INTERVIEWEE: Dr. Alfred "Fred" Sadler
INTERVIEWER: Dr. William "Bill" Wilson
DATE: February 5, 2003
PLACE: Carmel, California
SADLER INTERVIEW NO. 1
WILSON:
My name is Bill Wilson. Today is February 5th. We're in Carmel, California, to
record the history of Dr. Alfred Sadler. Dr. Sadler was among the handful of pioneers who
started the PA profession. And it's my pleasure to be able to be the person who is here to
interview him. Dr. Fred Sadler.
SADLER:
Good morning. The year is 2003, Bill. You didn't say that.
WILSON:
So if I'm—
SADLER:
Just in case this film is available 50 years from now. What year was that,
anyway? Oh, it was 2003—
WILSON:
(laughs) that’s right, institutional memory.
SADLER:
—2003. This is a treat, to see Lyle and Bill. I haven't seen you for—let's see—25
years, maybe, more. We're sitting in my living room in Carmel. I'm off today.
I love to talk about the PA world and how that world began. It was certainly a privilege and an
honor to be present at the beginning. (Cat meowing) There's a cat walking around here. So
don't mind the cat.
I grew up in Allentown, Pennsylvania. I was born in New York City. The important
genetic information about me is that I have an identical twin brother named Blair. Blair and I did
collaborative work together in health law, as you'll hear more about, and worked together in the
early development of PA's. We both graduated from Amherst College in 1962. I went on to
Hahnemann Medical School in Philadelphia on a scholarship, and Blair went to University of
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Pennsylvania Law School. I Interned in Surgery at the Hospital of the University of
Pennsylvania. We decided to go into the US Public Health Service together in 1967. We started
out at the National Institutes of Health to tackle a variety of health law problems and became
very involved in organ transplantation. [We studied the legal and ethical issues extensively and
consulted on and helped write the Uniform Anatomical Gift Act, which was adopted in every
state by 1971. This enabled the nationwide sharing of cadaver organs and tissues that exists
today.]
We turned our attention to the emerging field of physicians' assistants and nurse
practitioners. The Duke PA program had started in 1965, under Dr. Eugene Stead. The Colorado
pediatric nurse practitioner program had begun under Dr. Henry Silver, in 1965. MEDEX began
in 1969 with Dr. Richard Smith, who'd been a Peace Corps doctor, and was impressed with what
non-physicians could do. The concern of NIH and more generally, DHEW (now DHHS), was to
explore how PA's would fit in with existing health professionals such as doctors and nurses. We
were asked to examine the credentialing and legal issues relating to PA's, by Roger O. Egeberg
MD, the Assistant Secretary of Health and Surgeon General and Dr. Kenneth Endicott, who later
became director of the Bureau of Health Manpower. We studied all the state laws and began to
visit programs. At Duke we met Dr. Stead and Thelma Ingles (who helped him start the PA
program) and Drs. Harvey Estes and Bob Howard and Martha Ballenger who were among the
principals. They were looking at many of the same issues that we were. We went to Colorado
and met with Dr. Silver and Loretta Ford RN, DrEd. and then to Seattle and Richard Smith. It
was clear to all of us that a separate practices act for PA's would restrict the new profession
unnecessarily. The PA's in the military and overseas had worked flexibly because they were not
restricted by laws the way nurses or physical therapists were. Our recommendation was simply
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to amend the medical practices acts of the various states to make it clear that nothing in the
medical practice act would prohibit a doctor from turning over part of his or her role to a
specially trained person. The key words were, "operate, diagnose, treat, and prescribe." Those
are the functions—
WILSON:
That would be—
SADLER:
Only a doctor could operate, diagnose, treat, and prescribe, at least in an
unrestricted way. Those key functions, representing the broader physician functions, were to be
delegatable to specially trained personnel. [We completed a detailed position paper for the
Surgeon General, which subsequently became the federal position. Most training programs
followed this path. The task for each state was to pass an amendment to the medical practice act
to allow the practice of PA’s (Blair and I helped achieve this in Connecticut in the early 1970’s).]
Some states were more elaborate and added regulatory language that in some cases was very
detailed about how a program should be set up and what education the graduates would receive.
Others were basic and used two or three sentences that said essentially: "Nothing in the medical
practice act shall prevent delegation of these authorities to a PA”.
