Case #1

The Community Health Clinic is located on the perimeter of a large, urban housing project. There are several small produce stores, a large supermarket, a small number of ethnic restaurants, a Baptist church and two gas station convenience stores in the area. There is also a community dental clinic locate two blocks away next door to the daycare center and community center of the housing project. The Community Health Clinic occupies the south and west sides of a building that also contains a neighborhood drug store.

The clinic is staffed by 2 clinic assistants (front desk reception, medical records, and appointments) and 1 on-site billing clerk. The clinic manager splits her time betrween this community clinic and another in a location 20 miles away. There are 2 nurses, 2 nurse practioners, a social worker, a part-time physical therapist, and a part-time physician. The pharmacy in the neighborhood drug store is staffed with 1 full-time pharmacist, 1 part-time pharmacist, and a pharmacy technition. The pharmacist is involved in managing several difficult patients that are seen in the clinic and wants to initiate discussion about providing consultation services to the clinic.

The physician, Dr. D., sees patients from 9 AM to noon on Monday's, Wednesdays, and Friday's. The rest of her time is spent in practice and lecturing at the academic medical center which is 30 miles away. Dr. D. reviews nurse practioner cases on Fridays from 11 AM until noon.

Work at the clinic is not going well.

The social worker feels angry and discounted because Dr. D. never consults with her, the clinic assistants don't pull charts for her, and the ARNP's resent her counseling interventions. She feels that her only expected role is to "deal with managed care insurance companies and arrange home health and chore services.

The nurses feel overworked. There have been conflicts with the ARNP's over the triaging of patients, since the nurses steer what they feel are the more difficult cases to Dr. D., whose appointments tend to be filled many weeks in advance. This creates a continual problem of deciding between long waits or seeing other practioners.

The ARNP's feel the nurses aren't sufficiently qualified to decide whether a patient needs to see Dr. D. or one of them. Furthermore, they both feel that they will never progress in their capabilities if they are not challenged by more complicated cases. In the same vein, they feel very strongly that one hour per week is not nearly enough time to go over cases with a physician. They also feel that Dr. D. doesn't do a good enough job in teaching from the cases presented. She generally agrees without comment or makes changes in the care plans without really explaining why. One of the nurse practioners will be taking a 3 month maternity leave in 5 weeks and expresses some ambivalance about returning to her employment with the clinic.

Dr. D. leads a hectic life. She is working on a grant at the university focusing on urban underserved populations. This grant has provided her with on-line linkages with the university's health science library resources at the clinic location as well as access to a consultant to provide on-line literature services. She teaches physiology to university medical students, and has a private practice outside of the city. She enjoy's working at the clinic, but finds the commute and negative staff attitudes at the clinic to be significant stressors.

Although Dr. D. has worked with physician's assistants (PA's) before, she has never worked with A nurse practitioner prior to her job with the clinic. She assumes they know what they are doing; their patient management strategies seem conventional and reasonable. She knows they would like more time with her, as would her spouse, her children, her patients, and her students. Dr. D. has arranged with the clinic manager to hire a PA during the maternity leave of the ARNP and that person began orienting at the clinic one week ago. Since work volumes have been on the rise at the clinic, Dr. D. has been hoping to bring a PA in on a permanent basis, despite resistance from the clinic manager due to budget constraints. During the leave, Dr. D. and the clinic manager have agreed to evaluate the respective strengths of the PA and the nurse practitioner roles since they want to insure the best professional mix both from an efficiency and financial perspective. Preceding this meeting, the clinic manager is informed by his boss (The Director of Community Care Clinics) that not only is the clinic losing money but patient complaints about poor service, long waits, and billing problems are far above those of other clinics. He feels his job is in danger and would like Dr. D. to help him both give the staff a wake-up call and examine staffing cutbacks.