful at improving access to care that many other medical centers—such as the University of Chicago and the University of Washington—are taking Arora’s idea and adopting a similar system.

“It sort of spread in a way he never imagined,” Thornton says. “It’s really a great program. It provides care for people who couldn’t otherwise have it.”

For more information about the ECHO program, visit echo.unm.edu or send an e-mail to [email protected].

At any given time, federal experts estimate, approximately 10% of the population of Mexico is living in the United States. And plenty of Americans are going to Mexico, too: An estimated 50 million pedestrians and 200 million cars cross the border each year.

Unfortunately, infectious diseases cross the border between the countries as well. That is why, in 1988, the US government established the US–Mexico Border AIDS ­Education Steering Team (UMBAST). The organization has AIDS Education Training Centers (AETC) in the border states of Arizona, California, Texas, and New Mexico.

Clinicians who run these UMBAST centers provide CE/CME training modules and resources for physicians, advanced practice nurses, and physician assistants, to help them improve continuity of care for migrant patients who cross between the US and Mexico (as well as those who come to the US from and return to other countries in Central and South America).

Creating Continuity
A health care provider’s most important goal is to make sure there are no gaps in services, even when the patient leaves the US to return to their native country.

“We started this program because [at the time] AIDS was a new disease and nobody knew anything about it,” says Lucy Bradley-Springer, PhD, RN, ACRN, FAAN, principal investigator for the Mountain Plains AETC in Denver.

Now, although much more is known, educational and training programs for PAs and NPs do not always focus much on HIV and AIDS. To enhance their education, clinicians who treat patients with HIV and AIDS may need to seek additional training on their own.

That’s where UMBAST comes in. The organization offers CE/CME training courses and online modules. The agency’s Web site (www.AETCborderhealth.org) also provides detailed information on caring for HIV-infected patients from Mexico and Central or South America.

Fact sheets in both English and Spanish offer information on available services and associated costs of HIV and AIDS treatment in Mexico, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama—as well as what documentation patients will need when they return to their native country, and contact information (Web sites and often phone numbers) for services that can connect patients to clinics and hospitals back home, before they leave the US.

Also available online are a slide presentation addressing continuity of care for patients with HIV who are returning to Mexico, and a chart showing which antiviral medications are available in the US and in Mexico, with the generic and brand names used in each country. There are also reports containing epidemiologic and demographic data on HIV/AIDS.

How It’s Done in Mexico
One of the most valuable lessons is how the Mexican health care system works.

“No two countries share as many people and no two countries have a border that is crossed as frequently as the US and Mexico,” says Tom Donohoe, MBA, a family practice professor at the University of California–Los Angeles’ David Geffen School of Medicine. “It’s good for both countries if we know how health care works.”

Many people don’t realize that Mexico now has a government-run health care program, Seguro Popular. Any Mexican citizen who is not insured by an employer can access care under this system.

“If somebody is working with a client who is returning to Mexico and they happen to have HIV, then they will have access to antiretroviral medications,” says Donohoe, the director and principal investigator for the UCLA training center.

Donohoe often encounters health care providers who don’t believe HIV medication is even available in Mexico. “Those stories were probably true 10 years ago,” he says. “But they’re not very true any more.”

In fact, Mexico now has dedicated outpatient HIV clinics in each state, which are staffed by trained and qualified nurses and doctors.

When Mexican patients are preparing to return to their home country, clinicians should make sure they have the name and contact information for an HIV clinic in Mexico, copies of their lab work, and an adequate supply of medication, plus the proper citizen ID cards to sign up for health care programs, says Bradley-Springer. (Again, see www.AETCborderhealth.org for salient details.)

Display Simpatico
A big part of being an effective caregiver entails understanding the cultural issues involved in migrant care.

“This is a public health issue, but it is also a personal issue,” Bradley-Springer says. “People are not getting the care they need.”

First of all, few clinics in the US are willing to care for immigrants who do not have health insurance. Sometimes, even if a clinic is available, immigrants are afraid to seek care because they are in the country illegally.

“They are discriminated against because they’re Hispanic, because they are poor, and now [because] they have HIV,” Bradley-Springer says. “A lot of times immigrants don’t have access to health care services—and when they do, they are scared of being deported.”

If the patient does make it to a clinic, talking about HIV and AIDS can be sensitive, particularly for men from Mexico or Central or South America.

“A lot of health care providers have trouble dealing with the different cultures that come through their door,” Bradley-Springer says. “If you don’t speak Spanish and you don’t understand the concept of machismo, and you have no idea what health care is like in Mexico, then that makes it harder.”

Meanwhile, it can be frustrating to start making progress with a patient, only to have them leave the country and return to Mexico, Panama, or Honduras. But knowing you connected that patient with good care back home brings peace of mind.

“We’re trying to help our clinicians help their patients get the services when they need them,” Bradley-Springer says.

Consequences of Failure
If that connection doesn’t happen, what’s at stake? Despite progress, many HIV-infected immigrants aren’t aware of the significance of the symptoms they are experiencing.

For example, they will feel fatigue but will work right through it, Bradley-Springer explains. If they do not start antiretroviral drugs soon enough, she adds, they will have a greater viral load and will be more likely to spread the infection to others.

Another important aspect of caring for a migrant patient with HIV is the need to emphasize medication compliance.

“They need to know if they stop taking these drugs and then start taking them again sometime in the future, they may not work,” explains Bradley-Springer, who also is a professor of nursing at the University of Colorado, “and eventually, they are going to run out of choices.”

There is also a cost issue. When people ignore the manifestations of HIV and AIDS, they often show up in the emergency department, feeling weak and short of breath, and often in severe pain.

“Unfortunately, this happens more than it should. This is not an emergency, it’s a chronic disease,” she says. “You frequently find out you’re infected when you’re really sick. But when you’re really sick, the drugs don’t work very well.”

So as with any chronic condition, she adds, prevention is best. Health care providers who work with people from Mexico have a responsibility to learn more about HIV and reach out to those who may be at risk of falling through the cracks, especially in those states along the US–Mexico border.

“We should all be able to share our information and education,” Donohoe says. “Hopefully, one day our two countries are going to be more communicative.”        

At any given time, federal experts estimate, approximately 10% of the population of Mexico is living in the United States. And plenty of Americans are going to Mexico, too: An estimated 50 million pedestrians and 200 million cars cross the border each year.

Unfortunately, infectious diseases cross the border between the countries as well. That is why, in 1988, the US government established the US–Mexico Border AIDS ­Education Steering Team (UMBAST). The organization has AIDS Education Training Centers (AETC) in the border states of Arizona, California, Texas, and New Mexico.

Clinicians who run these UMBAST centers provide CE/CME training modules and resources for physicians, advanced practice nurses, and physician assistants, to help them improve continuity of care for migrant patients who cross between the US and Mexico (as well as those who come to the US from and return to other countries in Central and South America).

Creating Continuity
A health care provider’s most important goal is to make sure there are no gaps in services, even when the patient leaves the US to return to their native country.

“We started this program because [at the time] AIDS was a new disease and nobody knew anything about it,” says Lucy Bradley-Springer, PhD, RN, ACRN, FAAN, principal investigator for the Mountain Plains AETC in Denver.

Now, although much more is known, educational and training programs for PAs and NPs do not always focus much on HIV and AIDS. To enhance their education, clinicians who treat patients with HIV and AIDS may need to seek additional training on their own.

That’s where UMBAST comes in. The organization offers CE/CME training courses and online modules. The agency’s Web site (www.AETCborderhealth.org) also provides detailed information on caring for HIV-infected patients from Mexico and Central or South America.

Fact sheets in both English and Spanish offer information on available services and associated costs of HIV and AIDS treatment in Mexico, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama—as well as what documentation patients will need when they return to their native country, and contact information (Web sites and often phone numbers) for services that can connect patients to clinics and hospitals back home, before they leave the US.

Also available online are a slide presentation addressing continuity of care for patients with HIV who are returning to Mexico, and a chart showing which antiviral medications are available in the US and in Mexico, with the generic and brand names used in each country. There are also reports containing epidemiologic and demographic data on HIV/AIDS.

How It’s Done in Mexico
One of the most valuable lessons is how the Mexican health care system works.

“No two countries share as many people and no two countries have a border that is crossed as frequently as the US and Mexico,” says Tom Donohoe, MBA, a family practice professor at the University of California–Los Angeles’ David Geffen School of Medicine. “It’s good for both countries if we know how health care works.”

Many people don’t realize that Mexico now has a government-run health care program, Seguro Popular. Any Mexican citizen who is not insured by an employer can access care under this system.

“If somebody is working with a client who is returning to Mexico and they happen to have HIV, then they will have access to antiretroviral medications,” says Donohoe, the director and principal investigator for the UCLA training center.

Donohoe often encounters health care providers who don’t believe HIV medication is even available in Mexico. “Those stories were probably true 10 years ago,” he says. “But they’re not very true any more.”

In fact, Mexico now has dedicated outpatient HIV clinics in each state, which are staffed by trained and qualified nurses and doctors.

When Mexican patients are preparing to return to their home country, clinicians should make sure they have the name and contact information for an HIV clinic in Mexico, copies of their lab work, and an adequate supply of medication, plus the proper citizen ID cards to sign up for health care programs, says Bradley-Springer. (Again, see www.AETCborderhealth.org for salient details.)

Display Simpatico
A big part of being an effective caregiver entails understanding the cultural issues involved in migrant care.

“This is a public health issue, but it is also a personal issue,” Bradley-Springer says. “People are not getting the care they need.”

First of all, few clinics in the US are willing to care for immigrants who do not have health insurance. Sometimes, even if a clinic is available, immigrants are afraid to seek care because they are in the country illegally.

“They are discriminated against because they’re Hispanic, because they are poor, and now [because] they have HIV,” Bradley-Springer says. “A lot of times immigrants don’t have access to health care services—and when they do, they are scared of being deported.”

If the patient does make it to a clinic, talking about HIV and AIDS can be sensitive, particularly for men from Mexico or Central or South America.

“A lot of health care providers have trouble dealing with the different cultures that come through their door,” Bradley-Springer says. “If you don’t speak Spanish and you don’t understand the concept of machismo, and you have no idea what health care is like in Mexico, then that makes it harder.”

Meanwhile, it can be frustrating to start making progress with a patient, only to have them leave the country and return to Mexico, Panama, or Honduras. But knowing you connected that patient with good care back home brings peace of mind.

“We’re trying to help our clinicians help their patients get the services when they need them,” Bradley-Springer says.

Consequences of Failure
If that connection doesn’t happen, what’s at stake? Despite progress, many HIV-infected immigrants aren’t aware of the significance of the symptoms they are experiencing.

For example, they will feel fatigue but will work right through it, Bradley-Springer explains. If they do not start antiretroviral drugs soon enough, she adds, they will have a greater viral load and will be more likely to spread the infection to others.

Another important aspect of caring for a migrant patient with HIV is the need to emphasize medication compliance.

“They need to know if they stop taking these drugs and then start taking them again sometime in the future, they may not work,” explains Bradley-Springer, who also is a professor of nursing at the University of Colorado, “and eventually, they are going to run out of choices.”

There is also a cost issue. When people ignore the manifestations of HIV and AIDS, they often show up in the emergency department, feeling weak and short of breath, and often in severe pain.

“Unfortunately, this happens more than it should. This is not an emergency, it’s a chronic disease,” she says. “You frequently find out you’re infected when you’re really sick. But when you’re really sick, the drugs don’t work very well.”

So as with any chronic condition, she adds, prevention is best. Health care providers who work with people from Mexico have a responsibility to learn more about HIV and reach out to those who may be at risk of falling through the cracks, especially in those states along the US–Mexico border.

“We should all be able to share our information and education,” Donohoe says. “Hopefully, one day our two countries are going to be more communicative.”        

At any given time, federal experts estimate, approximately 10% of the population of Mexico is living in the United States. And plenty of Americans are going to Mexico, too: An estimated 50 million pedestrians and 200 million cars cross the border each year.

Unfortunately, infectious diseases cross the border between the countries as well. That is why, in 1988, the US government established the US–Mexico Border AIDS ­Education Steering Team (UMBAST). The organization has AIDS Education Training Centers (AETC) in the border states of Arizona, California, Texas, and New Mexico.

Clinicians who run these UMBAST centers provide CE/CME training modules and resources for physicians, advanced practice nurses, and physician assistants, to help them improve continuity of care for migrant patients who cross between the US and Mexico (as well as those who come to the US from and return to other countries in Central and South America).

Creating Continuity
A health care provider’s most important goal is to make sure there are no gaps in services, even when the patient leaves the US to return to their native country.

“We started this program because [at the time] AIDS was a new disease and nobody knew anything about it,” says Lucy Bradley-Springer, PhD, RN, ACRN, FAAN, principal investigator for the Mountain Plains AETC in Denver.

Now, although much more is known, educational and training programs for PAs and NPs do not always focus much on HIV and AIDS. To enhance their education, clinicians who treat patients with HIV and AIDS may need to seek additional training on their own.

That’s where UMBAST comes in. The organization offers CE/CME training courses and online modules. The agency’s Web site (www.AETCborderhealth.org) also provides detailed information on caring for HIV-infected patients from Mexico and Central or South America.

Fact sheets in both English and Spanish offer information on available services and associated costs of HIV and AIDS treatment in Mexico, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama—as well as what documentation patients will need when they return to their native country, and contact information (Web sites and often phone numbers) for services that can connect patients to clinics and hospitals back home, before they leave the US.

Also available online are a slide presentation addressing continuity of care for patients with HIV who are returning to Mexico, and a chart showing which antiviral medications are available in the US and in Mexico, with the generic and brand names used in each country. There are also reports containing epidemiologic and demographic data on HIV/AIDS.

How It’s Done in Mexico
One of the most valuable lessons is how the Mexican health care system works.

“No two countries share as many people and no two countries have a border that is crossed as frequently as the US and Mexico,” says Tom Donohoe, MBA, a family practice professor at the University of California–Los Angeles’ David Geffen School of Medicine. “It’s good for both countries if we know how health care works.”

Many people don’t realize that Mexico now has a government-run health care program, Seguro Popular. Any Mexican citizen who is not insured by an employer can access care under this system.

“If somebody is working with a client who is returning to Mexico and they happen to have HIV, then they will have access to antiretroviral medications,” says Donohoe, the director and principal investigator for the UCLA training center.

Donohoe often encounters health care providers who don’t believe HIV medication is even available in Mexico. “Those stories were probably true 10 years ago,” he says. “But they’re not very true any more.”

In fact, Mexico now has dedicated outpatient HIV clinics in each state, which are staffed by trained and qualified nurses and doctors.

When Mexican patients are preparing to return to their home country, clinicians should make sure they have the name and contact information for an HIV clinic in Mexico, copies of their lab work, and an adequate supply of medication, plus the proper citizen ID cards to sign up for health care programs, says Bradley-Springer. (Again, see www.AETCborderhealth.org for salient details.)

Display Simpatico
A big part of being an effective caregiver entails understanding the cultural issues involved in migrant care.

“This is a public health issue, but it is also a personal issue,” Bradley-Springer says. “People are not getting the care they need.”

First of all, few clinics in the US are willing to care for immigrants who do not have health insurance. Sometimes, even if a clinic is available, immigrants are afraid to seek care because they are in the country illegally.

“They are discriminated against because they’re Hispanic, because they are poor, and now [because] they have HIV,” Bradley-Springer says. “A lot of times immigrants don’t have access to health care services—and when they do, they are scared of being deported.”

If the patient does make it to a clinic, talking about HIV and AIDS can be sensitive, particularly for men from Mexico or Central or South America.