Blair and I moved on to Yale in 1970 to continue our medical legal collaboration. Yale’s
Department of Surgery had received a large grant from the Commonwealth Fund of New York to
develop solutions to the problems of emergency medicine and trauma. [Accidents and their
aftermath were labeled “the neglected disease of our society” by the National Academy of
Sciences.] Dr. Jack W.Cole was Professor and Chairman of the Department of Surgery, who I
had known in medical school; we kept in touch. Dr. Cole invited us to join him to direct the
program in Trauma and Emergency Medicine. Blair and I were very impressed with PA's and
we asked him if we could include a PA program as part of the Trauma Program grant. He was
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very supportive. Thus we had the authority, the impetus and the money to start the program at
Yale. In the fall of 1970, the first class of five students was enrolled. We asked a PA named Paul
Moson, who was one of the first graduates of the Duke program to join us. He and I met with
the faculty at Yale Medical School and the Yale School of Public Health and developed a
curriculum from scratch. We recruited students and trained them over 24 months.
We collaborated with Ann Bliss RN, an outstanding clinical nurse who had a Master's
Degree in clinical psychology and social work and was very interested in expanded roles and
what nurses could and couldn't do. She helped us understand the background of organized
nursing and what their views were about expanded roles of nursing and what their view about
PA's were likely to be.
In 1971, we were asked to write a position paper for five private Foundations, called, "A
White Paper on Physician Assistants: Looking at the Future". The Foundations were The
Commonwealth Fund, The Rockefeller Foundation, The Carnegie Corporation, The Foundation
for the Aid to Crippled Children, and The Macy Foundation. In the course of our studies, we
traveled and met other people in other programs, officials at the National League for Nursing, the
American Nurses' Association, and learned that organized nursing was not happy with idea of
PA's. In fact, organized nursing had spent most of its last 20 years trying to be separate from
doctors and separate from hospital administration. They were looking for independence. Nurses
didn't want to be “handmaidens” of doctors any more or “handmaidens” of hospital
administrators either.
On the other hand, what Duke had learned, with Thelma Ingles and Dr. Stead, was there
was a lot to be gained by taking in non-nurses and starting a new project, a new program—not
that nurses were excluded—that would work with doctors, tied legally to the practice of
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medicine. In fact, one very important bit of history that we learned from the Duke leaders was
that they originally started out with advanced nurses. They took some of the best cardiac nurses,
in the early 60's, and decided to train them at an advanced level to work with patients coming out
of ICU after heart surgery or after a heart attack, to do a lot of the care that residents in
cardiology and cardiac surgery—
WILSON:
Understood.
SADLER:
—didn't have time to do. So that, I think, was one of the reasons for developing a
”midlevel practitioner”. They started with highly qualified nurses. The pilot project was going
well and they wanted to get the program credentialed by the National League for Nursing, who
came to Duke and turned down the program. The reason the program was turned down was
there was too much medical input. It wasn't taught by the nursing school. So Thelma and—and
if I can call her by her first name; I got to know her and Dr. Stead quite well, just delightful,
creative people—decided, well, we're not going to give up. Let’s try Plan B. Plan B was built on
the fact that 6,000 independent duty military corpsmen were coming out of the service, every
year, because of the huge demands in Vietnam, and these corpsmen, in this case, mostly men,
were very well trained and were looking for a job in civilian medicine. There wasn’t a slot for
them in civilian medicine. They could go be an orderly, or they could do something outside of
health. Dr. Stead and Thelma Ingles said "Let's have a new program." And “physicians'
assistants” was the name they came up with, in 1965 I believe.
It was very important to us that we write about this background, which is what we did,
and try and make it clear to others that there were “lessons from nursing”—which was actually
the chapter in our book and not make the same mistake with PA’s. Let's not try to be
independent from doctors. Let's not compete. Let's not have tight boundaries about what PA’s
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do. Let’s be flexible. We also believed that it was very important that PA's stay close to doctors,
and we recommended an interdependent mode of practice. (Cat meowing) That's Bubba the cat,
by the way, looking for attention. She is not a nurse practitioner, a PA or a doctor. She's just a
cat.
We continued to train PA’s at Yale and in 1972 decided to take our Foundation paper,
which was comprehensive, and expand it into a book. The Physician's Assistant: Today and
Tomorrow, produced by Yale University Press. [Ann, Blair and I came up with a number of
recommendations, many of which became part of the national debate. In 1975, we updated and
greatly expanded the book, added the subtitle “Issues Confronting New Health Practitioners”
and published a second edition through Ballinger Press of Cambridge, Mass.]
