FROM THE BOOK "TOGETHER: A Case Study of Joint Practices in Primary Care"

© 1977 The National Joint Practice Commission

The eight-story Doctors Office Building, towering high above the treetops in a quiet neighorhood in Cambridge, Massachusetts, is occupied-with one notable exception--by physicians on the staff of the adjoining 300-bed Mt. Auburn Hospital. The exception is the occupants of Suite 511. The sign on the door of Suite 511 reads: R. K. Funkhouser, M.D., J. E. Steel, R.N. Doctor Funkhouser--Robert K. Funkhouser--is a Harvard-trained internist, gerontologist, and specialist in community medicine. Jean E. Steel is an adult nurse practitioner and an expert in community nursing. The two have pooled their unique but highly complementary talents to form a nurse-physician joint practice.

Doctor Funkhouser, a rumpled giant of a man (6 feet, 6 inches tall), is approaching 50. He was born in St. Louis, Missouri, where his grandfather, a lawyer-doctor, was a famous coroner, and his father was a surgeon. At the age of eight, he saw his first post-mortem. At 22, he graduated from Harvard Medical School. His precosity then ended. He was 33 before he began to practice medicine. "I was young," he says. "I had a leisurely sense of time."

Those "leisurely" 11 years shaped the aging young physician. He spent three years as an intern in Cleveland, switching from surgery to medicine. He served aboard a troop transport as the ship's doctor. He completed a residency in internal medicine and a fellowship in cardiology. Then, raised an atheist, he began worrying about how the dying were treated, became interested in the theology of Paul Tillich, and accepted a two-year fellowship at Harvard Divinity School. There, he studied the background of the Bible and existential philosophy. He also worked at Boston's famous Peter Bent Brigham Hospital, trying to understand how it felt to be dying.

When he finally hung out his shingle in 1959, Doctor Funkhouser embarked on his present course of working only half-time in private practice. With a cavalier disregard for money, he used the rest of his time in such causes as running neighborhood health centers in poverty neighborhoods, worrying about "the forgotten old people" in nursing homes, running a geriatric clinic in a Harvard teaching hospital, and using his expertise to train young doctors in planning for their elderly patients' care after discharge from a hospital.

"You can be helping patients with medical things until the cows come home," he says, "but if you don't make practical arrangements for food and shelter and nursing care for these down and out old people, then you're not approaching their needs at the right level."

Jean Steel, a slim energetic woman of 39, with short-cut greying hair, is the daughter of a Cleveland doctor and nurse. After a brief career as a medical secretary, she ended up at Cornell University--New York Hospital School of Nursing, where she earned a bachelor of science degree. That set her direction.

"While in school, I worked in East Harlem with the Visiting Nurse Association and 1 knew from the first that I wanted to do community nursing," says Ms. Steel. "I liked working with black people and other minorities and, to my surprise, they liked me. Marvelous old people would grin from ear to ear when they'd open their doors and see it was me.

Ms. Steel's parents had long had a place on Cape Cod and she spent many pleasant summers there, so it was not unnatural for her to choose to work in Boston. She spent eight years with the Boston Visiting Nurse Association (VNA)--two years as a staff nurse, and the rest as a VNA supervisor in poor neighborhoods, such as Roxbury and the South End. But that wasn't quite what she wanted. She went back to school, to Boston University, and earned a master of science degree in community health nursing. She went to work again, and served for three years as executive director of the VNA in Framingham, a bedroom community 20 miles west of Boston.

Her next job was nursing director of the Harvard Community Health Plan, a new health maintenance organization (HMO). The plan was considering training its own nurse practitioners, so Ms. Steel felt compelled "to learn what it was all about" by enrolling in a new course for nurses at Peter Bent Brigham Hospital. Dr. Funkhouser was one of the course instructors.

"The course was supposed to be part-time," Ms. Steel says, except that it wasn't. Classes then met for only a day and a half a week, but there was a tremendous amount of studying to do and it was impossible to do all that and work at my job, too" Her problem was resolved, however, when disagreement regarding who should hire and fire nurses resulted in Ms. Steel's resignation. She then had plenty of time to finish the four-month course.