“A lot of health care providers have trouble dealing with the different cultures that come through their door,” Bradley-Springer says. “If you don’t speak Spanish and you don’t understand the concept of machismo, and you have no idea what health care is like in Mexico, then that makes it harder.”

Meanwhile, it can be frustrating to start making progress with a patient, only to have them leave the country and return to Mexico, Panama, or Honduras. But knowing you connected that patient with good care back home brings peace of mind.

“We’re trying to help our clinicians help their patients get the services when they need them,” Bradley-Springer says.

Consequences of Failure
If that connection doesn’t happen, what’s at stake? Despite progress, many HIV-infected immigrants aren’t aware of the significance of the symptoms they are experiencing.

For example, they will feel fatigue but will work right through it, Bradley-Springer explains. If they do not start antiretroviral drugs soon enough, she adds, they will have a greater viral load and will be more likely to spread the infection to others.

Another important aspect of caring for a migrant patient with HIV is the need to emphasize medication compliance.

“They need to know if they stop taking these drugs and then start taking them again sometime in the future, they may not work,” explains Bradley-Springer, who also is a professor of nursing at the University of Colorado, “and eventually, they are going to run out of choices.”

There is also a cost issue. When people ignore the manifestations of HIV and AIDS, they often show up in the emergency department, feeling weak and short of breath, and often in severe pain.

“Unfortunately, this happens more than it should. This is not an emergency, it’s a chronic disease,” she says. “You frequently find out you’re infected when you’re really sick. But when you’re really sick, the drugs don’t work very well.”

So as with any chronic condition, she adds, prevention is best. Health care providers who work with people from Mexico have a responsibility to learn more about HIV and reach out to those who may be at risk of falling through the cracks, especially in those states along the US–Mexico border.

“We should all be able to share our information and education,” Donohoe says. “Hopefully, one day our two countries are going to be more communicative.”        

Primary care providers spend much of their workday trying to help patients with depression. What many clinicians do not realize, however, is that an estimated two-thirds of patients have a suboptimal response to antidepressants.

These patients—and those with several other conditions, ranging from HIV to Alzheimer’s disease—may benefit from medical foods, a growing trend in medicine. As more companies bring such products to market, health care providers are gradually incorporating them into their day-to-day practice.

These products are not traditional drugs, and yet they are stronger than vitamins and dietary supplements. They are regulated under the FDA’s Orphan Drug program. Consumers can use them only if they have a prescription.

Nurse practitioners and physician assistants can prescribe medical foods, just as they can most drugs. “We clinicians need more and more tools to help our patients,” says Rakesh Jain, MD, MPH, a psychiatrist in Lake Jackson, Texas. “If this will bring someone out of a depression sooner, of course I’m going to use it.”

“It Certainly Can’t Hurt”
Recent research has shown that patients with depression who experience persistent symptoms may have insufficient levels of folate in the brain. For patients who have not achieved sufficient response to antidepressants, Jain, Director of Psychiatric Drug Research at R/D Clinical Research Center in Lake Jackson, often prescribes a product called Deplin^®, made by Louisiana-based Pamlab.

Deplin, described as an augmentation to depression treatment, is a trimonoamine modulator. Its active ingredient, L-methylfolate, is the only active form of folate that can cross the blood-brain barrier, and regulates the synthesis of serotonin, norepinephrine, and dopamine. Deplin essentially helps to boost levels of folate in a patient’s brain; the folate, in turn, helps to activate the neurotransmitters in the brain that are associated with mood.

Studies have demonstrated that when folate levels rise, patients start to feel better within a few weeks or months. That’s because their brain is able to access the benefits of their antidepressant medication more effectively.

“If I’m sitting in front of a patient who is suffering at work and suffering at home, I will try Deplin,” Jain says. “The data do predict they will have a better response.” And since patients have not reported any adverse effects, it certainly can’t hurt to try it, he adds.

Sometimes patients wonder if they can just eat more green vegetables, such as spinach. But Jain says these patients’ folate deficits are so great that they would have to eat bags and bags of spinach every day to make up for it. Instead, Deplin offers a highly concentrated dose of the ingredient.

Details about Deplin and its effect in patients with depression can be found at www.deplin.com.

An “Elegantly Simple” Approach to Alzheimer’s
In the Rocky Mountains of Colorado, a Broomfield-based company, Accera, focuses on medical foods for central nervous system disorders, such as Alzheimer’s disease and Parkinson’s disease. Clinical studies show their new medical food product, Axona™, can significantly improve cognitive functioning and memory in patients with mild to moderate Alzheimer’s disease.

Scientists who developed the product knew that one cause of Alzheimer’s disease is the brain’s reduced ability to properly metabolize glucose. The resulting glucose deficits lead to symptoms such as memory loss.

As the body digests Axona, it causes the liver to produce extra ketones, compounds that occur naturally in the body. In a brain with insufficient glucose, ketones provide an “alternative energy source” that helps the brain continue to function despite the deficit.

Accera CEO Steve Orndorff, PhD, and company cofounder Sam Henderson, PhD, both had a personal interest in finding better therapies for Alzheimer’s disease: They both had seen parents and grandparents develop the condition and try to live with it. “We saw the need firsthand,” Orndorff says.

Henderson, who was conducting research on the genetics of aging at the University of Colorado at Boulder, showed Orndorff data from several NIH studies that showed ketones have a neuroprotective effect. “He thought if we give patients these medium-chain triglycerides, the body will produce ketones and it will basically rescue those cells from the hypometabolism of glucose,” Orndorff explains. “It’s an elegantly simple approach to the disease.”

If the brain is allowed to function with a deficient amount of glucose, Orndorff adds, neurons begin to die—and memory loss begins. That is why the ketones are so essential for prevention of this form of dementia.

The two scientists formed their company in 2001 and brought Axona to the market in March 2009. A clinical trial of their product yielded very positive results. Patients who took Axona (in the form of a sweet drink packet) had a sevenfold improvement on cognitive function tests. By comparison, Orndorff says, patients using Alzheimer’s disease drugs currently on the market tend to experience about a 2.7-fold improvement. “We were more than double the efficacy of those drugs,” he explains.

To put those figures in perspective, Orndorff points out that the typical patient with mild to moderate Alzheimer’s disease will demonstrate a decline of 5 to 10 points a year, on average, on those same cognitive function tests. “So with a seven-point improvement, you’re looking at delaying that disease by a whole year,” he says.

While no specific data are available yet, Axona also appears to prevent other types of early age-related memory loss, Orndorff says.

Accera currently is reaching out to clinicians across the country to educate them about their product. More information is available in the provider section of their Web site, www.accerapharma.com.

“It Really Does Help” Memory Impairment
Meanwhile, clinicians with large populations of elderly patients are seeing good results with another medical food product from Pamlab, called Cerefolin^®. It is designed to help patients combat the forgetfulness typically associated with aging (also known as age-associated memory impairment). Like Deplin, Cerefolin contains high doses of folate, in a form that is easier for the body to metabolize.

Bennett Machanic, MD, a neurologist and associate clinical professor at the University of Colorado, turned to medical foods, in part, because he was not happy with the choice of conventional drugs on the market for patients with premature memory loss. “At best, there is a modest benefit from those medicines, but they are not cures,” he says.

Machanic typically tries Cere-folin for any patient who comes in with an elevated level of homocysteine. “I figure at the very worst, it’s harmless, and at the very best, it may improve memory, cognition, and behavior,” Machanic says. “Families are telling me it really does help.”

Word is spreading slowly through the medical community, Machanic says. But once clinicians learn about medical foods like Cerefolin, they are convinced, he adds. “There are physicians across the country who are taking it themselves” to slow memory loss, he says. “Many of these people feel they can prevent Alzheimer’s by taking this (although there is no shred of evidence to prove it). They just feel they are mentally sharper when they take it.”

For details on Cerefolin dosages and prescribing, visit www.pamlabs.com.

“The Perfect Drugs” for Neuropathy?
Diabetic neuropathy is another area in which medical foods can offer patients some new hope. Studies show they can also cut costs by reducing the need for pricey conventional treatments.

Diabetic neuropathy can be very dangerous for diabetic patients because they lose sensation in their feet and legs. Falls become increasingly common, and if they step on a nail, they might not feel the warning signals of pain and the wound can become infected. Too often, that leads patients to lose a toe or an entire limb.

Like Machanic, Dorothy Merritt, MD, an internal medicine provider in Texas City, Texas, turned to medical foods out of frustration. Merritt says her practice has a high percentage of diabetic patients, many with neuropathy. While most clinicians treat this painful condition with antiseizure drugs, the conventional treatments are not very effective, Merritt says. They also have many troublesome adverse effects. “They cause a lot of sedation,” she adds.

Merritt confesses she was aware of medical foods for two years before she started prescribing them. “I let them sit on the shelf,” she says.

But when she read an NIH article about the gene MTHSR, she realized nearly half of all Americans have a genetic inability to process the folate in the foods they eat. Even if they take vitamins like B12 and folic acid, their bodies cannot convert these substances into a
usable form, Merritt explains. “This gene is easy to test for, and 90% of the people in my practice have it,” she says.

Medical foods like Metanx^® (another product from Pamlab) and Cerefolin offer folate in a more bioavailable form that the body can use, even if the patient has this genetic defect. Metanx, in particular, has been shown to be effective in reducing the pain and numbness associated with diabetic neuropathy. “Metanx restores their nervous system,” Merritt says.

Medical foods have dramatically changed the way Merritt practices medicine. She jokes that her drug reps thought she had retired because she and the two PAs on her staff are now writing about half as many prescriptions for conventional drugs as they once were.

“I like these medical foods because they get down to heal the basis of what is making people ill (instead of masking the symptoms),” Merritt says, adding that these agents seem to have very few adverse effects. “From a clinical point of view, they are the perfect drugs.”

Primary care providers spend much of their workday trying to help patients with depression. What many clinicians do not realize, however, is that an estimated two-thirds of patients have a suboptimal response to antidepressants.

These patients—and those with several other conditions, ranging from HIV to Alzheimer’s disease—may benefit from medical foods, a growing trend in medicine. As more companies bring such products to market, health care providers are gradually incorporating them into their day-to-day practice.

These products are not traditional drugs, and yet they are stronger than vitamins and dietary supplements. They are regulated under the FDA’s Orphan Drug program. Consumers can use them only if they have a prescription.

Nurse practitioners and physician assistants can prescribe medical foods, just as they can most drugs. “We clinicians need more and more tools to help our patients,” says Rakesh Jain, MD, MPH, a psychiatrist in Lake Jackson, Texas. “If this will bring someone out of a depression sooner, of course I’m going to use it.”

“It Certainly Can’t Hurt”
Recent research has shown that patients with depression who experience persistent symptoms may have insufficient levels of folate in the brain. For patients who have not achieved sufficient response to antidepressants, Jain, Director of Psychiatric Drug Research at R/D Clinical Research Center in Lake Jackson, often prescribes a product called Deplin^®, made by Louisiana-based Pamlab.

Deplin, described as an augmentation to depression treatment, is a trimonoamine modulator. Its active ingredient, L-methylfolate, is the only active form of folate that can cross the blood-brain barrier, and regulates the synthesis of serotonin, norepinephrine, and dopamine. Deplin essentially helps to boost levels of folate in a patient’s brain; the folate, in turn, helps to activate the neurotransmitters in the brain that are associated with mood.

Studies have demonstrated that when folate levels rise, patients start to feel better within a few weeks or months. That’s because their brain is able to access the benefits of their antidepressant medication more effectively.

“If I’m sitting in front of a patient who is suffering at work and suffering at home, I will try Deplin,” Jain says. “The data do predict they will have a better response.” And since patients have not reported any adverse effects, it certainly can’t hurt to try it, he adds.

Sometimes patients wonder if they can just eat more green vegetables, such as spinach. But Jain says these patients’ folate deficits are so great that they would have to eat bags and bags of spinach every day to make up for it. Instead, Deplin offers a highly concentrated dose of the ingredient.

Details about Deplin and its effect in patients with depression can be found at www.deplin.com.

An “Elegantly Simple” Approach to Alzheimer’s
In the Rocky Mountains of Colorado, a Broomfield-based company, Accera, focuses on medical foods for central nervous system disorders, such as Alzheimer’s disease and Parkinson’s disease. Clinical studies show their new medical food product, Axona™, can significantly improve cognitive functioning and memory in patients with mild to moderate Alzheimer’s disease.

Scientists who developed the product knew that one cause of Alzheimer’s disease is the brain’s reduced ability to properly metabolize glucose. The resulting glucose deficits lead to symptoms such as memory loss.

As the body digests Axona, it causes the liver to produce extra ketones, compounds that occur naturally in the body. In a brain with insufficient glucose, ketones provide an “alternative energy source” that helps the brain continue to function despite the deficit.

Accera CEO Steve Orndorff, PhD, and company cofounder Sam Henderson, PhD, both had a personal interest in finding better therapies for Alzheimer’s disease: They both had seen parents and grandparents develop the condition and try to live with it. “We saw the need firsthand,” Orndorff says.

Henderson, who was conducting research on the genetics of aging at the University of Colorado at Boulder, showed Orndorff data from several NIH studies that showed ketones have a neuroprotective effect. “He thought if we give patients these medium-chain triglycerides, the body will produce ketones and it will basically rescue those cells from the hypometabolism of glucose,” Orndorff explains. “It’s an elegantly simple approach to the disease.”

If the brain is allowed to function with a deficient amount of glucose, Orndorff adds, neurons begin to die—and memory loss begins. That is why the ketones are so essential for prevention of this form of dementia.

The two scientists formed their company in 2001 and brought Axona to the market in March 2009. A clinical trial of their product yielded very positive results. Patients who took Axona (in the form of a sweet drink packet) had a sevenfold improvement on cognitive function tests. By comparison, Orndorff says, patients using Alzheimer’s disease drugs currently on the market tend to experience about a 2.7-fold improvement. “We were more than double the efficacy of those drugs,” he explains.

To put those figures in perspective, Orndorff points out that the typical patient with mild to moderate Alzheimer’s disease will demonstrate a decline of 5 to 10 points a year, on average, on those same cognitive function tests. “So with a seven-point improvement, you’re looking at delaying that disease by a whole year,” he says.

While no specific data are available yet, Axona also appears to prevent other types of early age-related memory loss, Orndorff says.

Accera currently is reaching out to clinicians across the country to educate them about their product. More information is available in the provider section of their Web site, www.accerapharma.com.

“It Really Does Help” Memory Impairment
Meanwhile, clinicians with large populations of elderly patients are seeing good results with another medical food product from Pamlab, called Cerefolin^®. It is designed to help patients combat the forgetfulness typically associated with aging (also known as age-associated memory impairment). Like Deplin, Cerefolin contains high doses of folate, in a form that is easier for the body to metabolize.

Bennett Machanic, MD, a neurologist and associate clinical professor at the University of Colorado, turned to medical foods, in part, because he was not happy with the choice of conventional drugs on the market for patients with premature memory loss. “At best, there is a modest benefit from those medicines, but they are not cures,” he says.

Machanic typically tries Cere-folin for any patient who comes in with an elevated level of homocysteine. “I figure at the very worst, it’s harmless, and at the very best, it may improve memory, cognition, and behavior,” Machanic says. “Families are telling me it really does help.”

Word is spreading slowly through the medical community, Machanic says. But once clinicians learn about medical foods like Cerefolin, they are convinced, he adds. “There are physicians across the country who are taking it themselves” to slow memory loss, he says. “Many of these people feel they can prevent Alzheimer’s by taking this (although there is no shred of evidence to prove it). They just feel they are mentally sharper when they take it.”