One of the joys for me was working with others at other programs. Bill, I enjoyed
meeting your colleagues at Salt Lake City and the other MEDEX people. Dave Lawrence in
Seattle was actually a college classmate of mine at Amherst—
WILSON:
(inaudible).
SADLER:
—was the quarterback on our football team, class of '62. Go Jeff's! Beat
Williams.
WILSON:
(laughs)
SADLER:
Dave, wherever you are, you're still the best. He became, as you know, the
director of the MEDEX program in Seattle and later, was president of Kaiser out here. More
programs got started in other places, including at George Washington, where I met Tom Piemme
MD, who also was actively involved in the training of new health practitioners. A meeting at
Duke called the Annual Duke Conference on Physicians' Assistants was held. Soon there were
ten programs, then 20 programs, and people from credentialing and other fields attended. We
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decided to have a national meeting. We needed to have an organization. The PA’s coming out of
Duke and elsewhere needed to be registered and listed somewhere so they could get jobs. A
Registry was formed, by Dr. Bob Howard, who was the first PA Program Director at Duke. He
was the first president of the American Registry on Physicians' Assistants.
WILSON:
Ruth Ballweg asked me to have you clarify the relationship in history of the
Registry vis-à-vis the NCCPA. Because nobody knows how that happened.
SADLER:
Great.
WILSON:
OK? I'm glad you mentioned that because I would have forgotten.
SADLER:
The Registry was set up really as a place to put, in one setting, the list of all the
graduates of PA programs, so that, if a state legislature wanted to find out was this person a
legitimate graduate of the Duke program or wherever, they could. At these early meetings in the
early 70’s, we soon realized we had a lot more to worry about than simply registering PA's. We
needed to discuss curriculum, and what worked in your program and what worked in our
program. MEDEX was a very decentralized curriculum, with just six weeks, as I recall,
originally, or three months—correct me if I'm wrong, Bill—
WILSON:
It was three months.
SADLER:
—of didactic training at the university center and then going out with a
preceptor—
WILSON:
Right.
SADLER:
—for the rest of the training. At Yale and at Duke and some of the others, we had
a more centralized training. How could we learn from each other? And how did we teach? How
much basic science? How broad should this be? Should there be subspecialty elements? Many
of the same issues were being addressed by medical education. We needed to talk about that and
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decided to form an Association. We called ourselves the Association of Physician Assistant
Programs, APAP. I was elected the first President [I had also served as President of the Registry
after Bob Howard]. We started meeting and holding conferences. We recognized the need for
certification and testing of physician assistant graduates.
WILSON:
Standalone. Just—yeah.
SADLER:
At that time, the National Board of Medical Examiners, based in Philadelphia
became very interested. Dr. John Hubbard was the president. Dr. Edie Leavitt, who later became
president, was one of his chief deputies. And they were looking at credentialing of physicians.
The GAP report, a report on the future of medical education, examined credentialing of
physicians in general and subspecialty training in particular. They became aware of PA training
and were willing to consider, for the first time, testing and credentialing non-physicians. A group
was convened in the early 70's, of which Blair and I were the chairs. There were about 15 of us.
I remember Archie Golden from Johns Hopkins, Tom Piemme from George Washington
WILSON:
Bob Kane, from—
SADLER:
Bob Kane Right. Chuck Lewis I think was involved. Some of the MEDEX
leaders were too. Our charge was to develop a certifying exam. Barbara Andrew PhD, of the
National Board in Philadelphia, was assigned to actually write the test.
WILSON:
She was a psychometrician.
SADLER:
Yes.
WILSON:
And then we got money from the foundations and the feds to help us do it, and
were—
SADLER:
Yes
WILSON:
We had to get— it was a lot too. Because—
8
SADLER:
It was a big undertaking
WILSON:
Yeah.
SADLER:
We used some studies at Hopkins, where they'd looked at the functions of what
people do, physicians doing primary care, and stepped back from that to develop core knowledge
and skills for primary care.
WILSON:
Task analysis or—
SADLER:
Yes, task analysis
WILSON:
—needs assessment.
SADLER:
We focused on a clinical exam, with less emphasis on basic science. In addition to
the multiple choice questions and answers, there were clinical problem test questions. There was
a hands-on physical exam part of this—
WILSON:
Right.