"We had lectures from 8:00 a.m. to 5:00 p.m.," she says. "They covered various systems. When we studied the heart, we'd hear from a physiologist and cardiologist; we'd study nursing responsibilities and the phalmacology of cardiac care. I had learned most of this before. The course was actually a review of things I'd studied in college, but added the skills of history-taking and physical examination."

Neverthless, it changed her life. Her acquaintanceship with Doctor Funkhouser ripened into friendship. "I was especially impressed with his concern for very old people," she says. And he was impressed with her.

When she received her certification as an adult nurse practitioner in January, 1974, Funkhouser offered her a job at a salary of $17,500 a year --somewhat less than she had been earning before. But she accepted. In actuality, her income was determined by the time she spent in practice, which turned out to be less than full time, and only amounted to $12,000 for the first year. Says Ms. Steel about the reduced income that first year: " I did not feel it fair to charge Rob for time spent in building my caseload, or for time spent when no patients were present."

Ms. Steel says that, originally, Doctor Funkhouser had offered to let her keep her own fees after paying her share of the expenses. "But I was nervous about fee-for-service," she says. "I didn't know whether I'd be any good at it or not. I never had had to sell my nursing skill."

Things improved, however, when Doctor Funkhouser, preparing to move into his present new and larger office, sent his patients a letter saying: "Joining me in the office will be Ms. Jean Steel, R.N.... Because of our collegial teamwork, we will be more available for patient care. Ms. Steel will be providing any nursing care needed and, in addition, will be available for physical examinations, treatment of minor illness and chronic disease, as well as teaching and counsel. I regularly confer with her regarding patient care and management. I hope you will ask for her, particularly when I am not available. We are a 'first' in Cambridge in a team of medicine and nursing private practitioners." They had both, at last, found themselves.

Patients coming to Suite 511 in the Doctors Building see a good-sized waiting room, staffed by a receptionist occupied with typing medical records. The five elegant wooden chairs are mostly antiques, inherited by Doctor Funkhouser from his father; the worn Oriental rug came from the New York office of a music publisher, who was Doctor Funkhouser's father-in-law. On the wall, a chart of Boston Harbor reflects Doctor Funkhouser's interest in sailing. He owns a 33-foot Bristol auxiliary sloop which he anchors near the Boston airport.

Most of our patients are upper middle class," Doctor Funkhouser says Some are professors and students who don't want to go to a universlty health service. We also encourage Medicare patients, and they make up 15 to 20 percent. For a long time, I was the only doctor in Cambridge who was giving birth control advice--it used to be against the state law--and this made up about a third of mv practice. Now we can do this openly, and it is a good part of what Jean is doing. We also develop plans of care for elderly people and Jean does an awful lot of home visits.

At first, when new patients came in the receptionist would offer them the services of either the physician or the nurse practitioner and too many to suit both the doctor and the nurse practitioner would select the physician. Nowadays, the receptionist is instructed to explain Ms. Steel's qualifications and try to get her to do the initial workup. "Our patients are a sophisticated bunch," she says. "It's not unusual for them to ask the receptionist for my curriculum vitae. They want to see how I was trained."

By the end of 1974, Ms. Steel was attracting her own patients, but some of Doctor Funkhouser's old ones stubbornly resisted seeing her. "A lot of patients who first see Jean will stick with her after the initial exam," he says. "But those who have been my patients for years still expect to see me. One woman said yesterday: 'When I chose you, I chose you.' She was very hurt that somebody else might take her blood pressure and supervise her hypertension. If people feel that strongly about it, I'll take their blood pressure."

Both practitioners have their own examining rooms. Ms. Steel furnished her own. The instrument table is made of two old, repainted chests with a new formica top laid over them. The examining table is an ancient one, scrounged from a friend and repainted in the front where it shows. On the wall, in Old English lettering, is a credo that Ms. Steel composed:

O Lord. Give me the wisdom to accept necessary counsel, the power and knowledge to make sound decisions, the creative freedom to initiate and accept change, and the skill and means to provide the finest nursing care to my fellow man in a safe, humane, and loving manner. Above all, guide me in gentle ways to be sensitive to others, their beliefs their needs, their opinions, and their ultimate dreams.
Ms. Steel says that many of her patients react favorably to this statement. "They say, 'Gee, that really tells me a lot about you!'," declares Ms. Steel. "That's good. I want them to know that these are my standards."

