Physicians’ assistants: a n opinion

Muriel T . Hanewinckel, RN

Editor’s note: Comments on this or any other AORN Journal article are invited and welcome.

In January of this year, Ernest B. Howard, MD, executive vice president of the American Medical Association delivered the Lowell Lecture in Boston. In that lecture Dr. Howard advocated that the RN become the future “doctor’s assistant.”

Because good health care has attained prime importance in this country, and we face a critically short supply of med- ical services, the AMA proposed that the RN, because of her special training,

Muriel T. Hanewinckel, RN, i s a member of the National Editorial Committee of the Association of

Operoting Room Nurses. She i s employed as otologic assistant to Victor Hildeyeard, MD, Denver. Mrs. Hanwinckel wos educated at the Mercy College of Nursing, Son Diega, served six months in the

United States Army, has been employed as scrub

nurse at the Lor Angeles Eye, Ear, Nose and Throat

Hospital, and or administrator of New Underwood Hospital, South Dakota.

would be the most logically available person to fill the role.’

Since that lecture, the literature has been flooded with material pertaining to this “new” individual, the physician’s assistant.

With the exception of the American Medical Association’s immediate reac- tion, objecting to the idea, too few re- sponses have come from the very per- son in the middle of the controversy . . . the nurse herself.

Because I am a “doctor’s assistant,” and have been for 13 rewarding years, I would like to offer a few thoughts from one nurses’ viewpoint.

When I read Dr. Howard’s idea about nurses filling this role, my first reaction was “So what’s new?”

However, after much serious thought and deliberation, and a bit of research into the subject, I found that nurses

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have little or no real knowledge about this “new” idea. They are uninformed about the job’s requirements, duties, re- wards or personal satisfactions. They are, in fact, defensive about the entire subject.

Several years ago, our local chapter of the Association of Operating Room Nurses, which has always been involved in a student interest group, presented a panel discussion at a student tea. The panel, composed of surgical assist- ants, (once known as “private scrubs,”) elaborated on the responsibilities of the surgical assistant.

Many of our nurse colleagues were startled to find surgical assistants equipt to do more than assist the surgeon in the OR suite. Their duties were drawn out to include counseling patients on preoperative, operative and postoper- ative procedures; writing preoperative orders; dictating histories and physicals prior to hospital admissions; writing and signing prescriptions, (narcotics ex- cluded ).

They were able to answer in more detail, patients’ inquiries about their ail- ments and medications, and fill-in for the occupied surgeon who could not possibly find time for such discussions.

Other jobs were assistance with minor surgical procedures encountered during office hours, removal of sutures or dress- ing changes on hospitalized postoper- ative patients, administration of IV medications, withdrawal of blood and completion of lab tests, and removal of casts.

Perhaps most important was the con- trasting, by phone, of “emergency” vers- us “panic,” the reassurance to patients, and in some instances, the house call.

These are just a few of the responsi- bilities delegated to the physician’s as- sistant, under the direct supervision of the surgeon-employer.

Although Dr. Howard’s idea is new to many nurses, the concept has, in fact, been practiced for many years. Ther5 are thousands of nurses already em- ployed in this type of position. These are the nurses who have been willing - eager - to assume more responsibility in order to relieve the physician’s over- whelming work load.

They have been quietly working un- der the title of “scrub nurse” or “office nurse,” when in reality, they are phy- sicians’ assistants.

It is not unusual to find that a nurse in this catagory has been in her present employ for 15 or 20 years. And why do you suppose a nurse stays in this sort of position for so long? Because the “job satisfactions” are enormous - pro- fessionally, monitarily and personally.

Most of us will agree that‘ the public image of the RN has slipped a few notches. The warm, sympathetic, “angel of mercy in white” has long since been replaced by the too busy, cool and ef- ficient nurse whose hospital responsibil- ities force her to delegate most of her patient closeness to someone else.

Consequently, the young, idealistic nurse-the one who entered nurses’ training in the first place to care for peo- ple - is slightly disallusioned by the time she has taken her state board exams.

And perhaps the most disalhsioned person of all is the patient who is on the receiving end.

The average hospitalized patient to- day has no idea who “his” nurse is.

November 1970 51

Granted, he is probably receiving better, more sophisticated care than has ever been given before, but the humanistic, personalized element seems to him sore- ly lacking.

I like to think, however, that his faith in the nurse practitioner is restored when he comes in contact with the “physician’s assistant.” Patient contact is probably in its most ideal context here, for it is part of the PA’s job to see that he, the patient, a sick human being, is given the tender loving care he needs and wants.

If we, as RN’s do not rise to the challenge the AMA is offering us, there will be other groups in the health field to take it. The pilot programs started five years ago by several university med- icaI schools have already graduated groups of young men, trained to take case histories, help with patient instruc- tions, follow patients in hospitals, su- ture minor lacerations, change dressings, and oversee the other repetitious tasks which were once the responsibility of the MD.

General practitioners, in isolated rural areas, who have long been totally de- pendant upon R N s for assistants, are already hiring these young men to as- sist them in their own programs to render immediate health care. Working with individual physicians, medical ad- visory boards, local medical societies and other paramedical groups, nurses are functioning in the capacity of “phy- sicians’ associates.” Nurses and investi- gators of these sporadic programs agree that longer experience and training in assuming responsibility leads to more ability and self-confidence in providing care for patients.3

Approximately 20 programs through- out the United States are focusing on

specialized training which will ultimate- ly result in physicians’ assistants. The educational settings vary widely and in- clude medical schools and medical cen- ters, public and private hospitals, clinics, two-year and four-year colleges. More than half these programs require prev- ious experience in the health field; nurs- es and medical corpsmen are identified more often than others as trainees. Training periods are from 14 weeks to five years. Sponsoring institutions award certificates, Baccalaureate degrees, and associate degrees.4

A recent survey of a cross-section of nurses in many fields of nursing, re- vealed that nurses do expect to be per- forming the tasks Dr. Howard men- tioned in his lecture. In fact, many R N s eagerly look forward to being allowed to perform the repetitious tasks which they have daily watched physicians per- forming, knowing their own capabilities of doing the same.

