Extending access and quality: A conversation with Mary E. Klotman

Extending access and quality: A conversation with Mary E. KlotmanMary E. Klotman M.D., dean of Duke University School of Medicine and vice chancellor for health affairs at Duke University, recently sat down with David B. Wilkins, Lester Kissel Professor of Law at Harvard Law School and faculty director of the Center on the Legal Profession (CLP), for a conversation on how medicine has changed over time, particularly with respect to the development of professional roles within it.

This interview is featured in the most recent issue of CLP’s The Practice, a unique digital publication that highlights the most critical topics and issues facing the global legal profession.

David B. Wilkins: Over the past decade, one of the core issues surrounding debates over the creation of new paraprofessional roles within the legal profession has been access to justice. At the core, the argument is that there are not enough affordable legal service providers. Therefore, by creating new types of service providers—by creating paraprofessional legal service roles distinct from traditional lawyers—costs would lower and access would increase. Medicine has a much longer history regarding the use of paraprofessionals. For instance, it has been more than 50 years since physician assistants (PAs) emerged in medicine—a history in which Duke Medical School played an integral role. Viewed through the context of this longer history, how do you view the role of physician assistants, as a prime example of a paraprofessional role, impacting access to medical care?

The conversation in medicine typically isn’t about a tradeoff between access and quality. It’s about what individual skill sets are needed to provide a full range of care to patient populations.

Dean Mary E. Klotman: In medicine, we think about PAs and nurse practitioners (NPs) as “extenders.” In the last five to eight years, I’ve seen a remarkable rethinking of the roles of extenders in our delivery models—delivery debates being in a large part driven by debates over access to care. Extenders are increasingly doing everything from being primary care providers for many individuals to being part of a team delivering some sort of specialty care. A lot of this is happening in outpatient services, where medicine is really struggling with access in high-volume specialties. To give a concrete example, in endocrinology you often see patients at high frequencies. While the initial visit may be with a highly trained specialist—the endocrinologist—follow-ups are really about implementing care plans. It is in these cases that extenders are extremely helpful, to the practice as well as to individual patients.

Of course, to make this work seamlessly, as a profession, we have had to educate our physician leaders to really understand what extenders are trained to do. We do this from the perspective of what the extenders are trained to do, as opposed to the more myopic vision of what they cannot do. We want everybody to be able to work up to the maximum limit of their license. We also are thinking about the value proposition, where you want to make sure your providers are using their professional skills in ways that make economic sense.

To be sure, understanding what skills and formal certification mean across different role types, as well as what economically makes sense and what doesn’t, has been a process. But it has largely been driven by rethinking our delivery systems, given access issues.

Wilkins: This raises a second question that has been a big part of the debate in the legal world around quality. By creating these new roles, yes, you may get better access. And yes, you may have more-affordable services. But is there a quality tradeoff? Is there a risk that the quality will suffer? Is there a tradeoff between access and quality?

Klotman: I think it is safe to say that medicine has, by and large, moved beyond the tradeoff concern. The conversation in medicine typically isn’t about a tradeoff between access and quality. The conversation is about what individual skill sets are needed to provide a full range of care to patient populations. In different practices, the answer might be different. Rheumatology is one good example. We’re only training 200 rheumatologists a year in this country. With an aging population with a lot of arthritis, there’s no way you’re going to be able to provide access to all the people who need help. I had a very forward-looking chief of rheumatology who knew that something needed to be done. So, he started to train NPs in his practice in frontline rheumatology skills so that they could increasingly provide direct patient care. Again, it’s not the tradeoff conversation. Rather, it’s a skill set conversation and whether these individuals are being utilized at the most optimal levels.

Another example is orthopedic surgery, where there are actually very trainable skills. Indeed, there are formal programs that train PAs in orthopedic skills to a level that they are able to see a broad range of individuals who come to any given orthopedic practice. Now, they may not be performing the operation, but they’re really great at seeing the sports injuries and being a first line of care or doing pre- and post-op care. So, again, it’s not a tradeoff conversation. It’s different skills for different levels of care.

In either of these examples, medicine has largely moved beyond the concern that only MD physicians can provide care to the more strategic question about how to use a team of individuals to provide the best care.

There is tremendous value in training all our providers in integrated systems because ultimately that’s the delivery model.

Wilkins: Dean, this is really important because in the legal profession we have not yet arrived at that point. Indeed, we still sometimes foolishly divide the world into two static camps: lawyers and “nonlawyers.” Some of this relates to a cultural divide. It sounds to me like there has been a real cultural shift among physicians to value the skills that these other professional roles provide. Could you talk about what brought about this culture shift about?