The letterhead on which bills are sent out carries the names of both practitioners. Their business card also carries both names. The prescription form lists only Doctor Funkhouserss name, however. They both charge $15 for a standard 15-minute office visit. Ms. Steel charges $30 for an initial, comprehensive exam, for which Dr. Funkhouser's charge is $55.

"I've learned a very important thing from this practice," Doctor Funkhouser says. "At first I felt myself responsible for every act the nurse performed. But now I realize that the nurse is an independent practitioner, licensed by the Board of Registration, and she's practicing nursing. What she's doing is collecting data and that's always been a nurse's work."

Ms. Steel is in the office Monday through Friday, all day. Doctor Funkhouser, however, is away three afternoons a week. That means the nurse practitioner is used to being on her own. "After a workup," Doctor Funkhouser says, "Jean makes a list of things she wants to ask me and once or twice a week, between patients, we'll sit down and go over it. She'll run through a history and physical and ask about the things that she needs help with. I leave this entirely to her judgment. She's a highly experienced person with good clinical judgment."

A visitor gets a quick demonstration of how the associates in Suite 511 work together. Ms. Steel examines a "sty" that a young woman in jeans and sandals says has been bothering her for several weeks. The woman, a recent law graduate, had lanced it with a needle and some pus came out but the lid still looks swollen. Ms. Steel excuses herself and comes back: "I just looked in a textbook," she tells the young woman, "and there's nothing to do for a sty except the hot compresses that you've been putting on them. I want Doctor Funkhouser to look at it. Maybe hydrocortisone will help"

Doctor Funkhouser takes a quick look and says: 'What we have to tell is the difference here between a sty and a chalazion, a fat-filled cyst."He rolls the eyelid back. "This is a chalazion; it's like a wen. It has to be removed by an ophthalmologist." Ms. Steel gives the woman the name of an eye specialist in the building and bills her only $10, "because I took very little history and I'm sensitive to the fact that I had to refer her to someone else."

To the visitor, Ms. Steel notes that the young woman had said initially that "she was all for paramedical people, so that meant she was prepared to have me admit my limitations. I don't feel bad about telling someone I don't know all about stys."

If Doctor Funkhouser is absent from the office, Ms. Steel can usually reach him through the paging beeper he wears constantly on his belt. But if something comes up in the office and she can't reach him, she can get backup help from several doctors in the building. She gives an example:

An elderly lady in her 70's came in to have her toenails cut (she couldn't do that for herself ). She was in need of a checkup, and I found an enormous lump on the breast. It was the ugliest cancer I've ever seen; it was draining and indurated. Rob was not available, so I got the hospital chief of surgery on the phone and told him what I saw. He came right over and admitted her to the hospital immediately. She had surgery and is doing fine today."

Sometimes Ms. Steel will ask a patient to wait in the office until Doctor Funkhouser can come there. She remembers: "A man complaining of rectal bleeding came in and gave a history like hemorrhoids. The exam showed it was more like venereal warts but I wasn't sure. I asked the patient to wait for half an hour until Doctor Funkhouser could get there. I told the patient I wasn't sure of my diagnosis. Most patients are reassured by such honesty. Rob came in and I told him, in front of the patient, what I had found. It turned out the guy had a hemorrhoid, but it was so badly excoriated that it looked like venereal wart."

Commenting on the backup that she got in this case, Ms. Steel says: "This is one of the main reasons that I'm in a joint practice. Doctor Funkhouser comments: "The unique service that a doctor gives is understanding the complexity of a disease."

Ms. Steel has her own paging beeper and responds immediately by phone to any patients who call her answering service after hours. After assessing a complaint, she may direct the patient to the hospital emergency room. "Sometimes this doesn't work out too well," she says. "I had a woman go in who was threatening suicide. I talked to the intern on the phone and he was surprised that a nurse was seeing a patient as sick as this. Next day, the patient called back, again threatening suicide. She had been sent home. I talked to the resident and she was finally admitted."