For details on Cerefolin dosages and prescribing, visit www.pamlabs.com.

“The Perfect Drugs” for Neuropathy?
Diabetic neuropathy is another area in which medical foods can offer patients some new hope. Studies show they can also cut costs by reducing the need for pricey conventional treatments.

Diabetic neuropathy can be very dangerous for diabetic patients because they lose sensation in their feet and legs. Falls become increasingly common, and if they step on a nail, they might not feel the warning signals of pain and the wound can become infected. Too often, that leads patients to lose a toe or an entire limb.

Like Machanic, Dorothy Merritt, MD, an internal medicine provider in Texas City, Texas, turned to medical foods out of frustration. Merritt says her practice has a high percentage of diabetic patients, many with neuropathy. While most clinicians treat this painful condition with antiseizure drugs, the conventional treatments are not very effective, Merritt says. They also have many troublesome adverse effects. “They cause a lot of sedation,” she adds.

Merritt confesses she was aware of medical foods for two years before she started prescribing them. “I let them sit on the shelf,” she says.

But when she read an NIH article about the gene MTHSR, she realized nearly half of all Americans have a genetic inability to process the folate in the foods they eat. Even if they take vitamins like B12 and folic acid, their bodies cannot convert these substances into a
usable form, Merritt explains. “This gene is easy to test for, and 90% of the people in my practice have it,” she says.

Medical foods like Metanx^® (another product from Pamlab) and Cerefolin offer folate in a more bioavailable form that the body can use, even if the patient has this genetic defect. Metanx, in particular, has been shown to be effective in reducing the pain and numbness associated with diabetic neuropathy. “Metanx restores their nervous system,” Merritt says.

Medical foods have dramatically changed the way Merritt practices medicine. She jokes that her drug reps thought she had retired because she and the two PAs on her staff are now writing about half as many prescriptions for conventional drugs as they once were.

“I like these medical foods because they get down to heal the basis of what is making people ill (instead of masking the symptoms),” Merritt says, adding that these agents seem to have very few adverse effects. “From a clinical point of view, they are the perfect drugs.”

Primary care providers spend much of their workday trying to help patients with depression. What many clinicians do not realize, however, is that an estimated two-thirds of patients have a suboptimal response to antidepressants.

These patients—and those with several other conditions, ranging from HIV to Alzheimer’s disease—may benefit from medical foods, a growing trend in medicine. As more companies bring such products to market, health care providers are gradually incorporating them into their day-to-day practice.

These products are not traditional drugs, and yet they are stronger than vitamins and dietary supplements. They are regulated under the FDA’s Orphan Drug program. Consumers can use them only if they have a prescription.

Nurse practitioners and physician assistants can prescribe medical foods, just as they can most drugs. “We clinicians need more and more tools to help our patients,” says Rakesh Jain, MD, MPH, a psychiatrist in Lake Jackson, Texas. “If this will bring someone out of a depression sooner, of course I’m going to use it.”

“It Certainly Can’t Hurt”
Recent research has shown that patients with depression who experience persistent symptoms may have insufficient levels of folate in the brain. For patients who have not achieved sufficient response to antidepressants, Jain, Director of Psychiatric Drug Research at R/D Clinical Research Center in Lake Jackson, often prescribes a product called Deplin^®, made by Louisiana-based Pamlab.

Deplin, described as an augmentation to depression treatment, is a trimonoamine modulator. Its active ingredient, L-methylfolate, is the only active form of folate that can cross the blood-brain barrier, and regulates the synthesis of serotonin, norepinephrine, and dopamine. Deplin essentially helps to boost levels of folate in a patient’s brain; the folate, in turn, helps to activate the neurotransmitters in the brain that are associated with mood.

Studies have demonstrated that when folate levels rise, patients start to feel better within a few weeks or months. That’s because their brain is able to access the benefits of their antidepressant medication more effectively.

“If I’m sitting in front of a patient who is suffering at work and suffering at home, I will try Deplin,” Jain says. “The data do predict they will have a better response.” And since patients have not reported any adverse effects, it certainly can’t hurt to try it, he adds.

Sometimes patients wonder if they can just eat more green vegetables, such as spinach. But Jain says these patients’ folate deficits are so great that they would have to eat bags and bags of spinach every day to make up for it. Instead, Deplin offers a highly concentrated dose of the ingredient.

Details about Deplin and its effect in patients with depression can be found at www.deplin.com.

An “Elegantly Simple” Approach to Alzheimer’s
In the Rocky Mountains of Colorado, a Broomfield-based company, Accera, focuses on medical foods for central nervous system disorders, such as Alzheimer’s disease and Parkinson’s disease. Clinical studies show their new medical food product, Axona™, can significantly improve cognitive functioning and memory in patients with mild to moderate Alzheimer’s disease.

Scientists who developed the product knew that one cause of Alzheimer’s disease is the brain’s reduced ability to properly metabolize glucose. The resulting glucose deficits lead to symptoms such as memory loss.

As the body digests Axona, it causes the liver to produce extra ketones, compounds that occur naturally in the body. In a brain with insufficient glucose, ketones provide an “alternative energy source” that helps the brain continue to function despite the deficit.

Accera CEO Steve Orndorff, PhD, and company cofounder Sam Henderson, PhD, both had a personal interest in finding better therapies for Alzheimer’s disease: They both had seen parents and grandparents develop the condition and try to live with it. “We saw the need firsthand,” Orndorff says.

Henderson, who was conducting research on the genetics of aging at the University of Colorado at Boulder, showed Orndorff data from several NIH studies that showed ketones have a neuroprotective effect. “He thought if we give patients these medium-chain triglycerides, the body will produce ketones and it will basically rescue those cells from the hypometabolism of glucose,” Orndorff explains. “It’s an elegantly simple approach to the disease.”

If the brain is allowed to function with a deficient amount of glucose, Orndorff adds, neurons begin to die—and memory loss begins. That is why the ketones are so essential for prevention of this form of dementia.

The two scientists formed their company in 2001 and brought Axona to the market in March 2009. A clinical trial of their product yielded very positive results. Patients who took Axona (in the form of a sweet drink packet) had a sevenfold improvement on cognitive function tests. By comparison, Orndorff says, patients using Alzheimer’s disease drugs currently on the market tend to experience about a 2.7-fold improvement. “We were more than double the efficacy of those drugs,” he explains.

To put those figures in perspective, Orndorff points out that the typical patient with mild to moderate Alzheimer’s disease will demonstrate a decline of 5 to 10 points a year, on average, on those same cognitive function tests. “So with a seven-point improvement, you’re looking at delaying that disease by a whole year,” he says.

While no specific data are available yet, Axona also appears to prevent other types of early age-related memory loss, Orndorff says.

Accera currently is reaching out to clinicians across the country to educate them about their product. More information is available in the provider section of their Web site, www.accerapharma.com.

“It Really Does Help” Memory Impairment
Meanwhile, clinicians with large populations of elderly patients are seeing good results with another medical food product from Pamlab, called Cerefolin^®. It is designed to help patients combat the forgetfulness typically associated with aging (also known as age-associated memory impairment). Like Deplin, Cerefolin contains high doses of folate, in a form that is easier for the body to metabolize.

Bennett Machanic, MD, a neurologist and associate clinical professor at the University of Colorado, turned to medical foods, in part, because he was not happy with the choice of conventional drugs on the market for patients with premature memory loss. “At best, there is a modest benefit from those medicines, but they are not cures,” he says.

Machanic typically tries Cere-folin for any patient who comes in with an elevated level of homocysteine. “I figure at the very worst, it’s harmless, and at the very best, it may improve memory, cognition, and behavior,” Machanic says. “Families are telling me it really does help.”

Word is spreading slowly through the medical community, Machanic says. But once clinicians learn about medical foods like Cerefolin, they are convinced, he adds. “There are physicians across the country who are taking it themselves” to slow memory loss, he says. “Many of these people feel they can prevent Alzheimer’s by taking this (although there is no shred of evidence to prove it). They just feel they are mentally sharper when they take it.”

For details on Cerefolin dosages and prescribing, visit www.pamlabs.com.

“The Perfect Drugs” for Neuropathy?
Diabetic neuropathy is another area in which medical foods can offer patients some new hope. Studies show they can also cut costs by reducing the need for pricey conventional treatments.

Diabetic neuropathy can be very dangerous for diabetic patients because they lose sensation in their feet and legs. Falls become increasingly common, and if they step on a nail, they might not feel the warning signals of pain and the wound can become infected. Too often, that leads patients to lose a toe or an entire limb.

Like Machanic, Dorothy Merritt, MD, an internal medicine provider in Texas City, Texas, turned to medical foods out of frustration. Merritt says her practice has a high percentage of diabetic patients, many with neuropathy. While most clinicians treat this painful condition with antiseizure drugs, the conventional treatments are not very effective, Merritt says. They also have many troublesome adverse effects. “They cause a lot of sedation,” she adds.

Merritt confesses she was aware of medical foods for two years before she started prescribing them. “I let them sit on the shelf,” she says.

But when she read an NIH article about the gene MTHSR, she realized nearly half of all Americans have a genetic inability to process the folate in the foods they eat. Even if they take vitamins like B12 and folic acid, their bodies cannot convert these substances into a
usable form, Merritt explains. “This gene is easy to test for, and 90% of the people in my practice have it,” she says.

Medical foods like Metanx^® (another product from Pamlab) and Cerefolin offer folate in a more bioavailable form that the body can use, even if the patient has this genetic defect. Metanx, in particular, has been shown to be effective in reducing the pain and numbness associated with diabetic neuropathy. “Metanx restores their nervous system,” Merritt says.

Medical foods have dramatically changed the way Merritt practices medicine. She jokes that her drug reps thought she had retired because she and the two PAs on her staff are now writing about half as many prescriptions for conventional drugs as they once were.

“I like these medical foods because they get down to heal the basis of what is making people ill (instead of masking the symptoms),” Merritt says, adding that these agents seem to have very few adverse effects. “From a clinical point of view, they are the perfect drugs.”

On a recent day, a team of nurse practitioners from the University of Pennsylvania (UPenn) School of Nursing stopped by to visit an 80-year-old patient. She had just been discharged from the hospital, with a sheaf of prescriptions in her hand.

While visiting the patient in her home, less than 24 hours after discharge, the NPs discovered the woman had filled all but one of her prescriptions. Apparently, the pharmacy had told the woman that her insurance would not cover that medication.

So she simply didn’t fill it, even though it was an important pain medication that would ease her recovery. The NPs called the woman’s doctor and agreed on a different pain medication that would be covered, and the woman started taking it right away.

“Had we not been there, this lady would have taken most of her pills, but not this one,” says Kathleen McCauley, PhD, RN, ACNS-BC, FAAN, FAHA, an associate dean at UPenn. “She would have sat home, and her symptoms would have gotten worse and worse until she had to return to the hospital.”

SAVING MONEY, REDUCING STRESS
McCauley and the NPs are part of a long-term research project at UPenn, which focuses on keeping elderly patients out of the hospital. The concept is known as transitional care, and it has become an important part of President Obama’s health care reform plan. Prevention of hospital readmissions among Medicare patients alone could save nearly $20 billion per year, according to estimates recently published in the New England Journal of Medicine.

“Any change a patient makes—from a physician’s office to home, or from the hospital to a nursing home—those are all transitions, and those transitions don’t go very well,” says Kenneth Thorpe, PhD, chair of the Health Policy and Management Department at Emory University’s Rollins School of Public Health. “In fact, 20% of Medicare patients are readmitted within 30 days.”

Thorpe, who has been advising Washington lawmakers on ways to cut health care costs, estimates that communities could cut readmissions at least in half and save billions of dollars if they put transitional care teams, such as the UPenn group, in place.

Besides helping the local and national economy, transitional care teams can make a difference on a more personal level. Patients and families must deal with so many complex drugs and devices, from blood glucose monitors to oxygen machines and nebulizers that “it becomes a full-time job,” says Chileen Eze, BS, RN, who works for Rocky Mountain Home Health in Grand Junction, Colorado. “And they just don’t have the energy to do it, because they feel terrible.”

NPs and PAs will play a key role as this type of care comes to the forefront, experts predict, because they are team players with excellent communication skills and a broad knowledge base. “A big part of what the clinician has to do is go negotiate with the health care system on behalf of the patient,” McCauley says. “It takes tremendous sophistication and people skills.”

Mary Lou Stevens, PA-C, a hospitalist at St. Mary’s Hospital in Grand Junction, Colorado, loves her work, helping patients move successfully from hospital to home (or to a nursing home or hospice facility). “It’s a wonderful job,” she says. “It’s intellectually challenging, and I do think it’s a very good fit for a PA.”

Stevens says PAs are generally good at communicating and navigating the health care system on behalf of patients—basically seeing the big picture. In her case, Stevens became a PA after 25 years in nursing (primarily in oncology). “In this job, you are professionally growing all the time,” she says. “And it’s very satisfying.”

MODELS OF GOOD CARE
McCauley and her colleagues have been studying the “Naylor model” of transitional care—named for Mary Naylor, PhD, FAAN, RN, Director of UPenn’s New Courtland Center for Transitions and Health—in large clinical trials for 15 years. Now, they are sending advanced practice nurses and clinical nurse specialists out into the field to test the system in the real world. They are working through large existing health plans, such as Kaiser Permanente in California.

Most of the advanced practice nurses in the program have a strong background in acute care, home care, or both. Others have a specialty in gerontology.

Their first step is to study a series of online training modules, so they can brush up on diabetes, for example, or heart failure. “Next, we pair them with experienced transitional care nurses and key physicians who understand the model,” McCauley explains. “Over time, we gradually get them to be more and more independent.”

The NPs and other clinicians in the program have a conference call every week, during which they discuss their cases. The program has built up a network of key medical experts that the transitional care teams can tap into when they run into a challenge. “We’ve gotten this network of resource people together,” McCauley says, “so they have a support system.”

Eze’s home health agency is part of a health care co-op in Grand Junction, called Rocky Mountain Health Plans. As part of their daily responsibilities, designated staff from hospitals and home health agencies share notes about which patients are in the hospital and which are coming home soon. As a result, clinicians like Eze are at a patient’s bedside, working on the transition to home before the person has even left the hospital.

“That’s one big key here in Grand Junction,” she explains. “The moment they get hospitalized and it looks like they need home care, we try to target that patient and get services in place. That’s one good link right there, and it’s a very unique one.”

During his August visit to Grand Junction for a health reform town hall meeting, President Obama praised Eze’s community for keeping more people out of the hospital by providing excellent transitional care—and cutting costs in the process.

Stevens says the physicians who created the hospitalist program at St. Mary’s in Grand Junction put a special emphasis on communication and coordination of care. For example, they have a very thorough discharge plan for each patient and they get all of the caregivers together to talk with the patient and family before the person leaves the hospital. (For more on the hospitalist side of the story, see Hoppel AM. Hospitalists: ensuring quality care. Clinician Reviews. 2009;19[8]:cover, 36-38.)

The physicians who run the program care a lot about the community, Stevens says, so they set the right tone and expect a high standard of care. “They do the right thing for the patient, for the right reasons,” she adds.

GOALS AND ROLES
One of the important lessons McCauley and her colleagues teach nurses learning to provide transitional care is to tap into a patient’s goals to motivate them to make big lifestyle changes. “This is all about coaching and helping the patients to clarify their goals,” she says.

For example, McCauley remembers a heart failure patient who was very obese and had not left the second floor of her apartment for years. All it took was one important question from an NP: “What is your goal?” It turns out the woman had a strong desire to go to church. So the NP worked with her, setting up diet and exercise programs in her home and generally giving moral support. “She got her moving and that lady actually made it to church,” McCauley recalls triumphantly. “The whole thing was driven by the patient’s goals.”