SADLER:
—in which, as part of the exam, the student graduates would be observed doing a
physical exam on volunteers—
WILSON:
So—
SADLER:
—who would be simulated patients. It took a lot of creative activity to make this
exam work. The National Board was looking at a lot of the same issues for physicians, trying to
make physician testing more clinically directed rather than basic science-directed. We identified
a body of knowledge and test for that, rather than making a test that was so difficult that nobody
could pass it and then play with the cutoff level to separate the ‘good’ from the ‘bad’. If we could
define everything a PA should know, ideally, the programs could go back and teach that, and
every PA theoretically could get 100 on the test. I'm being simplistic, of course in my summary
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of this. It was a fascinating exercise. Since that time the National Board has continued to
provide the test. And we're in 2003, so its 30 years. Because it was 1973 that—
WILSON:
Yeah, '73 it was the first exam.
SADLER:
Another part of credentialing was how do you credential programs? The AAMC,
Association of American Medical Colleges, works with the AMA to support a joint commission
on accreditation of medical schools and residencies. We knew we wanted to work with
organized medicine and we met with the Association of American Medical Colleges. In fact, the
first several annual APAP meetings were always held in conjunction with the AAMC annual
meetings. We felt—
WILSON:
Yes.
SADLER:
—it was very important to be close to organized medical education and organized
medical practice.
WILSON:
With the exception of the first one, this was in Wichita Falls, Texas. Remember?
SADLER:
No, that was actually our first annual PA meeting after the Duke annual meeting
went nationwide.
WILSON:
Yeah.
SADLER:
That was not just an APAP meeting.
WILSON:
Actually, that was the academy's meeting.
SADLER:
That was an academy meeting. Yes.
WILSON:
Yeah. That's right.
WILSON:
But we did have—the APAP meetings.
SADLER:
The Air Force was willing to help host that first meeting on new health
practitioners at their base. [There was very little money to host an annual meting and we
10
appreciated their willingness to support the first venture.
Over the course of the early 70's, the
program leadership.]
WILSON:
Who were mostly physicians.
SADLER:
We were mostly physicians but some were early PA graduates like Tom Godkins,
Paul Moson, Bill Stanhope, and Carl Fasser. We went to Chicago and met with AMA. A number
of meetings were held, some of which were hosted by the feds, some by several Foundations, to
figure out the best way to credential programs. What was a “good” program? We discussed how
long it had to be and how much could be done off-campus.
WILSON:
Who could teach.
SADLER:
At the same time, new medical schools were being formed, at great rate. There
was expansion of medical school size. Some schools had very creative curricula, like University
of Georgia.
WILSON:
Yeah.
SADLER:
They were experimenting with offsite teaching. So it wasn't just PA training who
was doing this. We were, in many ways, pioneering in medical education more broadly.
WILSON:
Family medicine was just starting too.
SADLER:
In the early to mid-70's, the federal Office of Regional Medical Programs helped
fund decentralized education, first based on heart disease, cancer, and stroke, but eventually in
regionalized care and education for all kinds of health problems.
WILSON:
That's right.
SADLER:
Looking at inner city and rural areas.
WILSON:
Primary care shortage.
SADLER:
Yes, there was clearly a shortage in Primary care.
11
WILSON:
We have that every 20 years now, I notice. We have a crisis in primary care.
SADLER:
We were fortunate then. There was money and there was interest. “The Great
Society”, after all, was Lyndon Johnson's big domestic push in the late 60's. There was money
and interest at many levels to try and get care to people who were left out.
WILSON:
Change the system.
