High-level rewards for 'midlevels'

Science Article
November 7, 2002

Physician assistants and nurse practitioners play integral role in patient care

Shelly Mentzer, a Seattle Cancer Care Alliance physician asssistant since 2000. and Bruce Bolonesi, one of the original four physician assistants hired by Fred Hutchinson in 1984, prepare for a procedure in the Alliance clinic. Photo by Todd McNaught

By JEFFREY NACHTIGAL

Eighteen years ago, the decision to use phy- sician assistants to provide patient care at Fred Hutchinson was unprecedented.

Although physician assistants, or PAs, had long been a fixture in delivering primary medical care in hospitals, the concept of integrating midlevel caregivers into a specialty field such as the center's transplant program had not yet been put into practice. Doctors, not PAs, took care of transplant patients.

What was an innovative idea then works so well today that PAs are an integral foundation of patient care at the Seattle Cancer Care Alliance.

Today, 30 so-called "midlevels" (PAs and nurse practitioners) care for transplant patients, as well as work in specialized jobs in the infectious-disease unit, unrelated donor transplants, long-term follow-up care and pediatrics.

Midlevels are responsible for patients they diagnose and treat, under the supervision and direction of an attending physician. It's an increasingly visible role.

"In the old days, 18 years ago, few nurses or physicians knew what PAs did," said Bruce Bolonesi, one of the original four PAs hired in 1984. "It was unclear what our role would be in a research/teaching hospital.

"When we were first hired, it was a unique situation to have midlevels in a specialized system associated with teaching. It was very unusual to have PAs outside of a typical doctor's office taking care of sore throats."

Integration of midlevels into the patient-care system at the center, and later the Alliance, has served as a model for other teaching institutions and hospitals around the country.

"What we have here is certainly one of the largest numbers of midlevels, certainly on the West Coast," said Bolonesi, who administers the midlevel practitioner group along with Bill Levy.

"From four (PAs) 18 years ago to 30 now, that reflects on the importance of midlevels in the system," Bolonesi said.

A boon to growth

In 1984, Fred Hutchinson grew to a 60-bed transplant unit from 40 beds, and there weren't enough medical staff providers to give adequate care. Midlevel caregivers became a boon.

"The program was growing, and we had only so many residents and fellows who could devote rotation time to the transplant program, so we needed to find some physician extenders to help take care of patients," said Dr. Jean Sanders, director of the Alliance pediatric transplant program. "It seemed like the PA program was the best way to go.

"There aren't enough fellows in either program - pediatric or adult - to take care of the entire patient population without midlevel practitioners. We saw the handwriting on the wall a long time ago."

By 1996, the program had tripled to 12 midlevels, but more expansion was yet to come.

The move of patient-care services from First Hill and Swedish Hospital to the South Lake Union campus and the Alliance required more medical caregivers.

Until then, the center had relied on visiting physicians to provide the bulk of that patient care. But the center wanted to rely less on those individuals, whose availability and training were at times an issue, and to develop more consistency and cohesiveness in patient care, Bolonesi said.

"It's going very well now," he said. "There were some rough times when we made the move. A lot of it was logistics and the way Swedish ran, and doing patient care at different hospitals.

"The whole Alliance made for a different look to the system, but we still function in the same manner."

Surveys of patients confirm that, Bolonesi said. Patient respondents have said they perceive that PAs or nurse practitioners spend more time with them than their physicians. More important, patients feel more comfortable with the whole process because of the midlevel care.

"A set group of providers who know the system can provide that continuity of care," he said. "They are likely to see the same patients and are familiar with the logistics of the system."

Some Alliance midlevels have decades of experience, while others are fresh from school - a good mix of people working together, Bolonesi said.

Shelly Mentzer hadn't planned to become a physician assistant. Originally, she wanted to work as a veterinarian. Through her stepmother's treatment for multiple myeloma, including an autologous transplant, she became interested in a career in oncology.

Ironically, Mentzer's stepmother had worked at the Colorado Trust in Denver, which provided grant money to fund primary health-care ideas. She saw the need for PAs - exactly what she now does at the Alliance.

"It's a lot more meaningful than five-times-a-day back-pain care in family practice," Mentzer said about working as a PA since 2000.

"Doing something for the cancer patient and having people react and be appreciative of you is absolutely amazing. And when patients come back and search you out to thank you a year later, you realize that you actually made an impression."

Outpatients, inpatients

Mentzer looks at her position as two jobs. One is for outpatients. That day starts with team rounds in the morning, then moves to clinics, regular procedures and triage for emergency situations.

For inpatients, she attends rounds for two to four hours with the attending physician, then attends X-ray rounds, performs daily patient exams, follows up on medical orders, and is on-call overnight four nights a month, making it a standard, nine- or 10-hour day.

Busy as her PA schedule is, Mentzer is happy with her decision not to attend medical school and become a doctor.

"It's a career in which we can spend a little more time with patients, more quality time," she said. "It also leaves us more time to have a family life."

Mentzer said one of the challenges of the job is leaving a patient to go off clinical rotation. Midlevels generally work two-month rotations, while a typical allogeneic transplant process lasts four months.

Recently, Mentzer had shoulder surgery, forcing her to stay on rotation for five months. It turned out to be "really neat," she said, to see patients all the way through their transplants.

Top challenge

The biggest challenge for midlevels is the position's emotional toll.

"As close as we get to our patients, you definitely cannot ignore the fact of the acuity of our patients and what the potential outcome could be," Mentzer said. "Sometimes, you do lose a patient along the way, more often than in a primary-care setting, and that's pretty difficult."

One of the unique opportunities of the midlevel positions is working at a teaching center and being exposed to cutting-edge technology.

But the position isn't for everyone. Long hours, weekends, and the added pressure of keeping up with transplant advances makes the midlevel position a "self selecting" one, drawing a strong set of committed individuals, Bolonesi said.

Mentzer, along with her peers, has taken advantage of this situation at the Alliance and branched out to work with the unrelated donor office, learning more about the transplant field beyond patient care.

"I really am surprised at how much I do like this job," she said. "There's a lot of camaraderie in our group. It's a great group to work with."

"I think it's been a successful program without a question," added Sanders, who works with six PAs in pediatric.

"Some have branched out to be specialists within other areas, and I think this is good. To be able to step into other shoes to see how another area of the center works promotes longevity. It's a highly regarded program."

[Jeffrey Nachtigal is a Seattle freelance writer and former Alliance transplant patient.]

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