Other times, aging patients will fiercely protect their privacy. McCauley remembers one nurse who got around this by knocking on the door and saying he was there to visit the lady’s dog. “He came in, made nice with the dog, and then did everything he needed for her,” McCauley recalls.

Clinicians working in transitional care also must spend more of their time working with family caregivers. For example, there was one case in which the patient had a well-meaning son—but the transitional care team soon discovered that he had a mental illness that prevented him from being a dependable caregiver. So they brought in other home care resources to make sure the patient was taking the correct medications.

Another part of the job is being a watchdog when insurance companies mandate patients’ discharges before they are ready. Eze has seen this before. “We’ll look at them and say we can’t accept them [for transitional care] because they are too unstable,” she says. “These are the sicker people they would never have sent out of the hospital 15 years ago.”

LONG-TERM IMPACT
Health reform experts such as Emory’s Thorpe predict transitional care will become more common across the country in the next few years, as long as health plans and hospitals are willing to pay for the extra staff required. Some of the current hot spots for transitional care include UPenn, Grand Junction, and the Care Transitions Program at the University of Colorado Medical School in Denver.

Policy analysts from AARP currently are pushing for a Medicare program that will cut reimbursement rates to hospitals that readmit patients within 30 days. Other bills requiring transitional care programs are pending in Congress and may even be folded into President Obama’s health reform plan.

So it’s an exciting time for this new field, McCauley says. The question is, will decision makers think for the short term or the long term? Thorpe estimates it would take an initial investment of $25 to $30 billion to put teams of clinicians in place to provide transitional care for the entire Medicare program. On the other hand, that investment would pay for itself within the first year. And it would bring significant savings for every year after that, according to the NEJM article.

“We’ve got to pay attention to these transitions,” McCauley says. “Because this kind of revolving door—from hospital to home back to hospital—is bad for patients, it’s bad for hospitals, and it’s bad for health care in general.”

On a recent day, a team of nurse practitioners from the University of Pennsylvania (UPenn) School of Nursing stopped by to visit an 80-year-old patient. She had just been discharged from the hospital, with a sheaf of prescriptions in her hand.

While visiting the patient in her home, less than 24 hours after discharge, the NPs discovered the woman had filled all but one of her prescriptions. Apparently, the pharmacy had told the woman that her insurance would not cover that medication.

So she simply didn’t fill it, even though it was an important pain medication that would ease her recovery. The NPs called the woman’s doctor and agreed on a different pain medication that would be covered, and the woman started taking it right away.

“Had we not been there, this lady would have taken most of her pills, but not this one,” says Kathleen McCauley, PhD, RN, ACNS-BC, FAAN, FAHA, an associate dean at UPenn. “She would have sat home, and her symptoms would have gotten worse and worse until she had to return to the hospital.”

SAVING MONEY, REDUCING STRESS
McCauley and the NPs are part of a long-term research project at UPenn, which focuses on keeping elderly patients out of the hospital. The concept is known as transitional care, and it has become an important part of President Obama’s health care reform plan. Prevention of hospital readmissions among Medicare patients alone could save nearly $20 billion per year, according to estimates recently published in the New England Journal of Medicine.

“Any change a patient makes—from a physician’s office to home, or from the hospital to a nursing home—those are all transitions, and those transitions don’t go very well,” says Kenneth Thorpe, PhD, chair of the Health Policy and Management Department at Emory University’s Rollins School of Public Health. “In fact, 20% of Medicare patients are readmitted within 30 days.”

Thorpe, who has been advising Washington lawmakers on ways to cut health care costs, estimates that communities could cut readmissions at least in half and save billions of dollars if they put transitional care teams, such as the UPenn group, in place.

Besides helping the local and national economy, transitional care teams can make a difference on a more personal level. Patients and families must deal with so many complex drugs and devices, from blood glucose monitors to oxygen machines and nebulizers that “it becomes a full-time job,” says Chileen Eze, BS, RN, who works for Rocky Mountain Home Health in Grand Junction, Colorado. “And they just don’t have the energy to do it, because they feel terrible.”

NPs and PAs will play a key role as this type of care comes to the forefront, experts predict, because they are team players with excellent communication skills and a broad knowledge base. “A big part of what the clinician has to do is go negotiate with the health care system on behalf of the patient,” McCauley says. “It takes tremendous sophistication and people skills.”

Mary Lou Stevens, PA-C, a hospitalist at St. Mary’s Hospital in Grand Junction, Colorado, loves her work, helping patients move successfully from hospital to home (or to a nursing home or hospice facility). “It’s a wonderful job,” she says. “It’s intellectually challenging, and I do think it’s a very good fit for a PA.”

Stevens says PAs are generally good at communicating and navigating the health care system on behalf of patients—basically seeing the big picture. In her case, Stevens became a PA after 25 years in nursing (primarily in oncology). “In this job, you are professionally growing all the time,” she says. “And it’s very satisfying.”

MODELS OF GOOD CARE
McCauley and her colleagues have been studying the “Naylor model” of transitional care—named for Mary Naylor, PhD, FAAN, RN, Director of UPenn’s New Courtland Center for Transitions and Health—in large clinical trials for 15 years. Now, they are sending advanced practice nurses and clinical nurse specialists out into the field to test the system in the real world. They are working through large existing health plans, such as Kaiser Permanente in California.

Most of the advanced practice nurses in the program have a strong background in acute care, home care, or both. Others have a specialty in gerontology.

Their first step is to study a series of online training modules, so they can brush up on diabetes, for example, or heart failure. “Next, we pair them with experienced transitional care nurses and key physicians who understand the model,” McCauley explains. “Over time, we gradually get them to be more and more independent.”

The NPs and other clinicians in the program have a conference call every week, during which they discuss their cases. The program has built up a network of key medical experts that the transitional care teams can tap into when they run into a challenge. “We’ve gotten this network of resource people together,” McCauley says, “so they have a support system.”

Eze’s home health agency is part of a health care co-op in Grand Junction, called Rocky Mountain Health Plans. As part of their daily responsibilities, designated staff from hospitals and home health agencies share notes about which patients are in the hospital and which are coming home soon. As a result, clinicians like Eze are at a patient’s bedside, working on the transition to home before the person has even left the hospital.

“That’s one big key here in Grand Junction,” she explains. “The moment they get hospitalized and it looks like they need home care, we try to target that patient and get services in place. That’s one good link right there, and it’s a very unique one.”

During his August visit to Grand Junction for a health reform town hall meeting, President Obama praised Eze’s community for keeping more people out of the hospital by providing excellent transitional care—and cutting costs in the process.

Stevens says the physicians who created the hospitalist program at St. Mary’s in Grand Junction put a special emphasis on communication and coordination of care. For example, they have a very thorough discharge plan for each patient and they get all of the caregivers together to talk with the patient and family before the person leaves the hospital. (For more on the hospitalist side of the story, see Hoppel AM. Hospitalists: ensuring quality care. Clinician Reviews. 2009;19[8]:cover, 36-38.)

The physicians who run the program care a lot about the community, Stevens says, so they set the right tone and expect a high standard of care. “They do the right thing for the patient, for the right reasons,” she adds.

GOALS AND ROLES
One of the important lessons McCauley and her colleagues teach nurses learning to provide transitional care is to tap into a patient’s goals to motivate them to make big lifestyle changes. “This is all about coaching and helping the patients to clarify their goals,” she says.

For example, McCauley remembers a heart failure patient who was very obese and had not left the second floor of her apartment for years. All it took was one important question from an NP: “What is your goal?” It turns out the woman had a strong desire to go to church. So the NP worked with her, setting up diet and exercise programs in her home and generally giving moral support. “She got her moving and that lady actually made it to church,” McCauley recalls triumphantly. “The whole thing was driven by the patient’s goals.”

Other times, aging patients will fiercely protect their privacy. McCauley remembers one nurse who got around this by knocking on the door and saying he was there to visit the lady’s dog. “He came in, made nice with the dog, and then did everything he needed for her,” McCauley recalls.

Clinicians working in transitional care also must spend more of their time working with family caregivers. For example, there was one case in which the patient had a well-meaning son—but the transitional care team soon discovered that he had a mental illness that prevented him from being a dependable caregiver. So they brought in other home care resources to make sure the patient was taking the correct medications.

Another part of the job is being a watchdog when insurance companies mandate patients’ discharges before they are ready. Eze has seen this before. “We’ll look at them and say we can’t accept them [for transitional care] because they are too unstable,” she says. “These are the sicker people they would never have sent out of the hospital 15 years ago.”

LONG-TERM IMPACT
Health reform experts such as Emory’s Thorpe predict transitional care will become more common across the country in the next few years, as long as health plans and hospitals are willing to pay for the extra staff required. Some of the current hot spots for transitional care include UPenn, Grand Junction, and the Care Transitions Program at the University of Colorado Medical School in Denver.

Policy analysts from AARP currently are pushing for a Medicare program that will cut reimbursement rates to hospitals that readmit patients within 30 days. Other bills requiring transitional care programs are pending in Congress and may even be folded into President Obama’s health reform plan.

So it’s an exciting time for this new field, McCauley says. The question is, will decision makers think for the short term or the long term? Thorpe estimates it would take an initial investment of $25 to $30 billion to put teams of clinicians in place to provide transitional care for the entire Medicare program. On the other hand, that investment would pay for itself within the first year. And it would bring significant savings for every year after that, according to the NEJM article.

“We’ve got to pay attention to these transitions,” McCauley says. “Because this kind of revolving door—from hospital to home back to hospital—is bad for patients, it’s bad for hospitals, and it’s bad for health care in general.”

On a recent day, a team of nurse practitioners from the University of Pennsylvania (UPenn) School of Nursing stopped by to visit an 80-year-old patient. She had just been discharged from the hospital, with a sheaf of prescriptions in her hand.

While visiting the patient in her home, less than 24 hours after discharge, the NPs discovered the woman had filled all but one of her prescriptions. Apparently, the pharmacy had told the woman that her insurance would not cover that medication.

So she simply didn’t fill it, even though it was an important pain medication that would ease her recovery. The NPs called the woman’s doctor and agreed on a different pain medication that would be covered, and the woman started taking it right away.

“Had we not been there, this lady would have taken most of her pills, but not this one,” says Kathleen McCauley, PhD, RN, ACNS-BC, FAAN, FAHA, an associate dean at UPenn. “She would have sat home, and her symptoms would have gotten worse and worse until she had to return to the hospital.”

SAVING MONEY, REDUCING STRESS
McCauley and the NPs are part of a long-term research project at UPenn, which focuses on keeping elderly patients out of the hospital. The concept is known as transitional care, and it has become an important part of President Obama’s health care reform plan. Prevention of hospital readmissions among Medicare patients alone could save nearly $20 billion per year, according to estimates recently published in the New England Journal of Medicine.

“Any change a patient makes—from a physician’s office to home, or from the hospital to a nursing home—those are all transitions, and those transitions don’t go very well,” says Kenneth Thorpe, PhD, chair of the Health Policy and Management Department at Emory University’s Rollins School of Public Health. “In fact, 20% of Medicare patients are readmitted within 30 days.”

Thorpe, who has been advising Washington lawmakers on ways to cut health care costs, estimates that communities could cut readmissions at least in half and save billions of dollars if they put transitional care teams, such as the UPenn group, in place.

Besides helping the local and national economy, transitional care teams can make a difference on a more personal level. Patients and families must deal with so many complex drugs and devices, from blood glucose monitors to oxygen machines and nebulizers that “it becomes a full-time job,” says Chileen Eze, BS, RN, who works for Rocky Mountain Home Health in Grand Junction, Colorado. “And they just don’t have the energy to do it, because they feel terrible.”

NPs and PAs will play a key role as this type of care comes to the forefront, experts predict, because they are team players with excellent communication skills and a broad knowledge base. “A big part of what the clinician has to do is go negotiate with the health care system on behalf of the patient,” McCauley says. “It takes tremendous sophistication and people skills.”

Mary Lou Stevens, PA-C, a hospitalist at St. Mary’s Hospital in Grand Junction, Colorado, loves her work, helping patients move successfully from hospital to home (or to a nursing home or hospice facility). “It’s a wonderful job,” she says. “It’s intellectually challenging, and I do think it’s a very good fit for a PA.”

Stevens says PAs are generally good at communicating and navigating the health care system on behalf of patients—basically seeing the big picture. In her case, Stevens became a PA after 25 years in nursing (primarily in oncology). “In this job, you are professionally growing all the time,” she says. “And it’s very satisfying.”

MODELS OF GOOD CARE
McCauley and her colleagues have been studying the “Naylor model” of transitional care—named for Mary Naylor, PhD, FAAN, RN, Director of UPenn’s New Courtland Center for Transitions and Health—in large clinical trials for 15 years. Now, they are sending advanced practice nurses and clinical nurse specialists out into the field to test the system in the real world. They are working through large existing health plans, such as Kaiser Permanente in California.

Most of the advanced practice nurses in the program have a strong background in acute care, home care, or both. Others have a specialty in gerontology.

Their first step is to study a series of online training modules, so they can brush up on diabetes, for example, or heart failure. “Next, we pair them with experienced transitional care nurses and key physicians who understand the model,” McCauley explains. “Over time, we gradually get them to be more and more independent.”

The NPs and other clinicians in the program have a conference call every week, during which they discuss their cases. The program has built up a network of key medical experts that the transitional care teams can tap into when they run into a challenge. “We’ve gotten this network of resource people together,” McCauley says, “so they have a support system.”

Eze’s home health agency is part of a health care co-op in Grand Junction, called Rocky Mountain Health Plans. As part of their daily responsibilities, designated staff from hospitals and home health agencies share notes about which patients are in the hospital and which are coming home soon. As a result, clinicians like Eze are at a patient’s bedside, working on the transition to home before the person has even left the hospital.

“That’s one big key here in Grand Junction,” she explains. “The moment they get hospitalized and it looks like they need home care, we try to target that patient and get services in place. That’s one good link right there, and it’s a very unique one.”

During his August visit to Grand Junction for a health reform town hall meeting, President Obama praised Eze’s community for keeping more people out of the hospital by providing excellent transitional care—and cutting costs in the process.

Stevens says the physicians who created the hospitalist program at St. Mary’s in Grand Junction put a special emphasis on communication and coordination of care. For example, they have a very thorough discharge plan for each patient and they get all of the caregivers together to talk with the patient and family before the person leaves the hospital. (For more on the hospitalist side of the story, see Hoppel AM. Hospitalists: ensuring quality care. Clinician Reviews. 2009;19[8]:cover, 36-38.)

The physicians who run the program care a lot about the community, Stevens says, so they set the right tone and expect a high standard of care. “They do the right thing for the patient, for the right reasons,” she adds.

GOALS AND ROLES
One of the important lessons McCauley and her colleagues teach nurses learning to provide transitional care is to tap into a patient’s goals to motivate them to make big lifestyle changes. “This is all about coaching and helping the patients to clarify their goals,” she says.

For example, McCauley remembers a heart failure patient who was very obese and had not left the second floor of her apartment for years. All it took was one important question from an NP: “What is your goal?” It turns out the woman had a strong desire to go to church. So the NP worked with her, setting up diet and exercise programs in her home and generally giving moral support. “She got her moving and that lady actually made it to church,” McCauley recalls triumphantly. “The whole thing was driven by the patient’s goals.”

Other times, aging patients will fiercely protect their privacy. McCauley remembers one nurse who got around this by knocking on the door and saying he was there to visit the lady’s dog. “He came in, made nice with the dog, and then did everything he needed for her,” McCauley recalls.