SADLER:
Change the system. A lot of us were very hopeful that we could do that. In fact,
we did. After credentialing of programs, and certification of graduates, another issue was how to
provide continuing education for PA's – and how to address recertification. How could the field
grow and develop, keep open to new ideas and yet have certification of quality that, if somebody
in a state like Montana, which didn't have a program at first, wanted to get a graduate from
another state, how could they be sure that the graduate was qualified? We came up with the idea
of a National Commission on Certification of PA's, the NCCPA. That organization, we believed,
should be broadly governed by organized medicine, nursing, medical education, hospital
medicine, AHA, specialty groups, particularly the specialty groups that were interested in PA
training, which was the primary care disciplines, and some at-large members. I think there were
21, originally, on that Commission. David Glazer, who had been working very successfully in
developing PA program at Emory, in Atlanta, was tapped to be the first Executive Director by
Tom Piemme and me. The NCCPA became the interface between the National Board of
Medical Examiners, which didn't want to deal with all the interface issues between the states and
the professions. The NBME wanted to stick to testing. That was their job. There is a medical
board for doctors in every state and a state nursing board. There was a need for some entity
nationally to interface with the various states regarding PA’s. The National Commission was
designed to be that entity. Another important entity that was established at that time was a
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National Office for the Academy of PA’s and for APAP. I remember Tom Piemme and I, one
day, walking—doing the foundation walk, we called it, in New York, and were able to raise
funds, at the Ittleson Family Foundation and—
WILSON:
$125,000, wasn't it?
SADLER:
I can't remember the exact amount -
And the Von Ameringen Foundation, to fund a national office. Don Fisher became the first
executive director. He was a PhD at the University of Mississippi, if I'm— Again, check me on
my facts, Bill.
WILSON:
I think you're right.
SADLER:
Don was a very dynamic leader and had done a great job with the PA Program at
Mississippi. He was willing to move to Washington and take on the new national executive
office for AAPA, the PA Academy, which was just getting going, and the society of programs
(APAP), which was at that point more evolved than the society of graduates, was. There were
more of us training PA’s, than there were graduates, in the early years.
We wanted to avoid the split between medical education, as represented by the AAMC,
and the practice of medicine, as represented by the AMA. Certainly, growing up in medical
schools, most of us were indoctrinated by professors and academics, who tended to talk down
about the people “out there in practice”. Yet we wanted PA's to be “out there in practice”. The
point was let's stay together. Let's have the education group—APAP and the practice society,
AAPA work together on all of these issues, where possible. Let's have a central executive office
and have that be a repository of information, knowledge, and research, etc. That was our grand
design in the early 70's.
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Personally, Blair and I did extensive work on emergency medicine at Yale, in the state of
Connecticut and nationally. We were asked to join the Robert Wood Johnson Foundation in
1973. Robert Wood Johnson was one of the founders of the Johnson & Johnson Company.
After his death in 1968, $1.2 billion was given to a foundation, named after him. After four
years of probating the will, the funds were available to give as grants to people and institutions,
in 1972.
We were invited to help Dr. David Rogers, president, and Margaret Mahoney, who was vice
president, and others direct the Foundation, based in Princeton. The focus was on three principle
issues: getting better access to care for inner cities and rural areas; studying policy questions and
getting data on healthcare access issues, and focusing on primary care training. We looked at
residency programs in internal medicine and pediatrics and tried to move some of them, toward
primary care. We funded residency programs that were willing to put, say, four slots out of 20 in
primary care. In these programs, interns and residents would receive more emphasis on
outpatient care, primary care, general care and less on subspecialty medicine. We did the same
with pediatrics. We helped support family medicine, which was emerging at the time (1973).
WILSON:
Yeah.
SADLER:
We also got very involved in emergency medicine. It was clear from our Yale
experience, that regionalization was essential. In Connecticut, we developed 11 regions, each
with its own central dispatching and organization. The Foundation established a large regional
program based on our Yale model that Blair directed, in 44 different areas in the country, to
regionalize emergency medicine.
WILSON:
And trauma centers—now, and—
SADLER:
Yes
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WILSON:
There were no EMT’s.
SADLER:
There was no Emergency Medicine Residency for physicians at that time.
WILSON:
I'll just butt in for a second.
SADLER:
Please do.
WILSON:
I tell my students that just imagine if you're in rural Utah and you’re hit by a boat
propeller, or a tractor runs over your legs. And here's what you don't have: the cell phones,
computers, Life Flight, EMT's, a doctor very close by, unless you can get to him yourself.
Certainly no ambulance is going to come out where you are.
SADLER:
Or if you've had an ambulance, it was shaped like a hearse. You couldn't work
around a patient.
WILSON:
No.
SADLER:
There was no room.
WILSON:
The first computer we ever had filled a whole floor of a hospital and cost a
million dollars, a million-one, or the computer, Control Data computer, and then another half a
million dollars for the environment for it so it wouldn't get too hot or too cold or all that. Now a
PC would do three times as much as that thing.