Ms. Steel's hospital privileges are a problem. She has none at all at Cambridge Hospital, where Doctor Funkhouser is director of community medicine and where he sees about half his patients. Nor have her privileges been formalized at Mt. Auburn Hospital. "However," she says, I just walk in and write on the record when I want to write on the record. Sometimes a resident will give me a hard time, then I get Rob to talk to him."

Occasionally Ms. Steel savors victory. She faced a real challenge with some nursing colleagues when a disoriented elderly woman she had admitted to Mt. Auburn after a fall "started raising all kinds of hell and getting all the nurses mad. The nurses became interested in my approach to the patient when the woman said she wanted a drink, and I bought her a gallon of rose wine, and she calmed down. Then they vvanted to know her background and what I saw as her problems. I explained that the woman couldn't see too well and suggested that when they went into her room that they should walk over and put a hand on her and tell her who they were. This worked fine. The nurses got to like the old lady and still ask me about her."

Ms. Steel has strong notions about what service she is not qualified to render. "For example, if a patient calls and says he has a bad back, I'll save him from paying two doctors and refer him immediately to an orthopedic surgeon," she says. "I don't know anything about bad backs."

"Another specific complaint that Rob and I have agreed I can't handle solo is when someone has a stomach ache. I may get the patient in to do the initial workup, but I'll either call Rob in or refer the patient to somebody else. I have good relationships with several internists in the building. When I refer a case I request a report. It amuses me that only about four of the men to whom I have sent referrals have replied with a note to me. The others insist on writing Rob."

The Funkhouser-Steel practice is guided by protocols. They are contained in a one-inch thick plastic looseleaf notebook with index tabs. The protocols, gleaned by Doctor Funkhouser from various hospitals, offer guidelines for managing such ailments as congestive heart failure, diabetes, hypertension, and strep throat.

"I don't like these protocols, but I haven't done anything about them," Ms. Steel says. "They were written by doctors and don't reflect nursing concerns. For example, a patient may be required to be on a low salt diet. A nurse would ask, does the patient eat the foods that a doctor thinks he eats? A patient who is told not to eat ham or pork because they are too salty might instead eat chitlings, which are even saltier. Or a patient told to avoid excessive sugar consumption might drink a kosher wine like Mogen David, on the mistaken assumption that kosher wines don't have sugar. Caring for people isn't as cut and dried as this book of protocols implies."

Despite the newness of her profession, Ms. Steel has had no trouble getting and keeping malpractice insurance. Doctor Funkhouser, checking on his own insurance, was told by his insurance agent that "we have had unusually good loss experience with doctors who work with nurse practitioners?" Ms. Steel buys her own insurance, at a modest price, through the Massachusetts Nurses Association.

Ms. Steel believes it is important that she have peer review. On the first Monday of every month, she meets at her office at 5:00 p.m. with two veteran nurses. One of them teaches geriatric nursing at Boston University and the other is skilled in psychiatry and community health. She pays them $10 each for the hour to go over notes she has accumulated during the previous four weeks. 'I keep a list of the patients I've had difficulty with--because I didn't know enough about their disease, because I had trouble communicating, or simply because I didn't like them. I also list interesting cases.

'I think I insulted Rob at first, because he thought he was my peer. So I invited him to join us for a session, and he was reassured that these nurses weren't domg something that he should be doing. I won't ask them how to treat a strep throat. That's what I ask him. That's medicine.

"I just felt that l needed someone to counsel me and remind me about doing a good job of nursing. These women give me their experience as nurses. They also give me comfort. In a solo arrangement like this, you're isolated from your own peers."

It may be that Ms. Steel's deep identification with nursing (she is running for president-elect of the Massachusetts Nurses Association) is responsible for such feelings. That identification is responsible for her answer when a patient asks, "Why don't you become a doctor?" Ms. Steel invariably replies, "I don't want to be a doctor. I want to be a nurse."

Ms. Steel is very definitely a nurse when she leaves her office to visit homebound patients. A visitor accompanies her to a monastery where an 85-year-old monk has been confined to his room after suffering a stroke two years earlier. Ms. Steel was instrumental in getting the 20 monks living there to agree to keep the old man in the monastery and care for him there instead of sending him away to a nursing home.