Clinicians working in transitional care also must spend more of their time working with family caregivers. For example, there was one case in which the patient had a well-meaning son—but the transitional care team soon discovered that he had a mental illness that prevented him from being a dependable caregiver. So they brought in other home care resources to make sure the patient was taking the correct medications.

Another part of the job is being a watchdog when insurance companies mandate patients’ discharges before they are ready. Eze has seen this before. “We’ll look at them and say we can’t accept them [for transitional care] because they are too unstable,” she says. “These are the sicker people they would never have sent out of the hospital 15 years ago.”

LONG-TERM IMPACT
Health reform experts such as Emory’s Thorpe predict transitional care will become more common across the country in the next few years, as long as health plans and hospitals are willing to pay for the extra staff required. Some of the current hot spots for transitional care include UPenn, Grand Junction, and the Care Transitions Program at the University of Colorado Medical School in Denver.

Policy analysts from AARP currently are pushing for a Medicare program that will cut reimbursement rates to hospitals that readmit patients within 30 days. Other bills requiring transitional care programs are pending in Congress and may even be folded into President Obama’s health reform plan.

So it’s an exciting time for this new field, McCauley says. The question is, will decision makers think for the short term or the long term? Thorpe estimates it would take an initial investment of $25 to $30 billion to put teams of clinicians in place to provide transitional care for the entire Medicare program. On the other hand, that investment would pay for itself within the first year. And it would bring significant savings for every year after that, according to the NEJM article.

“We’ve got to pay attention to these transitions,” McCauley says. “Because this kind of revolving door—from hospital to home back to hospital—is bad for patients, it’s bad for hospitals, and it’s bad for health care in general.”

When Cleveland Clinic NP Marianne D. Harris, MS, CNP, steps into the provider role during her postdischarge cardiac surgery group, she checks pain meds, answers questions about wound care, and soothes worried caregivers. But her favorite part of running a group medical appointment comes at the end, when the patients talk among themselves about their recent bypass or valve replacement.

“It’s very affirming for them to know they’re not alone in dealing with these issues,” Harris says. “They’re getting medical management, but they’re also getting a sense of support from other patients.”

Different Skill Set
Harris has been running group appointments since 2002. Over time, this unique format has grown in popularity. At Cleveland Clinic, patient satisfaction with group appointments is about 85%.

Group appointments seem to be most effective for patients with chronic diseases, such as diabetes or congestive heart failure, says Dee Ann K. Schmucker, MSW, LCSW. Schmucker, a Sacramento, California, consultant who helps medical facilities streamline their group appointment programs, wrote a book on the topic, Group Medical Appointments: An Introduction for Health Professionals (published by Jones and Bartlett).

Schmucker says NPs and PAs are particularly suited to running group appointments because they are well trained in patient education and work well in a team. Sheldon Weiss, MD, an internist in Rockford, Illinois, acknowledges that not everyone is cut out for group appointments. For the past six years, Weiss has offered eight different groups for nearly 300 diabetes patients in his practice.

Weiss decided to try it after learning about group appointments during an Institute for Healthcare Improvement conference. He has tried to persuade some of his physician colleagues to try it, but they didn’t like it.

“It does require a different skill set—it’s facilitating and educating and being able to manage group dynamics,” Weiss explains. “I’ve noticed a lot of physicians are reluctant to step out of their usual pattern.”

How It Works
Anyone who is able to prescribe medication can run a group medical appointment, Cleveland Clinic’s Harris says. In her case, the group appointment is billed as a bundled charge, but many clinicians can bill for it directly and receive about 85% of a physician’s fee (depending on the state).

As for privacy, at Cleveland Clinic, patients must sign a HIPAA form before the group meeting, agreeing to participate in a forum in which private information will be shared among patients. Harris also asks patients to agree to keep confidential what happens during the group appointments and not to discuss them outside the office.

Both Weiss and Harris begin the group appointment by doing a short physical exam, checking vitals, looking for wound infections, and adjusting medication. While the providers are busy with the exam, the facilitator (usually an RN) chats with the other patients and jots down their concerns.

Then, the group comes together with eight to 10 patients in a big circle. Usually, Weiss opens with a certain topic for discussion: a new medication on the market or something diabetes-related that has made the news. He keeps it brief, then opens the floor to questions. The facilitator makes sure the conversation flows smoothly and finds a way to tactfully redirect any patients who are going off topic or dominating the discussion.

Like Harris, Weiss enjoys watching the patients interact. “They seem to get to know each other, and they get comfortable talking in front of each other,” Weiss says. Often, they feel other patients have more credibility because they have been through the same thing. The patients keep each other honest and inspire one another. “Some of them have even started meeting to exercise together,” he says.

Start Your Own
These group appointment experts offered some general pointers to clinicians who might be new to the process. First, they all said it was important to have a scheduling staff that is flexible and excited about the program. They will be instrumental in recruiting patients to join the group appointments.

At Weiss’ office, they schedule the groups for a Saturday. He says to just block off a few hours, set a time, and go for it. If you make time for it, the patients will come.

If one patient drops out of the group, Weiss adds, it’s important to recruit a new one right away so the group stays full and does not gradually disband.

Harris said it’s also important to avoid treating a group appointment like medical school lecture time. If you let the patients do the talking about certain health issues you want to highlight, the group members will pay more attention than they would if a health professional gets up there and drones on for an hour.

The ideal group member is someone who is learning to live with a chronic condition but hasn’t mastered it yet—someone who can benefit from being around other patients. Groups may not be ideal for very frail elderly people with vision, hearing, or mobility issues, Harris says.

Switching to a group-appointments schedule can be very helpful for a busy practice that can no longer handle drop-ins or that has an extended wait time for appointments. Instead of blocking off an entire day to see eight to 10 patients for 15 minutes each, Harris says, you can take care of those people in an hour or so and leave the rest of the day open for other patients.

“If you want to increase productivity, increase patient satisfaction, and get patients seen in a timely manner, it might be worth pursuing,” she adds.

Harris predicts group appointments will become even more popular as research demonstrating their effectiveness comes into circulation.

“I think this is a fantastic role for PAs and NPs,” she says. “It really highlights our unique contribution to medicine.”

When Cleveland Clinic NP Marianne D. Harris, MS, CNP, steps into the provider role during her postdischarge cardiac surgery group, she checks pain meds, answers questions about wound care, and soothes worried caregivers. But her favorite part of running a group medical appointment comes at the end, when the patients talk among themselves about their recent bypass or valve replacement.

“It’s very affirming for them to know they’re not alone in dealing with these issues,” Harris says. “They’re getting medical management, but they’re also getting a sense of support from other patients.”

Different Skill Set
Harris has been running group appointments since 2002. Over time, this unique format has grown in popularity. At Cleveland Clinic, patient satisfaction with group appointments is about 85%.

Group appointments seem to be most effective for patients with chronic diseases, such as diabetes or congestive heart failure, says Dee Ann K. Schmucker, MSW, LCSW. Schmucker, a Sacramento, California, consultant who helps medical facilities streamline their group appointment programs, wrote a book on the topic, Group Medical Appointments: An Introduction for Health Professionals (published by Jones and Bartlett).

Schmucker says NPs and PAs are particularly suited to running group appointments because they are well trained in patient education and work well in a team. Sheldon Weiss, MD, an internist in Rockford, Illinois, acknowledges that not everyone is cut out for group appointments. For the past six years, Weiss has offered eight different groups for nearly 300 diabetes patients in his practice.

Weiss decided to try it after learning about group appointments during an Institute for Healthcare Improvement conference. He has tried to persuade some of his physician colleagues to try it, but they didn’t like it.

“It does require a different skill set—it’s facilitating and educating and being able to manage group dynamics,” Weiss explains. “I’ve noticed a lot of physicians are reluctant to step out of their usual pattern.”

How It Works
Anyone who is able to prescribe medication can run a group medical appointment, Cleveland Clinic’s Harris says. In her case, the group appointment is billed as a bundled charge, but many clinicians can bill for it directly and receive about 85% of a physician’s fee (depending on the state).

As for privacy, at Cleveland Clinic, patients must sign a HIPAA form before the group meeting, agreeing to participate in a forum in which private information will be shared among patients. Harris also asks patients to agree to keep confidential what happens during the group appointments and not to discuss them outside the office.

Both Weiss and Harris begin the group appointment by doing a short physical exam, checking vitals, looking for wound infections, and adjusting medication. While the providers are busy with the exam, the facilitator (usually an RN) chats with the other patients and jots down their concerns.

Then, the group comes together with eight to 10 patients in a big circle. Usually, Weiss opens with a certain topic for discussion: a new medication on the market or something diabetes-related that has made the news. He keeps it brief, then opens the floor to questions. The facilitator makes sure the conversation flows smoothly and finds a way to tactfully redirect any patients who are going off topic or dominating the discussion.

Like Harris, Weiss enjoys watching the patients interact. “They seem to get to know each other, and they get comfortable talking in front of each other,” Weiss says. Often, they feel other patients have more credibility because they have been through the same thing. The patients keep each other honest and inspire one another. “Some of them have even started meeting to exercise together,” he says.

Start Your Own
These group appointment experts offered some general pointers to clinicians who might be new to the process. First, they all said it was important to have a scheduling staff that is flexible and excited about the program. They will be instrumental in recruiting patients to join the group appointments.

At Weiss’ office, they schedule the groups for a Saturday. He says to just block off a few hours, set a time, and go for it. If you make time for it, the patients will come.

If one patient drops out of the group, Weiss adds, it’s important to recruit a new one right away so the group stays full and does not gradually disband.

Harris said it’s also important to avoid treating a group appointment like medical school lecture time. If you let the patients do the talking about certain health issues you want to highlight, the group members will pay more attention than they would if a health professional gets up there and drones on for an hour.

The ideal group member is someone who is learning to live with a chronic condition but hasn’t mastered it yet—someone who can benefit from being around other patients. Groups may not be ideal for very frail elderly people with vision, hearing, or mobility issues, Harris says.

Switching to a group-appointments schedule can be very helpful for a busy practice that can no longer handle drop-ins or that has an extended wait time for appointments. Instead of blocking off an entire day to see eight to 10 patients for 15 minutes each, Harris says, you can take care of those people in an hour or so and leave the rest of the day open for other patients.

“If you want to increase productivity, increase patient satisfaction, and get patients seen in a timely manner, it might be worth pursuing,” she adds.

Harris predicts group appointments will become even more popular as research demonstrating their effectiveness comes into circulation.

“I think this is a fantastic role for PAs and NPs,” she says. “It really highlights our unique contribution to medicine.”

When Cleveland Clinic NP Marianne D. Harris, MS, CNP, steps into the provider role during her postdischarge cardiac surgery group, she checks pain meds, answers questions about wound care, and soothes worried caregivers. But her favorite part of running a group medical appointment comes at the end, when the patients talk among themselves about their recent bypass or valve replacement.

“It’s very affirming for them to know they’re not alone in dealing with these issues,” Harris says. “They’re getting medical management, but they’re also getting a sense of support from other patients.”

Different Skill Set
Harris has been running group appointments since 2002. Over time, this unique format has grown in popularity. At Cleveland Clinic, patient satisfaction with group appointments is about 85%.

Group appointments seem to be most effective for patients with chronic diseases, such as diabetes or congestive heart failure, says Dee Ann K. Schmucker, MSW, LCSW. Schmucker, a Sacramento, California, consultant who helps medical facilities streamline their group appointment programs, wrote a book on the topic, Group Medical Appointments: An Introduction for Health Professionals (published by Jones and Bartlett).

Schmucker says NPs and PAs are particularly suited to running group appointments because they are well trained in patient education and work well in a team. Sheldon Weiss, MD, an internist in Rockford, Illinois, acknowledges that not everyone is cut out for group appointments. For the past six years, Weiss has offered eight different groups for nearly 300 diabetes patients in his practice.

Weiss decided to try it after learning about group appointments during an Institute for Healthcare Improvement conference. He has tried to persuade some of his physician colleagues to try it, but they didn’t like it.

“It does require a different skill set—it’s facilitating and educating and being able to manage group dynamics,” Weiss explains. “I’ve noticed a lot of physicians are reluctant to step out of their usual pattern.”

How It Works
Anyone who is able to prescribe medication can run a group medical appointment, Cleveland Clinic’s Harris says. In her case, the group appointment is billed as a bundled charge, but many clinicians can bill for it directly and receive about 85% of a physician’s fee (depending on the state).

As for privacy, at Cleveland Clinic, patients must sign a HIPAA form before the group meeting, agreeing to participate in a forum in which private information will be shared among patients. Harris also asks patients to agree to keep confidential what happens during the group appointments and not to discuss them outside the office.

Both Weiss and Harris begin the group appointment by doing a short physical exam, checking vitals, looking for wound infections, and adjusting medication. While the providers are busy with the exam, the facilitator (usually an RN) chats with the other patients and jots down their concerns.

Then, the group comes together with eight to 10 patients in a big circle. Usually, Weiss opens with a certain topic for discussion: a new medication on the market or something diabetes-related that has made the news. He keeps it brief, then opens the floor to questions. The facilitator makes sure the conversation flows smoothly and finds a way to tactfully redirect any patients who are going off topic or dominating the discussion.

Like Harris, Weiss enjoys watching the patients interact. “They seem to get to know each other, and they get comfortable talking in front of each other,” Weiss says. Often, they feel other patients have more credibility because they have been through the same thing. The patients keep each other honest and inspire one another. “Some of them have even started meeting to exercise together,” he says.

Start Your Own
These group appointment experts offered some general pointers to clinicians who might be new to the process. First, they all said it was important to have a scheduling staff that is flexible and excited about the program. They will be instrumental in recruiting patients to join the group appointments.

At Weiss’ office, they schedule the groups for a Saturday. He says to just block off a few hours, set a time, and go for it. If you make time for it, the patients will come.

If one patient drops out of the group, Weiss adds, it’s important to recruit a new one right away so the group stays full and does not gradually disband.

Harris said it’s also important to avoid treating a group appointment like medical school lecture time. If you let the patients do the talking about certain health issues you want to highlight, the group members will pay more attention than they would if a health professional gets up there and drones on for an hour.

The ideal group member is someone who is learning to live with a chronic condition but hasn’t mastered it yet—someone who can benefit from being around other patients. Groups may not be ideal for very frail elderly people with vision, hearing, or mobility issues, Harris says.

Switching to a group-appointments schedule can be very helpful for a busy practice that can no longer handle drop-ins or that has an extended wait time for appointments. Instead of blocking off an entire day to see eight to 10 patients for 15 minutes each, Harris says, you can take care of those people in an hour or so and leave the rest of the day open for other patients.

“If you want to increase productivity, increase patient satisfaction, and get patients seen in a timely manner, it might be worth pursuing,” she adds.

Harris predicts group appointments will become even more popular as research demonstrating their effectiveness comes into circulation.

“I think this is a fantastic role for PAs and NPs,” she says. “It really highlights our unique contribution to medicine.”

As Earth Day approaches, Clinician Reviews would like to shine a spotlight on clinicians who work hard to protect patients from environmental hazards, such as lead poisoning and pesticides. Other PAs and NPs work at the national and global level to track and prevent public health threats such as West Nile virus, HIV/AIDS, and pediatric asthma.

As more people recognize the intricate link between the environment and human health, interest in public health programs is increasing, according to a recent article in the Washington Post. At least one PA program, at George Washington University, offers a joint PA/public health degree.

For clinicians who are analytical and interested in health policy and who want to “do good” for the world, getting involved in public health may be an excellent career move. Perhaps the talented colleagues profiled below will inspire others to get involved and make a difference.