SADLER:
Yes
WILSON:
But those were the things that didn't exist when we started this. And one has to
think that we've made a difference, that all those things have made a difference. And they have.
If you look at people who die now of silly reasons, and in rural American, they're way down
from what they were in the 60's.
SADLER:
We're still human beings doing stupid things—
WILSON:
That's right.
15
SADLER:
—like driving too fast and eating too much,
WILSON:
But now you don't pay the price for it—
SADLER:
The emergency medical systems, at least are working much better. .
WILSON:
It's hard for kids, the new students, to understand that because those things have
always been there.
SADLER:
That brings me, personally, up to 1976. And after three years at the Robert Wood
Johnson, I decided to finish my clinical training. I had the primary care bug by that point and
went to Massachusetts General Hospital and Harvard Medical School and completed their
primary care track in internal medicine, which I enjoyed enormously. In 1979, I joined the
UCLA faculty as an associate professor of geriatric medicine and helped launch the geriatric
medicine program with Drs. John Beck, David Solomon and Bob Kane.
I came here to practice in 1981 and have been here on the Monterey Peninsula for 21
years. Currently I'm Medical Director of an Urgent Care Center in Salinas. We are open every
day of the year. We have an outstanding PA, trained at Stanford, Steve Panatonni, who works
with us, and another PA, who's a nurse and a PA, also trained at Stanford, who is with us parttime. In the 1980’s I established a primary care clinic in nearby Marina with a PA colleague
focusing on care for the underserved. [After eight years, we turned practice over to the Monterey
County Health Department who manages it today. Our Salinas Urgent Care Center has served as
a preceptor site for the Stanford PA Program and the San Jose State Masters Nurse Practitioner
Program.] I've tried to practice what I've talked and written about.
Bill, we were talking before our interview about Mary O'Hara – Devereaux and Dr. Len
Hughes Andrus. When I was at the Robert Wood Johnson, we invested in certain creative PA,
nurse practitioner programs, one of which was at UC Davis. This collaborative program with
16
Stanford was the only one to take nurses and non-nurses and train both side by side, and to see
how this would work. And it, in fact, worked great. I remember well a site visit to UC Davis that
Ann Bliss and I made for the RWJF in 1972.
WILSON:
Yeah.
SADLER:
Len Hughes Andrus grew up just down the road from me here in King City. I
didn't know where King City was back then, but I certainly do now.
WILSON:
And his father was a physician there too.
SADLER:
Really? It is so nice to hear about them again. I have the new novel that Hughes
wrote. Ann Bliss is still at Yale and teaching in the PA program there.
WILSON:
I didn't know that.
SADLER: I was very glad to hear about the 30th anniversary of APAP last year. I couldn't
believe it was 30 years. (laughs) And there is now a historical section at Duke, that Reggie
Carter, who I was happy to work with years ago at Duke, is chairing, to have a repository of PA
history, lore, data and information. I am thrilled to be one of the people being interviewed to
contribute to that. I got together with Tom Piemme when he and Judy came through here 18
months ago. Visiting with you now, I am stimulated to pick up the phone and call a few people
that I've been thinking about.
WILSON:
Call Dave Lawrence because he is now decompressing a little bit,
He’d love to talk.
SADLER:
Great!
WILSON:
I've got his number.
17
SADLER:
To bring you up to date on Brother Blair, he has been president of Children's
Hospital of San Diego for the last 22 years and has somehow survived all the buffeting of
reimbursement rising and falling and management crises of one sort or another.
I think maybe I'll end with that, unless you think of something else that I left out or want to ask
me something.
WILSON:
Well, I'd like to ask you two questions.
SADLER:
Sure.
WILSON:
When Mary, Hughes, and I talked about this stuff earlier in the week, all three of
us were worried that our system is broken again, the medical care system. For different reasons
now—
SADLER:
OK.
WILSON:
—than then, money being one of them, managed care being one of them, and a
whole lot of things. And I think the future PA's is going to be caught in that for a while - the
need for more geriatric facilities and training and practitioners, etc. And the question about what
can young PA's or beginning PA's starting out do to strengthen the profession, given the mistakes
of—given what we've learned in the past? What are the kinds of guideline one can follow to
keep the profession viable and as healthy as it has been? Do you have any prognostications?