"I went there three times for meetings with all the monks to talk about their feelings about aging and to get them to change their attitudes," she says. "I also helped them find a man to care for the patient and I spent a lot of time training him."

Today, the old monk greets her cheerfully. He has been listening to a recording of a book. Ms. Steel had suggested he send away for the Talking Book, after realizing he could no longer read easily. (She also got the monks to buy him a small TV set so he could watch the news, but, to their consternation, he quickly became addicted to daytime soap operas. )

Although the old monk is cheerful, Ms. Steel sees something amiss. The patient's paralyzed right arm is in a plastic splint and the hand is twisted into a claw. Rotating the wrist, she says: "This is really tightening up. What you need is a new and wider strap on the splint so this won't happen. Can I borrow this for a few days and get you a new strap?" Pleased, the old monk nods his assent.

Outside the patients hearing, Ms. Steel talks to one of the monks who cares for him. She wants to know if the old man is still so demanding. "You sometimes have to say no to hirn," she advises.

Her next visit is to a beautiful grey-haired woman in her 90's who has been exceptionally active until now--walking many blocks every day and keeping busy with several hobbies. recently, she fell--and she fell apart," Ms. Steel says. She went home and to bed from the emergency room and caught pneumonia as a result. I went over and walked her every day to keep her from having to go to a nursing home. Then I found a retired woman to stay with her. I want her to be able to get out of the house, but first she has to learn how to get up and down stairs again."

At the woman's apartment, Ms. Steel gets the woman to put aside her aluminum walker and, using a cane, practice walking down from the second floor. When the woman wearies, the nurse has her rest by sitting down on the stairs. Then she drills the woman's caretaker in the same exercise, and shows her how to stand below the woman to break her fall if necessary. "I'll be back to see you day after tomorrow," she says And she means it.

Ms. Steel also visits patients at nursing homes. She has courtesy privileges at the 75-bed Prospect Street Nursing Home, but at others she has to go as a "visitor" during visiting hours. She is enthusiastically received in the rooming houses that shelter the aged. "I went to see one patient in a Somerville rooming house, and before I left I had seven patients," she recalls with pleasure. This is impressive, since Medicare does not cover these patients' bills for neither Ms. Steel nor Doctor Funkhouser qualify as a home-care agency.

Many of Ms. Steel's referrals come from the Cambridge-Somerville Home Care Corporation, a government-funded project for providing meals, homemakers, and other services to the aged. "They call and say they've found someone very sick who doesn't have a physician," she says. "These are people who haven't seen a doctor in 20 years. In one visit, I can identify ten major problems. As a former visiting nurse, I know the importance of seeing someone in their own environment as a means of assessing needs. Then I get their lab tests started and make an appointment for them to see Rob. They like my taking the time I do when I take care of them."

The time Ms. Steel takes with older patients is indeed impressive. A visitor watches her spend nearly an hour in an office visit with a woman in her 80's who is suffering from congestive heart failure and arthritis of the hip. The waiting room is empty for a moment, so both Doctor Funkhouser and Ms. Steel chat there with the woman, apparently aimlessly, about her enthusiasms for gardening. "But this isn't just chit-chat," Ms. Steel later tells a visitor. "it's important for us to know that she's out in the garden, that she's active."

Besides old folks, Ms. Steel is also attracting young folks I suppose you could call some of them women libbers," she says. "They hate doctors, they hate medicine, and they particularly hate men doctors. They are setting up do-it-yourself clinics in the conununity and, I warn them, are getting second class care. But, after one of the women in the group first came to see me, a lot of them became my patients."

One of Ms. Steel's most important referral sources is Doctor Funkhouser. She is in her office talking to a visitor when the doctor brings a youngish man to the door. "This is Mr. Y., he says in introduction. "He came in with epigastric pain, and there's a lot of hepatitis going around at his job. He also has mild hypertension. I've ordered some tests. I won't be in next week, so will you take it from here?"

Ms. Steel nods her assent. "Now the patient has a relationship with both of us," she says later. "Rob ordered an SMA 12 and I'll explain the results to the patient. I also get a hypertensive workup going, an IVP, ECG, and a chest x-ray."