How a Single Question Saved Lives
Iowa emergency department (ED) PA Mark S. Johnson, PA-C, MPAS, MT (ASCP), saved nearly 100 lives when he discovered carbon monoxide poisoning in a local apartment complex.

It all started when two Bosnian immigrants, a mother and her 20-year-old son, walked into the ED at Ottumwa Regional Medical Center with a roster of vague complaints: headache, congestion, and earache. Johnson began to treat this as a routine upper respiratory case. He had the prescription in hand, and was about to send the patients home, when something stopped him. And he is glad he paid attention to that gut feeling.

“I thought to myself, ‘Well, it’s winter in Iowa,’ and they did have headaches,” Johnson said. So, he asked a few more questions. He learned that the mother’s apartment was located right next to the furnace room. The patients also told Johnson that workers had just been repairing the furnace. This information prompted Johnson to order a carbon monoxide test for both of them.

That testing revealed slightly elevated carbon monoxide levels for both the mother and son. Johnson then asked the woman’s younger son and her boyfriend to get tested. Their CO levels were also elevated. What had started as a seemingly routine case became a more clear-cut instance of carbon monoxide exposure.

“The levels were not toxic,” Johnson recalls. “But they were high enough to cause the headaches.”

Johnson called the maintenance man at the patients’ apartment complex. He, in turn, called the gas company. Their tests revealed—sure enough—that the furnace was not working properly. Carbon monoxide levels were high throughout the three-story building.

At that point, the local fire department evacuated the building. Paramedics checked carbon monoxide levels and told residents to stay away for several hours until the building had been aired out.

For a brief while, it looked as if all 100 of the apartment building residents might be headed to the Ottumwa Regional Medical Center’s 11-bed ED for testing; Johnson was glad the fire department handled that situation in the field. “The nurses I work with would never have let me live that down,” Johnson jokes.

Johnson hopes other clinicians will hear his story and stop to consider environmental causes of illness more carefully. “Before you dismiss something, go through your differential—just as you’re taught in school,” he says. “Go through that list of things you don’t want to miss.”

For example, if a patient has already seen 20 specialists and still complains of migraines, it could be a case of carbon monoxide exposure. It makes sense to ask about his/her furnace and whether there is a carbon monoxide detector in the home.

Johnson tends to dismiss the praise and attention he’s been getting from reporters who call him a hero. “I was kind of humbled by it,” he says. “Since this happened, I appreciate my work more, and I try to take the time to really listen carefully, because it might save somebody later on. You never know.”

Recognizing The Perils of Pesticide Exposure
A few years ago, a group of clinicians was eating lunch in a small health center near Tampa, Florida. Suddenly, a steady stream of farm workers started coming in with nausea, vomiting, chest pain, and respiratory problems.

The ED snapped into triage mode, separating the sickest from the less severely ill patients, who lined the hallways. The clinicians later learned the 84 farm workers they treated were working in a cauliflower field that had recently been sprayed with the chemical Phosdrin. Thirteen of the workers who had the greatest exposure to the pesticide stayed in the hospital for a week before recovering.

While PAs and NPs are often on the front lines of care for farm workers in rural clinics across the country, they receive very little formal training about how to handle pesticide poisoning. Amy Liebman, MPA, MA, hopes to change that through her work with the Austin, Texas–based Migrant Clinicians Network (www.migrantclinician.org).

Liebman, director of the network’s occupational and environmental health initiatives, coordinates continuing education and mentorship programs for 160 different migrant health centers in the United States.

“We’re all about trying to figure out ways clinicians can better recognize, better understand, and better treat occupational and environmental exposures,” Liebman says. “It’s about working strong, and working small, to make significant changes.”

Liebman’s group encourages clinicians, when they are taking a health history, to ask migrant farm workers about their occupation, particularly whether they are exposed to any substances at work or at home that might be harmful to them.

Migrant Clinicians Network CME programs cover such topics as how to document occupational exposure for workers’ compensation claims, the long-term health effects of pesticides, and what protective gear to recommend for farm workers. The organization also helps rural providers prepare for a large emergency, such as the one in Tampa, and set up decontamination areas.

Meanwhile, Liebman’s counterpart, Helen Murphy, MHS, DrPH(c), who practiced as a family nurse practitioner before entering the public health realm, is launching a similar effort in Seattle. Instead of reaching clinicians already in the field, Murphy’s program through the Pacific Northwest Agricultural Safety and Health Center targets PAs and NPs who are still in school. A pilot project is under way at the University of Washington’s PA program and Seattle Pacific University’s NP program, among others.

Murphy’s program offers a Web site loaded with real case studies, photos, videos, and details from medical charts to give clinicians more practice in identifying pesticide-related illness before they enter the workplace. “The instructors can just go into this database,” Murphy says, “and all of the class materials will be there.”

Both projects receive funding from the US Environmental Protection Agency’s Office of Pesticides. For more information on these programs, contact Liebman at [email protected] or Murphy at [email protected].

Tracking Environmental Health Threats
Nurse practitioner Frances Medaglia doesn’t work in a traditional primary care setting. In fact, she doesn’t work in a traditional setting at all. But she does have a positive impact on the health of children in Massachusetts every day. In her position with the Massachusetts Department of Public Health’s Bureau of Environmental Health, Medaglia’s work has touched on everything from preventing prenatal exposure to chemicals to reducing childhood asthma rates and making indoor air safer for school children.

Medaglia recently became the state’s clinical coordinator for an exciting new program, funded by the CDC, that will help health care providers monitor local environmental health issues, such as cancer, lead poisoning, and air and water pollution. The program, known as the Massachusetts National Environmental Public Health Tracking Network, currently has data from 26 states. The CDC hopes eventually to include all states in the US.

“With this tool, you can see how prevalent asthma is in your county,” Medaglia says. “Maybe even down to the zip code level.”

Medaglia says she drew on her clinical background while entering all of the pediatric asthma information into the database for the entire state of Massachusetts. She gathered the data by working closely with school nurses across the state.

Medaglia’s medical training has come into play before, such as when she worked with public health staff members to analyze developmental delays in babies born near the Housatonic River. The river had been contaminated with polychlorinated biphenyls (PCBs) years earlier, so most of the staff believed that was the cause of the defects. But Medaglia found epidemiologic studies that showed pregnant women in the area had a very low rate of prenatal care. The town (Pittsfield, Massachusetts) also had a high number of women who smoked during pregnancy. Many of the homes in the area were old and had lead contamination.

“I bring something to the table that might not be thought of by the other folks,” Medaglia says. “That’s the contribution nurses can have in public health.”

From 60s Activism to the CDC
Like the current US president, Geoff Beckett, PA-C, MPH, used to be a community organizer. During the 1960s, Beckett was involved in the antiwar effort. He also encouraged people to support Cesar Chavez’s workers and boycott grapes.

Since community organizing didn’t pay well back then, Beckett took a side job as an orderly at a New Mexico hospital. That’s when he got hooked on medicine and joined one of the first PA training programs in the 1970s.

As a high-energy person, Beckett was attracted to the action-oriented pace of emergency medicine. He landed his first job at an ED in central Maine. In the 1980s, while working in a campus health center at Bowdoin College in Brunswick, Maine, Beckett set up an HIV testing program.

Around that time, some colleagues at a national PA meeting encouraged him to pursue his interest in public health. He was accepted to a master of public health program at Johns Hopkins University and found a job with the Maine Department of Public Health. Beckett stayed there for 20 happy years, tracking such health threats as Lyme disease, West Nile virus, and SARS. “I got to be involved at the local level,” he says, “kind of on the front line of these things.”

Beckett feels his medical background helped him to interact better with the physicians, nursing home directors, and ED staff members who called in with mysterious symptoms and diseases. “I’d like to say one of my major contributions was to improve those communications,” he says. “In an emergency, they could call me 24/7 and talk with someone who understands the clinical nuances.” In fact, Beckett continued to practice in a local ED while working for the department, just to keep his clinical skills fresh.

Returning to his roots as a community organizer, Beckett worked with citizen groups and elected officials to increase awareness about and promote prevention measures for Lyme disease. “I’ve been very lucky to combine my interest in clinical issues with policy,” he says.

Recently, Beckett took his career to the next level. After enrolling in a doctor of public health program at Boston University, he was offered a position as chief of the Prevention Branch for the Division of Viral Hepatitis at the CDC in Atlanta. “I got interested in international aspects of disease control,” Beckett explains, “and I decided I would like to do something that involved policy on a more national level.” Now, he travels around the country—and the world—perfecting programs that educate patients about preventing HIV and hepatitis B and evaluating ways to use vaccines most effectively.

Beckett doesn’t bump into many other PAs in the hallway at the CDC, but he thinks that day is coming. “I hope to be involved from the CDC end to promote collaboration between PA schools and public health programs,” he says. “It’s critical that they have people in health departments who can communicate with clinicians.”

To be successful at both, you need to enjoy the clinical aspects plus politics and policy, Beckett says. It helps to be motivated by a sense of social responsibility. Writing ability and feeling comfortable with public speaking also are key. “It’s great for somebody who’s been practicing for a while,” Beckett adds, “and might be looking for a new challenge.”     

As Earth Day approaches, Clinician Reviews would like to shine a spotlight on clinicians who work hard to protect patients from environmental hazards, such as lead poisoning and pesticides. Other PAs and NPs work at the national and global level to track and prevent public health threats such as West Nile virus, HIV/AIDS, and pediatric asthma.

As more people recognize the intricate link between the environment and human health, interest in public health programs is increasing, according to a recent article in the Washington Post. At least one PA program, at George Washington University, offers a joint PA/public health degree.

For clinicians who are analytical and interested in health policy and who want to “do good” for the world, getting involved in public health may be an excellent career move. Perhaps the talented colleagues profiled below will inspire others to get involved and make a difference.

How a Single Question Saved Lives
Iowa emergency department (ED) PA Mark S. Johnson, PA-C, MPAS, MT (ASCP), saved nearly 100 lives when he discovered carbon monoxide poisoning in a local apartment complex.

It all started when two Bosnian immigrants, a mother and her 20-year-old son, walked into the ED at Ottumwa Regional Medical Center with a roster of vague complaints: headache, congestion, and earache. Johnson began to treat this as a routine upper respiratory case. He had the prescription in hand, and was about to send the patients home, when something stopped him. And he is glad he paid attention to that gut feeling.

“I thought to myself, ‘Well, it’s winter in Iowa,’ and they did have headaches,” Johnson said. So, he asked a few more questions. He learned that the mother’s apartment was located right next to the furnace room. The patients also told Johnson that workers had just been repairing the furnace. This information prompted Johnson to order a carbon monoxide test for both of them.

That testing revealed slightly elevated carbon monoxide levels for both the mother and son. Johnson then asked the woman’s younger son and her boyfriend to get tested. Their CO levels were also elevated. What had started as a seemingly routine case became a more clear-cut instance of carbon monoxide exposure.

“The levels were not toxic,” Johnson recalls. “But they were high enough to cause the headaches.”

Johnson called the maintenance man at the patients’ apartment complex. He, in turn, called the gas company. Their tests revealed—sure enough—that the furnace was not working properly. Carbon monoxide levels were high throughout the three-story building.

At that point, the local fire department evacuated the building. Paramedics checked carbon monoxide levels and told residents to stay away for several hours until the building had been aired out.

For a brief while, it looked as if all 100 of the apartment building residents might be headed to the Ottumwa Regional Medical Center’s 11-bed ED for testing; Johnson was glad the fire department handled that situation in the field. “The nurses I work with would never have let me live that down,” Johnson jokes.

Johnson hopes other clinicians will hear his story and stop to consider environmental causes of illness more carefully. “Before you dismiss something, go through your differential—just as you’re taught in school,” he says. “Go through that list of things you don’t want to miss.”

For example, if a patient has already seen 20 specialists and still complains of migraines, it could be a case of carbon monoxide exposure. It makes sense to ask about his/her furnace and whether there is a carbon monoxide detector in the home.

Johnson tends to dismiss the praise and attention he’s been getting from reporters who call him a hero. “I was kind of humbled by it,” he says. “Since this happened, I appreciate my work more, and I try to take the time to really listen carefully, because it might save somebody later on. You never know.”

Recognizing The Perils of Pesticide Exposure
A few years ago, a group of clinicians was eating lunch in a small health center near Tampa, Florida. Suddenly, a steady stream of farm workers started coming in with nausea, vomiting, chest pain, and respiratory problems.

The ED snapped into triage mode, separating the sickest from the less severely ill patients, who lined the hallways. The clinicians later learned the 84 farm workers they treated were working in a cauliflower field that had recently been sprayed with the chemical Phosdrin. Thirteen of the workers who had the greatest exposure to the pesticide stayed in the hospital for a week before recovering.

While PAs and NPs are often on the front lines of care for farm workers in rural clinics across the country, they receive very little formal training about how to handle pesticide poisoning. Amy Liebman, MPA, MA, hopes to change that through her work with the Austin, Texas–based Migrant Clinicians Network (www.migrantclinician.org).

Liebman, director of the network’s occupational and environmental health initiatives, coordinates continuing education and mentorship programs for 160 different migrant health centers in the United States.

“We’re all about trying to figure out ways clinicians can better recognize, better understand, and better treat occupational and environmental exposures,” Liebman says. “It’s about working strong, and working small, to make significant changes.”

Liebman’s group encourages clinicians, when they are taking a health history, to ask migrant farm workers about their occupation, particularly whether they are exposed to any substances at work or at home that might be harmful to them.

Migrant Clinicians Network CME programs cover such topics as how to document occupational exposure for workers’ compensation claims, the long-term health effects of pesticides, and what protective gear to recommend for farm workers. The organization also helps rural providers prepare for a large emergency, such as the one in Tampa, and set up decontamination areas.

Meanwhile, Liebman’s counterpart, Helen Murphy, MHS, DrPH(c), who practiced as a family nurse practitioner before entering the public health realm, is launching a similar effort in Seattle. Instead of reaching clinicians already in the field, Murphy’s program through the Pacific Northwest Agricultural Safety and Health Center targets PAs and NPs who are still in school. A pilot project is under way at the University of Washington’s PA program and Seattle Pacific University’s NP program, among others.

Murphy’s program offers a Web site loaded with real case studies, photos, videos, and details from medical charts to give clinicians more practice in identifying pesticide-related illness before they enter the workplace. “The instructors can just go into this database,” Murphy says, “and all of the class materials will be there.”

Both projects receive funding from the US Environmental Protection Agency’s Office of Pesticides. For more information on these programs, contact Liebman at [email protected] or Murphy at [email protected].

Tracking Environmental Health Threats
Nurse practitioner Frances Medaglia doesn’t work in a traditional primary care setting. In fact, she doesn’t work in a traditional setting at all. But she does have a positive impact on the health of children in Massachusetts every day. In her position with the Massachusetts Department of Public Health’s Bureau of Environmental Health, Medaglia’s work has touched on everything from preventing prenatal exposure to chemicals to reducing childhood asthma rates and making indoor air safer for school children.

Medaglia recently became the state’s clinical coordinator for an exciting new program, funded by the CDC, that will help health care providers monitor local environmental health issues, such as cancer, lead poisoning, and air and water pollution. The program, known as the Massachusetts National Environmental Public Health Tracking Network, currently has data from 26 states. The CDC hopes eventually to include all states in the US.

“With this tool, you can see how prevalent asthma is in your county,” Medaglia says. “Maybe even down to the zip code level.”

Medaglia says she drew on her clinical background while entering all of the pediatric asthma information into the database for the entire state of Massachusetts. She gathered the data by working closely with school nurses across the state.