SADLER:
I think we need single-payer health insurance. I've joined the group of doctors to
move this country toward a single-payer health insurance. John Conyers, in the House, just
submitted a bill yesterday for single-payer health insurance. It’s based on the work of Stephie
Woolhandler and Bruce Himmelstein in Boston, Quentin Young in Chicago and others.
WILSON:
Yes.
18
SADLER:
Many people have studied how much waste there is by having all the separate
insurance companies competing, with all the bureaucracies that need to be funded, that doesn't
have anything to do with providing health care.
WILSON:
That's right.
SADLER:
So we need to go to something that's very simple. I think a single-payer system is
the only way to go. Should the government take it over? No. I would say it should be “quasigovernmental”. There could be an entity set up, like there has been in other areas of our society,
in education, in transportation, where there's a central federal focus and funding. I'd like to see a
nongovernmental organization established that has wide participation much like the NCCPA did
for PA's.
WILSON:
Yeah, freestanding.
SADLER:
It should have some public input, physician input, expertise from academic health
centers and from the insurance companies and financial people.
WILSON:
And the data.
SADLER:
This group can help make policy on the tough questions, such as what should be
included in insurance, address alternative medicine issues and stop-loss issues for very expensive
care for one person. The debate would be open to the public, to provide full disclosure. Certain
states tried some of these things, the Oregon, Hawaii—
WILSON:
Yeah.
SADLER:
We also need to come up with a budget for health. It would cut out the insurance
middleman and simplify matters. We'd have one form, one way to do it. I don't think the
marketplace has worked in medicine. HMO's have not worked. And—
WILSON:
It's been a disaster!
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SADLER:
I think we should try this and all work together to do achieve a new system.
WILSON:
Do you think George Bush and Dick Cheney would agree to do anything like
that?
SADLER:
I think they're more interested in keeping the market forces and insurance
companies and try to tweak the present system. I think we're past that solution. As far as PA's
are concerned, I think it's critical that PA's, doctors, nurses, all stay working together, and that
we credential together and not get into an adversarial relationship like what happened with
nursing, medicine and hospitals in the 60's. I have been out of PA politics for the last 20 years
and am serving on the frontlines of patient care but from what I understand, there's been a lot of
dialogue back and forth regarding the NCCPA as to whether it should be taken over by PA's and
run by PA's, which I would be against. I think the reason it had such credibility is because there
has been physician, hospital, nursing input, as well as, of course, PA input. Interdependence is
crucial. Within medicine, we doctors depend on each other. As a primary care doctor, I deal
with all specialties. Our Center is part of the Department of Emergency Medicine at my
community hospital. We're dealing with our emergency room doctors when something's beyond
our scope of care. There's a new group of hospitalists now.
WILSON:
Yeah.
SADLER:
PA’s will still be dependent, legally, upon physicians. And as a result of being
dependent legally, they'll be able to do a lot more.
WILSON:
Yeah.
SADLER:
That was the paradox that we tried to drive home in our book 30 years ago—and
certainly we weren't the only ones saying it, that if you were dependent legally you could do a lot
more clinically.
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WILSON:
Yeah, there's—
SADLER:
If you're independent, then by definition, since you don't have full physician
training, you will be more narrowly circumscribed as to what you're allowed to do.
WILSON:
That's right.
SADLER:
Otherwise, have a doctor do it.
WILSON:
I think that nursing educators are still back on that old song. I don't think they've
changed.
SADLER:
Well, I'm not close enough to that to know.
WILSON:
At least in my area, I think that's true.
SADLER:
I am concerned that many nurse practitioners programs are directed and taught by
nurses only and lack adequate medical education.
WILSON:
Yeah.
SADLER:
We need to be able to keep the dialogue going. It's fun, creative and stimulating.
WILSON:
Would you be willing to come off the sidelines and play if we have another
skirmish on the national field about changing the system?
SADLER:
Oh, sure. I've got enough gray hair now. Maybe someone will listen to me!
WILSON:
Will listen to us?
(laughter)
SADLER:
Yes.
WILSON:
We had to yell, before.
SADLER:
I just enjoy being part of the process.
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WILSON:
One of my fantasies is we get some of those very creative people back together
again and see if anybody will listen to us about changing the way the system pays for itself
now—and denies access arbitrarily also.
SADLER:
We can put our two cents in.
WILSON:
Why not? Why not? Thank you, very much.
SADLER:
Thanks Bill. Thanks, Lyle.
(End of interview)
Edited by Alfred Sadler – January 2007
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