Klotman: Need was a big reason. When you get in a critical situation—when you just don’t have the workforce to meet the demand—that forces you into a real change, including of culture. It is also about recognizing diverse skill sets. Here, I think, history really matters. When you look at the history of the PA program, which was started at Duke by Eugene Stead in 1965, it began because there was a need and a group of very skilled individuals coming back from the Vietnam War. These individuals were coming from war zones, and they had real practical skills complemented by training. From the beginning, therefore, they were recognized for having very specific skill sets. And, importantly, they were not viewed as “lesser” skill sets. They were just different skill sets. From this perspective, PAs have always been accepted as part of the workforce. It is also important to note that context matters and that extenders provide different care in different settings than the highly subspecialized surgeon. As such, it’s not that whole fields have to culturally change. Indeed, there are parts of medicine that largely don’t use extenders. But, for the most part, there has been a general recognition in medicine of the diverse skill sets combined with a need for diverse delivery models. And that has moved us very rapidly into team-based models of care.

The other issue that has driven these developments has been payers, including Medicaid, Medicare, and private insurance. They now pay for care delivered by different types of providers. From this context, it always helps when you have clarity around, “Can you afford to have a different workforce?” If care provided by extenders wasn’t recognized, that would be a challenge. But because extenders can bill—because they can get reimbursed directly—that provides the financial model for how we think about care. And, as you look toward the future, debates are increasingly about providing high-quality care for lower cost. Insurers are pushing us to think differently about what our core workforce is, because, in the end, we’re going to be responsible for figuring out the cost-quality equation. Having a mix of providers is really important to figuring out that equation, and our workforce knows that.

So far we haven’t seen the development of AI-type systems that have replaced the professional judgment that is at the heart of care.

Wilkins: Is there a worry that the extenders will begin to do things beyond their core competencies? And are there regulatory lines that are important to keep hard and fast in a way to separate the boundaries between what’s acceptable and what’s not acceptable in this field?

Klotman: You have formal credentialing processes, and those credentialing processes define for each individual the scope of his or her practice. For example, within each profession, particularly NPs and PAs, there are clear things they can do and things they can’t do. Does that mean on an individual basis you hear occasional stories where there is legitimate disagreement about scope of practice? Yes, but not very frequently.

Wilkins: A controversy in the legal profession has to do with what kinds of institutions should be doing the credentialing. For example, how much of the education of paraprofessionals should be in common with lawyers and how much should be separate? How does medicine think about the training processes for MDs, PAs, NPs, and other extenders? What is the same? What is different?

Klotman: On the top level, there are national certification bodies that offer pretty detailed rules for what training programs should look like, whether for PAs, NPs, or physicians. In that sense, it’s not like Duke can do it one way and another school can do it a completely alternative way. There are national guidelines that training programs must follow, and those guidelines are set by individual professional organizations. These standards are then applied locally. So, on one level, there are different standards because there are different national bodies.

At the same time, however, there is tremendous value in training all our providers in integrated systems because ultimately that’s the delivery model. In other words, the reality often is that PAs will be working in tandem with MDs, NPs, and others. The question therefore becomes: How do you connect independent training programs? In a hospital or clinical setting, you’re naturally working side by side so that training is inherently more integrated. In a classroom sense, it’s more difficult. We are trying to be more purposeful in offering interprofessional training opportunities. Indeed, many schools now have interprofessional training officers. But it is tough. To give one example, student bodies here at Duke are on different calendars—medical students might arrive in August and PA students might arrive in September. The ultimate goal, however, is to start integrating education even before students get into the clinical environments so that when they do, they already have a good feeling for the different roles.

When you get in a critical situation—when you just don’t have the workforce to meet the demand—that forces you into a real change, including of culture.

Wilkins: Dean, this is just enormously helpful. I want to end by asking you to think a little bit about the future. As you just noted, the profession is already moving to a more integrated care model and how to create an integrated training model to reflect that reality. How does technology impact this picture? To give an example, in the early days, the development of the PA model was partly about getting care to rural areas where there were not sufficient physicians. Today, you could have technology projecting physicians anywhere and everywhere. On the flip side, technology might also extend the competencies of PAs through using some sort of background artificial intelligence system. How do you think these roles are likely to evolve over the next 10 years given the technological revolution?

Klotman: I view technology as a tool. Rural medicine is a great example where you can link providers in the field with those in a more central hub. Those providers could be MDs, PAs, or NPs. For example, you could have a PA primary care provider in the field, technologically linked to a team of subspecialty care providers. To give a specific example, take ICU medicine. Here, there are examples of a physician intensivist sitting in front of a huge screen observing three of four intensive care units staffed by NPs. In this case, technology is just the tool through which individuals with different roles and skill sets collaborate on patient care. Another example is in the VA system. The VA has utilized telemedicine in dermatology where you have an extender onsite with a dermatologist in another city working on diagnoses together. That all being said, so far we haven’t seen the development of AI-type systems that have replaced the professional judgment that is at the heart of care—care that all care providers offer in different ways. So, whether an AI machine could replace whole levels of providers, I’m not betting on that one yet.

Wilkins: I cannot thank you enough for taking time out of what I know is an incredibly busy schedule to share your thoughts with us. We here at the Center on the Legal Profession believe that more interprofessional dialogue is critical, and we are grateful to learn a bit about how medicine understands and has grappled with these issues.