Medaglia’s medical training has come into play before, such as when she worked with public health staff members to analyze developmental delays in babies born near the Housatonic River. The river had been contaminated with polychlorinated biphenyls (PCBs) years earlier, so most of the staff believed that was the cause of the defects. But Medaglia found epidemiologic studies that showed pregnant women in the area had a very low rate of prenatal care. The town (Pittsfield, Massachusetts) also had a high number of women who smoked during pregnancy. Many of the homes in the area were old and had lead contamination.

“I bring something to the table that might not be thought of by the other folks,” Medaglia says. “That’s the contribution nurses can have in public health.”

From 60s Activism to the CDC
Like the current US president, Geoff Beckett, PA-C, MPH, used to be a community organizer. During the 1960s, Beckett was involved in the antiwar effort. He also encouraged people to support Cesar Chavez’s workers and boycott grapes.

Since community organizing didn’t pay well back then, Beckett took a side job as an orderly at a New Mexico hospital. That’s when he got hooked on medicine and joined one of the first PA training programs in the 1970s.

As a high-energy person, Beckett was attracted to the action-oriented pace of emergency medicine. He landed his first job at an ED in central Maine. In the 1980s, while working in a campus health center at Bowdoin College in Brunswick, Maine, Beckett set up an HIV testing program.

Around that time, some colleagues at a national PA meeting encouraged him to pursue his interest in public health. He was accepted to a master of public health program at Johns Hopkins University and found a job with the Maine Department of Public Health. Beckett stayed there for 20 happy years, tracking such health threats as Lyme disease, West Nile virus, and SARS. “I got to be involved at the local level,” he says, “kind of on the front line of these things.”

Beckett feels his medical background helped him to interact better with the physicians, nursing home directors, and ED staff members who called in with mysterious symptoms and diseases. “I’d like to say one of my major contributions was to improve those communications,” he says. “In an emergency, they could call me 24/7 and talk with someone who understands the clinical nuances.” In fact, Beckett continued to practice in a local ED while working for the department, just to keep his clinical skills fresh.

Returning to his roots as a community organizer, Beckett worked with citizen groups and elected officials to increase awareness about and promote prevention measures for Lyme disease. “I’ve been very lucky to combine my interest in clinical issues with policy,” he says.

Recently, Beckett took his career to the next level. After enrolling in a doctor of public health program at Boston University, he was offered a position as chief of the Prevention Branch for the Division of Viral Hepatitis at the CDC in Atlanta. “I got interested in international aspects of disease control,” Beckett explains, “and I decided I would like to do something that involved policy on a more national level.” Now, he travels around the country—and the world—perfecting programs that educate patients about preventing HIV and hepatitis B and evaluating ways to use vaccines most effectively.

Beckett doesn’t bump into many other PAs in the hallway at the CDC, but he thinks that day is coming. “I hope to be involved from the CDC end to promote collaboration between PA schools and public health programs,” he says. “It’s critical that they have people in health departments who can communicate with clinicians.”

To be successful at both, you need to enjoy the clinical aspects plus politics and policy, Beckett says. It helps to be motivated by a sense of social responsibility. Writing ability and feeling comfortable with public speaking also are key. “It’s great for somebody who’s been practicing for a while,” Beckett adds, “and might be looking for a new challenge.”     

As Earth Day approaches, Clinician Reviews would like to shine a spotlight on clinicians who work hard to protect patients from environmental hazards, such as lead poisoning and pesticides. Other PAs and NPs work at the national and global level to track and prevent public health threats such as West Nile virus, HIV/AIDS, and pediatric asthma.

As more people recognize the intricate link between the environment and human health, interest in public health programs is increasing, according to a recent article in the Washington Post. At least one PA program, at George Washington University, offers a joint PA/public health degree.

For clinicians who are analytical and interested in health policy and who want to “do good” for the world, getting involved in public health may be an excellent career move. Perhaps the talented colleagues profiled below will inspire others to get involved and make a difference.

How a Single Question Saved Lives
Iowa emergency department (ED) PA Mark S. Johnson, PA-C, MPAS, MT (ASCP), saved nearly 100 lives when he discovered carbon monoxide poisoning in a local apartment complex.

It all started when two Bosnian immigrants, a mother and her 20-year-old son, walked into the ED at Ottumwa Regional Medical Center with a roster of vague complaints: headache, congestion, and earache. Johnson began to treat this as a routine upper respiratory case. He had the prescription in hand, and was about to send the patients home, when something stopped him. And he is glad he paid attention to that gut feeling.

“I thought to myself, ‘Well, it’s winter in Iowa,’ and they did have headaches,” Johnson said. So, he asked a few more questions. He learned that the mother’s apartment was located right next to the furnace room. The patients also told Johnson that workers had just been repairing the furnace. This information prompted Johnson to order a carbon monoxide test for both of them.

That testing revealed slightly elevated carbon monoxide levels for both the mother and son. Johnson then asked the woman’s younger son and her boyfriend to get tested. Their CO levels were also elevated. What had started as a seemingly routine case became a more clear-cut instance of carbon monoxide exposure.

“The levels were not toxic,” Johnson recalls. “But they were high enough to cause the headaches.”

Johnson called the maintenance man at the patients’ apartment complex. He, in turn, called the gas company. Their tests revealed—sure enough—that the furnace was not working properly. Carbon monoxide levels were high throughout the three-story building.

At that point, the local fire department evacuated the building. Paramedics checked carbon monoxide levels and told residents to stay away for several hours until the building had been aired out.

For a brief while, it looked as if all 100 of the apartment building residents might be headed to the Ottumwa Regional Medical Center’s 11-bed ED for testing; Johnson was glad the fire department handled that situation in the field. “The nurses I work with would never have let me live that down,” Johnson jokes.

Johnson hopes other clinicians will hear his story and stop to consider environmental causes of illness more carefully. “Before you dismiss something, go through your differential—just as you’re taught in school,” he says. “Go through that list of things you don’t want to miss.”

For example, if a patient has already seen 20 specialists and still complains of migraines, it could be a case of carbon monoxide exposure. It makes sense to ask about his/her furnace and whether there is a carbon monoxide detector in the home.

Johnson tends to dismiss the praise and attention he’s been getting from reporters who call him a hero. “I was kind of humbled by it,” he says. “Since this happened, I appreciate my work more, and I try to take the time to really listen carefully, because it might save somebody later on. You never know.”

Recognizing The Perils of Pesticide Exposure
A few years ago, a group of clinicians was eating lunch in a small health center near Tampa, Florida. Suddenly, a steady stream of farm workers started coming in with nausea, vomiting, chest pain, and respiratory problems.

The ED snapped into triage mode, separating the sickest from the less severely ill patients, who lined the hallways. The clinicians later learned the 84 farm workers they treated were working in a cauliflower field that had recently been sprayed with the chemical Phosdrin. Thirteen of the workers who had the greatest exposure to the pesticide stayed in the hospital for a week before recovering.

While PAs and NPs are often on the front lines of care for farm workers in rural clinics across the country, they receive very little formal training about how to handle pesticide poisoning. Amy Liebman, MPA, MA, hopes to change that through her work with the Austin, Texas–based Migrant Clinicians Network (www.migrantclinician.org).

Liebman, director of the network’s occupational and environmental health initiatives, coordinates continuing education and mentorship programs for 160 different migrant health centers in the United States.

“We’re all about trying to figure out ways clinicians can better recognize, better understand, and better treat occupational and environmental exposures,” Liebman says. “It’s about working strong, and working small, to make significant changes.”

Liebman’s group encourages clinicians, when they are taking a health history, to ask migrant farm workers about their occupation, particularly whether they are exposed to any substances at work or at home that might be harmful to them.

Migrant Clinicians Network CME programs cover such topics as how to document occupational exposure for workers’ compensation claims, the long-term health effects of pesticides, and what protective gear to recommend for farm workers. The organization also helps rural providers prepare for a large emergency, such as the one in Tampa, and set up decontamination areas.

Meanwhile, Liebman’s counterpart, Helen Murphy, MHS, DrPH(c), who practiced as a family nurse practitioner before entering the public health realm, is launching a similar effort in Seattle. Instead of reaching clinicians already in the field, Murphy’s program through the Pacific Northwest Agricultural Safety and Health Center targets PAs and NPs who are still in school. A pilot project is under way at the University of Washington’s PA program and Seattle Pacific University’s NP program, among others.

Murphy’s program offers a Web site loaded with real case studies, photos, videos, and details from medical charts to give clinicians more practice in identifying pesticide-related illness before they enter the workplace. “The instructors can just go into this database,” Murphy says, “and all of the class materials will be there.”

Both projects receive funding from the US Environmental Protection Agency’s Office of Pesticides. For more information on these programs, contact Liebman at [email protected] or Murphy at [email protected].

Tracking Environmental Health Threats
Nurse practitioner Frances Medaglia doesn’t work in a traditional primary care setting. In fact, she doesn’t work in a traditional setting at all. But she does have a positive impact on the health of children in Massachusetts every day. In her position with the Massachusetts Department of Public Health’s Bureau of Environmental Health, Medaglia’s work has touched on everything from preventing prenatal exposure to chemicals to reducing childhood asthma rates and making indoor air safer for school children.

Medaglia recently became the state’s clinical coordinator for an exciting new program, funded by the CDC, that will help health care providers monitor local environmental health issues, such as cancer, lead poisoning, and air and water pollution. The program, known as the Massachusetts National Environmental Public Health Tracking Network, currently has data from 26 states. The CDC hopes eventually to include all states in the US.

“With this tool, you can see how prevalent asthma is in your county,” Medaglia says. “Maybe even down to the zip code level.”

Medaglia says she drew on her clinical background while entering all of the pediatric asthma information into the database for the entire state of Massachusetts. She gathered the data by working closely with school nurses across the state.

Medaglia’s medical training has come into play before, such as when she worked with public health staff members to analyze developmental delays in babies born near the Housatonic River. The river had been contaminated with polychlorinated biphenyls (PCBs) years earlier, so most of the staff believed that was the cause of the defects. But Medaglia found epidemiologic studies that showed pregnant women in the area had a very low rate of prenatal care. The town (Pittsfield, Massachusetts) also had a high number of women who smoked during pregnancy. Many of the homes in the area were old and had lead contamination.

“I bring something to the table that might not be thought of by the other folks,” Medaglia says. “That’s the contribution nurses can have in public health.”

From 60s Activism to the CDC
Like the current US president, Geoff Beckett, PA-C, MPH, used to be a community organizer. During the 1960s, Beckett was involved in the antiwar effort. He also encouraged people to support Cesar Chavez’s workers and boycott grapes.

Since community organizing didn’t pay well back then, Beckett took a side job as an orderly at a New Mexico hospital. That’s when he got hooked on medicine and joined one of the first PA training programs in the 1970s.

As a high-energy person, Beckett was attracted to the action-oriented pace of emergency medicine. He landed his first job at an ED in central Maine. In the 1980s, while working in a campus health center at Bowdoin College in Brunswick, Maine, Beckett set up an HIV testing program.

Around that time, some colleagues at a national PA meeting encouraged him to pursue his interest in public health. He was accepted to a master of public health program at Johns Hopkins University and found a job with the Maine Department of Public Health. Beckett stayed there for 20 happy years, tracking such health threats as Lyme disease, West Nile virus, and SARS. “I got to be involved at the local level,” he says, “kind of on the front line of these things.”

Beckett feels his medical background helped him to interact better with the physicians, nursing home directors, and ED staff members who called in with mysterious symptoms and diseases. “I’d like to say one of my major contributions was to improve those communications,” he says. “In an emergency, they could call me 24/7 and talk with someone who understands the clinical nuances.” In fact, Beckett continued to practice in a local ED while working for the department, just to keep his clinical skills fresh.

Returning to his roots as a community organizer, Beckett worked with citizen groups and elected officials to increase awareness about and promote prevention measures for Lyme disease. “I’ve been very lucky to combine my interest in clinical issues with policy,” he says.

Recently, Beckett took his career to the next level. After enrolling in a doctor of public health program at Boston University, he was offered a position as chief of the Prevention Branch for the Division of Viral Hepatitis at the CDC in Atlanta. “I got interested in international aspects of disease control,” Beckett explains, “and I decided I would like to do something that involved policy on a more national level.” Now, he travels around the country—and the world—perfecting programs that educate patients about preventing HIV and hepatitis B and evaluating ways to use vaccines most effectively.

Beckett doesn’t bump into many other PAs in the hallway at the CDC, but he thinks that day is coming. “I hope to be involved from the CDC end to promote collaboration between PA schools and public health programs,” he says. “It’s critical that they have people in health departments who can communicate with clinicians.”

To be successful at both, you need to enjoy the clinical aspects plus politics and policy, Beckett says. It helps to be motivated by a sense of social responsibility. Writing ability and feeling comfortable with public speaking also are key. “It’s great for somebody who’s been practicing for a while,” Beckett adds, “and might be looking for a new challenge.”     

Joseph Doescher and Daniel Raess worked side by side in the operating room at St. Francis Hospital in Beech Grove, Indiana. Doescher and the other perfusionists often had to put up with yelling, swearing, and belittling comments from Raess, the heart surgeon. Finally, Doescher reported the behavior to his supervisor. Raess got wind of it and retaliated.

In subsequent court proceedings, Doescher described looking up at Raess’ red face and popping veins. He was afraid Raess was going to hit him. In the end, Doescher left his job with a debilitating case of depression. Later, he sued Raess and was awarded $325,000 in compensatory (but not punitive) damages.

Shortly after the Indiana Supreme Court decided this high-profile medical case, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a safety alert, requiring hospitals to adopt a zero-tolerance policy toward workplace bullying. By January 2009, hospitals must also comply with the new disruptive behavior standard (LD.3.15). They will create new training, post a code of conduct for employees, and set up a mechanism for workers to report inappropriate outbursts.

“It’s been widely recognized that this kind of behavior goes on in health care settings,” says Peter Angood, MD, Chief Patient Safety Officer for JCAHO. “It seemed to be increasing in frequency, so we felt it was important to put standards in place.”

Perfect Targets
Researchers, including Gerald Hickson, MD, at Vanderbilt University, and Alan H. Rosenstein, MD, have shown how inappropriate workplace behavior can lead to increased legal costs and put patient safety at risk. Other studies have shown that clinicians working in a hostile environment make more errors while dispensing medication.

“If there are people in the workplace who don’t play well with others, sometimes they cause other members of the team to lose focus,” Hickson says, “and an error will occur.”

According to Gary Namie, PhD, Cofounder of the Workplace Bullying Institute in Bellingham, Washington, this issue is coming to the forefront, just as sexual harassment did about 20 years ago. Employers are starting to see training programs and prevention as a good investment. And Namie says the need is great—in all sectors of the work world. His organization conducted a survey and found that 37% of American workers say they have been victims of workplace bullying.

Health care, with its hierarchical structure of authority and caste-like training systems, is rife with this type of negative behavior. In part, Namie says, this is because there are so many caring and compassionate people in the field, who make perfect targets: They would rather help people and keep a low profile than fight back.

“It’s the people mix,” Namie says. “You’ve got just enough people with strong egos and narcissistic personalities. Then you’ve got this vast pool of targets who have an altruistic bent—they want to focus on the work itself, and they have a belief in a benevolent world. They don’t respond to aggression with aggression.”

Workplace bullies usually target a person with good social skills who is well liked, as Namie explains: “It’s usually a person with an established record who poses a threat, and the bully wants to take him or her down.”

Nurses at the Forefront
Frequently, physicians are the aggressors and nurses are the targets. In fact, a JCAHO survey found that 50% of nurses had been targets of this kind of intimidation, and 90% of nurses reported having witnessed it.