Because of the many demands on his time, Doctor Funkhouser is delighted to be associated wih Ms. Steel. Jean frees me from those endless birth control exams," he says. "What's really challenging to me is to identify when a person is in trouble and to be able to help with personal problems. The girls coming ih for birth control advice are embarrassed to ask me questions that they freely ask Jean, because she's a woman. This is an illustration of why our joint practice is better than either of us working alone." One

While noting that Ms. Steel often saves him "from taking initial histories with an awful lot of repetitious questions." Doctor Funkhouser is not convinced that this is an ideal situation. "One fly in the ointment is that I'm not as close to the patient. If you're the authority who sits in the back office and answers questions, you're bound to be a little remote."

Ms. Steel says, however, that sometimes she does better than Doctor Funkhouser in relating to certain patients. 'We have some male homosexuals coming in," she says, "and at first I feared they wouldn't accept me--but they have, better than Rob. I also do well with the teenagers-they know I would never be judgmental . . . and I have done well supporting a couple of young women who've had really bad rape experiiences.

Ms. Steel is especially good in detecting psychological problems and helping her patients with them. A visitor notes that, when taking a case h istory, she'll say (to a college professor), "Tell me about your emotional health, or (to an Italian gardener), "How are your nerves?," or (to a young student), "How are you getting along with others; are you making friends?

"I tune in whenever I hear bizarre, vague complaints, like stomach cramps when there's nothing there," she says. "The vaguer a person gets the more persistent I get. I'll come right out and ask: 'Do you find yourself depressed lately?' It's better to come right out with it."

For a while, Ms. Steel was seeing a 40-year-old woman every two weeks to help her through a persistent depression. In addition, she was counseling an older man in whom alcoholism became evident after his wife died. "I also do diet counseling, but I don't like it," Ms. Steel says "I want to do it as a whole thing and not just as a diet problem." full tilt, we'll be seeing three times as many patients." One reason he was slow in building up his practice is that "my wife became seriously ill and I spent a lot of time with my wife and as little as I could at the office, he says. Jean was keeping things together."

Because of their relationship, Ms. Steel has taken on unusual responsibilities. A visitor sees her opening all the mail and extracting the checks from the envelopes. "I have taken on the financial management," she says, "because there was nobody else to do these chores." She grins, ruefully, when the visitor catches her changing the linen on. Funkhouser's examining table. "I do this for Rob because it wouldn't get done if I didn't do it."

Ms. Steel finds enormous pleasure in every aspect of her work. Should she ever feel momentarily discouraged she only has to consult a sheaf of "fan mail" from her patients. Her favorite letter is from a woman she found to be suffering from breast cancer. The patient wrote:

When I agreed to have you examine me, I honestly thought I was making an effort to live according to my beliefs by supporting women professionals. Instead, I'm afraid I managed to provide you with a panoply of problems, and apologize for your having to expend so much of your time on me.... I am sincerely grateful for your thoughtfulness and will always owe you my gratitude for identifying those annoyances before their (sic) becoming major problems.

''I also have a confession to make. The other day I told you that it didn't make much difference to me if the medical people whom I would have contact with treated me like a board--as long as they were competent in medical analysis. You disagreed, saying that understanding and sensitivity to problems were vital. Seeing as I've never written such a note as this before, I'd say that the evidence for your case is sufficient to win on the merits. make much difference to me if the medical people whom I would have contact with treated me like a board--as long as they were competent in medical analysis. You disagreed, saying that understanding and sensitivity to problems were vital. Seeing as I've never written such a note as this before, I'd say that the evidence for your case is sufficient to win on the merits.

"Formerly, I always figured with respect to medical care that I got what I paid for, and the shorter the duration of my exposure to anyone, the better. Now l must admit that the understanding and empathy which you bring to your profession made this whole hassle easier for me, and I also wish such competence and sensitivity were available to all--especially those without means to receive medical attention.

"You were, however, wrong on one point. You said it took time for trust to develop between people--particularly in a doctor-patient relationship. Not so, for I only met you once. Again, my sincere thanks for all your help."