If young men can be taught to suture lacerations and abrasions, surely experi- enced nurses can do so . . . it was even suggested in the survey that nurses would someday be permitted to suture the surgical skin incision in the OR3

Dr. Howard’s proposed plan should appeal to many of the 380,000 “retired nurses in this country. Many of these nurses have left the field of nursing be- cause of the gradual drifting away from patient nursing to administrative nurs- ing. Think of the wealth of background in these nurses - experience which could again be usefully employed.

The AMA is suggesting that nurses be trained to make house calls, thus re- ducing hospital admissions and possibly

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aiding the earlier dismissal of hospital- ized patients. The public health nurse and visiting nurse has been making housecalls for years!

In the field of obstetrics, nurses have long been relied upon as doctors’ assist- ants. Some obstetricians, in fact, foresee the national licensure of nurse-midwives to help relieve the pressures placed upon the dwindling supply of obstetricians.6

If the idea of the nurse as physician’s assistant becomes widely accepted, not only will the professional status of such an RN be enhanced, but her salary will almost certainly be in a higher bracket. Many surgeons adopted the “fee-for- service” concept years ago by charg- ing the surgical patient a set fee to be paid to his nurse for assisting during surgery. Usually the nurse is paid a flat salary by her employer, and the surgical nurse’s fee serves as a supplement to her salary.

Fringe benefits, on the whole, are more generous when paid by a physi- cian-employer. Health insurance pro- grams, annual bonuses, car allowances, and vacations with pay are not out of the ordinary in most instances.

On the dark side of the picture, of course, are the usually long hours the nurse is expected to work. She is usu- ally expected to be available for emer- gency calls, and a 10-hour day is not out of the ordinary for a physician’s assistant. Here again, however, the phy- sician can, and usually does, make this up to his nurse. In order to stay abreast of medical knowledge in their respec- tive fields, most physicians feel com- pelled to attend educational meetings throughout the year, and frequently give time back to their assistants while they are away from their medical practices.

The way in which Dr. Howard’s an- nouncement was presented to the med- ical world is giving cause for some furor in nursing organizations.

Granted, nursing groups are obliged to come together with the AMA on a common meeting ground and voice nurs- ing ideas and opinions. However, I would hope that the negative approach stated by ANA, that the AMA has no right to infringe upon the nursing pro- fession, would be softened somewhat in the future. How can either profession do without the other?

Nurses need doctors, and doctors need nurses, and the patient profits from the inter-dependency.

We are objecting to Dr. Howard taking a stand and saying that nurses should be the future M D assistants be- cause of their educational backgrounds and qualifying present positions in the medical field. Shouldn’t we be thankful, instead, that hc didn’t propose other paramedical personnel to fill the role?

We hear a great deal about team work and team leaders. Can there be any greater team than the doctor and nurse working side by side, whether at the patient’s bedside, in the OR, or in the office?

The political world constantly re- minds us about manpower shortages in the health field; rising costs of medical care; the need for change in our way of thinking and planning for future health care; and that good medical care is the “right and privilege” of every person in this United States. Isn’t it about time some concrete ideas, such as Dr. Howard’s, be accepted from the medical world?

November 1970 53

Mountain rescue teams will be im- portant. These people will have to know how to give IVs and how to give medi- cations, and the same things will appiy for orthopedic technicians.

There’s another interesting field - helicopter technicians. The helicopter has the same problem in the air as the ambulance on the ground. That is, the idea of rushing somewhere in a hurry is no longer valid. What must be done is to train the individual for on-the-scene care, then he can drive or fly at a same speed to the hospital.

Now, the use of a doctor’s assistant. I challenge the nurses as to whether this isn’t an area that they should be in- volved.

Perhaps they have already lost their chance. Here again, perhaps better com- munication between physicians and nurses, and also a common sense of di- rection could remedy this.

The physician’s assistant will need the equivalent of a two-year college course. We can envision that this phy-

sician’s assistant will make rounds with the doctor, will change dressings. With the surgeons, the assistants may be closing some lacerations; may be doing some diagnostic tests the likes of which can’t even be imagined at the present time; may be changing casts and ap- plying casts; and may be assisting the surgeons in the OR.

Here again you’ve got to realize one can’t expand too rapidly because there aren’t that many teachers. We don’t have enough teachers to produce enough doctors. We don’t want to cut down on the quality of our education by increas- ing the number of doctors and produc- ing something poorer than we have today.

Still, there’s too much work to do for the MDs in this field.

Someone has got to help. Our philos- ophy is to upgrade the paramedical per- sonnel, train this individual, then pro- vide advanced study and then concern ourselves with the doctor’s assistant.

Paradoxes bow to modern America Man has been altering his total environment so swiftly and suddenly thaf the whole choin of l i fe on this planet is endangered, says on article “Now is the Time for All Good Men to Come to the A id of Their Planet,” from The Challenge, reprinted from an advertisement in Time Magazine, Nov 74, 1969.

Some of the paradoxes of the modern age, according to the article are these:

As saciety grows richer, environment grows poorer.

As the arroy of objects expands, the vigor of l i fe declines.

I t is no one’s fault; i t is everyone’s fault.

The real culprits are the three main currents of the 20th century - population, industrialization and urbanization.

“We have the weapons that enable us to die together; can we not forge the tools that enable us oll to live together?”

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