Dianne Felblinger, EdD, MSN, WHNP-BC, CNS, RN, a nursing instructor at the University of Cincinnati, believes the nursing shortage is driving some of the frustration—but also may hold the key to solving the problem.

First of all, many hospitals do not have optimal nurse-to-patient ratios right now, due to the shortage. That, in turn, leads to high stress and more confrontations. “I have pretty much seen it all,” Felblinger says. “I have seen yelling, screaming, and chart throwing. I once saw a physician throw a needle, and it pierced the nurse’s skin.”

On the other hand, she adds, the nursing shortage has helped nurses find their voices and ask for better treatment. Hospitals know if they don’t retain their nurses and keep them happy, nurses have a lot of career options these days—and they just might walk.

Felblinger worries about NPs who may be the sole nurse in a clinic, surrounded by physicians. Those NPs could become targets, since they don’t have other nurses to turn to for support.

The best prevention, according to Felblinger, is to speak up right away. Unfortunately, most targets of bullying let the problems continue for as long as two years.

“The most civil thing is to always address it with the person,” Felblinger says. “Get it out in the open, and request that the behavior stop.”

It’s about learning to set boundaries and deciding you want to be treated with respect, she adds. “Sometimes things can be worked out really well,” Felblinger says. “Sometimes people don’t realize they’re doing this, because nobody ever brought it to their attention.”

Building Momentum for Change
With the new JCAHO standards in place, clinicians should have an easier time reporting negative incidents.

Still, Namie warns, the JCAHO standards really don’t have teeth. Health care workers won’t truly be protected until legislators pass laws that will cause a workplace bully to lose his or her job (just as they did for sexual harassment). That’s still years away, but with two bills in the New York State Legislature and six other active bills in states across the country, Namie says the movement “continues to catch fire.”

Meanwhile, clinicians who do call out a bully may run into resistance at the top. Bullies are often adept at charming and building allies in high places. Felblinger says that some hospital administrators may also value the money top surgeons or physicians are able to attract to the institution—sometimes more than they value their own workers.

One shining star in this area is Vanderbilt University Medical Center, which has adopted effective prevention policies of its own and shared the model with 40 other hospitals around the country. (For details, visit www.mc.vanderbilt .edu/cppa.)

Vanderbilt uses patient surveys, suggestion cards, and waiting room videos to make it clear to patients that their feedback is welcome. Staff members use an online program to report unprofessional behavior, Hickson says. Once the data are there, the hospital searches for recurring names and patterns of negative behavior. Clinicians who are repeatedly mentioned must then go through training programs and, in certain cases, counseling through an employee assistance program.

It’s not as simple as printing up a statement about zero tolerance, Hickson says. “So many people think you can slap a policy on this and make it go away,” he adds. In fact, it can take years to make inroads and establish civil behavior as a core value for a medical institution.

For Patients and Clinicians
Clinical nurse specialist Theresa Mulherin, MSN, RN, CEN, is in charge of implementing the new JCAHO standards for workplace behavior at Sentara Careplex in Hampton, Virginia. At times, she feels as if she is operating in uncharted territory, but she is also honored to do this job.

“I’m excited about this,” Mulherin says. “As nurses, we’ve known for a long time that this needed to be addressed. This is about patient safety, and that’s why it’s so important to me.”

While it may be a far from perfect world for health care workers, it’s important not to lose heart. Clinicians need to stick together, support each other, and really work on this cause, Felblinger says: “We can lose some of our best and brightest if we don’t deal with it.”

Joseph Doescher and Daniel Raess worked side by side in the operating room at St. Francis Hospital in Beech Grove, Indiana. Doescher and the other perfusionists often had to put up with yelling, swearing, and belittling comments from Raess, the heart surgeon. Finally, Doescher reported the behavior to his supervisor. Raess got wind of it and retaliated.

In subsequent court proceedings, Doescher described looking up at Raess’ red face and popping veins. He was afraid Raess was going to hit him. In the end, Doescher left his job with a debilitating case of depression. Later, he sued Raess and was awarded $325,000 in compensatory (but not punitive) damages.

Shortly after the Indiana Supreme Court decided this high-profile medical case, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a safety alert, requiring hospitals to adopt a zero-tolerance policy toward workplace bullying. By January 2009, hospitals must also comply with the new disruptive behavior standard (LD.3.15). They will create new training, post a code of conduct for employees, and set up a mechanism for workers to report inappropriate outbursts.

“It’s been widely recognized that this kind of behavior goes on in health care settings,” says Peter Angood, MD, Chief Patient Safety Officer for JCAHO. “It seemed to be increasing in frequency, so we felt it was important to put standards in place.”

Perfect Targets
Researchers, including Gerald Hickson, MD, at Vanderbilt University, and Alan H. Rosenstein, MD, have shown how inappropriate workplace behavior can lead to increased legal costs and put patient safety at risk. Other studies have shown that clinicians working in a hostile environment make more errors while dispensing medication.

“If there are people in the workplace who don’t play well with others, sometimes they cause other members of the team to lose focus,” Hickson says, “and an error will occur.”

According to Gary Namie, PhD, Cofounder of the Workplace Bullying Institute in Bellingham, Washington, this issue is coming to the forefront, just as sexual harassment did about 20 years ago. Employers are starting to see training programs and prevention as a good investment. And Namie says the need is great—in all sectors of the work world. His organization conducted a survey and found that 37% of American workers say they have been victims of workplace bullying.

Health care, with its hierarchical structure of authority and caste-like training systems, is rife with this type of negative behavior. In part, Namie says, this is because there are so many caring and compassionate people in the field, who make perfect targets: They would rather help people and keep a low profile than fight back.

“It’s the people mix,” Namie says. “You’ve got just enough people with strong egos and narcissistic personalities. Then you’ve got this vast pool of targets who have an altruistic bent—they want to focus on the work itself, and they have a belief in a benevolent world. They don’t respond to aggression with aggression.”

Workplace bullies usually target a person with good social skills who is well liked, as Namie explains: “It’s usually a person with an established record who poses a threat, and the bully wants to take him or her down.”

Nurses at the Forefront
Frequently, physicians are the aggressors and nurses are the targets. In fact, a JCAHO survey found that 50% of nurses had been targets of this kind of intimidation, and 90% of nurses reported having witnessed it.

Dianne Felblinger, EdD, MSN, WHNP-BC, CNS, RN, a nursing instructor at the University of Cincinnati, believes the nursing shortage is driving some of the frustration—but also may hold the key to solving the problem.

First of all, many hospitals do not have optimal nurse-to-patient ratios right now, due to the shortage. That, in turn, leads to high stress and more confrontations. “I have pretty much seen it all,” Felblinger says. “I have seen yelling, screaming, and chart throwing. I once saw a physician throw a needle, and it pierced the nurse’s skin.”

On the other hand, she adds, the nursing shortage has helped nurses find their voices and ask for better treatment. Hospitals know if they don’t retain their nurses and keep them happy, nurses have a lot of career options these days—and they just might walk.

Felblinger worries about NPs who may be the sole nurse in a clinic, surrounded by physicians. Those NPs could become targets, since they don’t have other nurses to turn to for support.

The best prevention, according to Felblinger, is to speak up right away. Unfortunately, most targets of bullying let the problems continue for as long as two years.

“The most civil thing is to always address it with the person,” Felblinger says. “Get it out in the open, and request that the behavior stop.”

It’s about learning to set boundaries and deciding you want to be treated with respect, she adds. “Sometimes things can be worked out really well,” Felblinger says. “Sometimes people don’t realize they’re doing this, because nobody ever brought it to their attention.”

Building Momentum for Change
With the new JCAHO standards in place, clinicians should have an easier time reporting negative incidents.

Still, Namie warns, the JCAHO standards really don’t have teeth. Health care workers won’t truly be protected until legislators pass laws that will cause a workplace bully to lose his or her job (just as they did for sexual harassment). That’s still years away, but with two bills in the New York State Legislature and six other active bills in states across the country, Namie says the movement “continues to catch fire.”

Meanwhile, clinicians who do call out a bully may run into resistance at the top. Bullies are often adept at charming and building allies in high places. Felblinger says that some hospital administrators may also value the money top surgeons or physicians are able to attract to the institution—sometimes more than they value their own workers.

One shining star in this area is Vanderbilt University Medical Center, which has adopted effective prevention policies of its own and shared the model with 40 other hospitals around the country. (For details, visit www.mc.vanderbilt .edu/cppa.)

Vanderbilt uses patient surveys, suggestion cards, and waiting room videos to make it clear to patients that their feedback is welcome. Staff members use an online program to report unprofessional behavior, Hickson says. Once the data are there, the hospital searches for recurring names and patterns of negative behavior. Clinicians who are repeatedly mentioned must then go through training programs and, in certain cases, counseling through an employee assistance program.

It’s not as simple as printing up a statement about zero tolerance, Hickson says. “So many people think you can slap a policy on this and make it go away,” he adds. In fact, it can take years to make inroads and establish civil behavior as a core value for a medical institution.

For Patients and Clinicians
Clinical nurse specialist Theresa Mulherin, MSN, RN, CEN, is in charge of implementing the new JCAHO standards for workplace behavior at Sentara Careplex in Hampton, Virginia. At times, she feels as if she is operating in uncharted territory, but she is also honored to do this job.

“I’m excited about this,” Mulherin says. “As nurses, we’ve known for a long time that this needed to be addressed. This is about patient safety, and that’s why it’s so important to me.”

While it may be a far from perfect world for health care workers, it’s important not to lose heart. Clinicians need to stick together, support each other, and really work on this cause, Felblinger says: “We can lose some of our best and brightest if we don’t deal with it.”

Joseph Doescher and Daniel Raess worked side by side in the operating room at St. Francis Hospital in Beech Grove, Indiana. Doescher and the other perfusionists often had to put up with yelling, swearing, and belittling comments from Raess, the heart surgeon. Finally, Doescher reported the behavior to his supervisor. Raess got wind of it and retaliated.

In subsequent court proceedings, Doescher described looking up at Raess’ red face and popping veins. He was afraid Raess was going to hit him. In the end, Doescher left his job with a debilitating case of depression. Later, he sued Raess and was awarded $325,000 in compensatory (but not punitive) damages.

Shortly after the Indiana Supreme Court decided this high-profile medical case, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a safety alert, requiring hospitals to adopt a zero-tolerance policy toward workplace bullying. By January 2009, hospitals must also comply with the new disruptive behavior standard (LD.3.15). They will create new training, post a code of conduct for employees, and set up a mechanism for workers to report inappropriate outbursts.

“It’s been widely recognized that this kind of behavior goes on in health care settings,” says Peter Angood, MD, Chief Patient Safety Officer for JCAHO. “It seemed to be increasing in frequency, so we felt it was important to put standards in place.”

Perfect Targets
Researchers, including Gerald Hickson, MD, at Vanderbilt University, and Alan H. Rosenstein, MD, have shown how inappropriate workplace behavior can lead to increased legal costs and put patient safety at risk. Other studies have shown that clinicians working in a hostile environment make more errors while dispensing medication.

“If there are people in the workplace who don’t play well with others, sometimes they cause other members of the team to lose focus,” Hickson says, “and an error will occur.”

According to Gary Namie, PhD, Cofounder of the Workplace Bullying Institute in Bellingham, Washington, this issue is coming to the forefront, just as sexual harassment did about 20 years ago. Employers are starting to see training programs and prevention as a good investment. And Namie says the need is great—in all sectors of the work world. His organization conducted a survey and found that 37% of American workers say they have been victims of workplace bullying.

Health care, with its hierarchical structure of authority and caste-like training systems, is rife with this type of negative behavior. In part, Namie says, this is because there are so many caring and compassionate people in the field, who make perfect targets: They would rather help people and keep a low profile than fight back.

“It’s the people mix,” Namie says. “You’ve got just enough people with strong egos and narcissistic personalities. Then you’ve got this vast pool of targets who have an altruistic bent—they want to focus on the work itself, and they have a belief in a benevolent world. They don’t respond to aggression with aggression.”

Workplace bullies usually target a person with good social skills who is well liked, as Namie explains: “It’s usually a person with an established record who poses a threat, and the bully wants to take him or her down.”

Nurses at the Forefront
Frequently, physicians are the aggressors and nurses are the targets. In fact, a JCAHO survey found that 50% of nurses had been targets of this kind of intimidation, and 90% of nurses reported having witnessed it.

Dianne Felblinger, EdD, MSN, WHNP-BC, CNS, RN, a nursing instructor at the University of Cincinnati, believes the nursing shortage is driving some of the frustration—but also may hold the key to solving the problem.

First of all, many hospitals do not have optimal nurse-to-patient ratios right now, due to the shortage. That, in turn, leads to high stress and more confrontations. “I have pretty much seen it all,” Felblinger says. “I have seen yelling, screaming, and chart throwing. I once saw a physician throw a needle, and it pierced the nurse’s skin.”

On the other hand, she adds, the nursing shortage has helped nurses find their voices and ask for better treatment. Hospitals know if they don’t retain their nurses and keep them happy, nurses have a lot of career options these days—and they just might walk.

Felblinger worries about NPs who may be the sole nurse in a clinic, surrounded by physicians. Those NPs could become targets, since they don’t have other nurses to turn to for support.

The best prevention, according to Felblinger, is to speak up right away. Unfortunately, most targets of bullying let the problems continue for as long as two years.

“The most civil thing is to always address it with the person,” Felblinger says. “Get it out in the open, and request that the behavior stop.”

It’s about learning to set boundaries and deciding you want to be treated with respect, she adds. “Sometimes things can be worked out really well,” Felblinger says. “Sometimes people don’t realize they’re doing this, because nobody ever brought it to their attention.”

Building Momentum for Change
With the new JCAHO standards in place, clinicians should have an easier time reporting negative incidents.

Still, Namie warns, the JCAHO standards really don’t have teeth. Health care workers won’t truly be protected until legislators pass laws that will cause a workplace bully to lose his or her job (just as they did for sexual harassment). That’s still years away, but with two bills in the New York State Legislature and six other active bills in states across the country, Namie says the movement “continues to catch fire.”

Meanwhile, clinicians who do call out a bully may run into resistance at the top. Bullies are often adept at charming and building allies in high places. Felblinger says that some hospital administrators may also value the money top surgeons or physicians are able to attract to the institution—sometimes more than they value their own workers.

One shining star in this area is Vanderbilt University Medical Center, which has adopted effective prevention policies of its own and shared the model with 40 other hospitals around the country. (For details, visit www.mc.vanderbilt .edu/cppa.)

Vanderbilt uses patient surveys, suggestion cards, and waiting room videos to make it clear to patients that their feedback is welcome. Staff members use an online program to report unprofessional behavior, Hickson says. Once the data are there, the hospital searches for recurring names and patterns of negative behavior. Clinicians who are repeatedly mentioned must then go through training programs and, in certain cases, counseling through an employee assistance program.

It’s not as simple as printing up a statement about zero tolerance, Hickson says. “So many people think you can slap a policy on this and make it go away,” he adds. In fact, it can take years to make inroads and establish civil behavior as a core value for a medical institution.

For Patients and Clinicians
Clinical nurse specialist Theresa Mulherin, MSN, RN, CEN, is in charge of implementing the new JCAHO standards for workplace behavior at Sentara Careplex in Hampton, Virginia. At times, she feels as if she is operating in uncharted territory, but she is also honored to do this job.

“I’m excited about this,” Mulherin says. “As nurses, we’ve known for a long time that this needed to be addressed. This is about patient safety, and that’s why it’s so important to me.”

While it may be a far from perfect world for health care workers, it’s important not to lose heart. Clinicians need to stick together, support each other, and really work on this cause, Felblinger says: “We can lose some of our best and brightest if we don’t deal with it.”