A blend of nursing, treatment, education:

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Nancy Laterra-Ferraro, pediatric nurse practitioner, left, pictured at her Goshen office examining patient Heidi Fleming. Local and national experts predict that nurse practitioners will fill a crucial gap when doctors from the baby-boomer generation retire in record numbers over the next decade. Times Herald-Record/TOM BUSHEY



Dorothy Rose isn't shy about expressing her confidence in Linda A. LaRocco, her nurse practitioner of about five years.

"I believe in everything she does for me," says the 80-year-old Town of Crawford resident. "She found the blood clots in my legs."

Because of Rose's level of risk, LaRocco explains, she immediately sent her for an ultrasound when symptoms presented two years ago.

WHAT EXACTLY IS A NURSE PRACTITIONER AUTHORIZED TO DO?

According to the Nurse Practitioner Association of New York state, NPs diagnose and treat a wide range of health problems, incorporating an approach that stresses care and cure. In addition to a comprehensive physical exam and ordering further tests, when necessary, a nurse practitioner can:

Diagnose and treat acute and chronic conditions, including hypertension, diabetes, infections and injuries

Prescribe medications and other treatments

Manage patients' overall care

Spend time counseling patients

Help patients understand how their actions affect their health and well-being

Deborah J. Botti



LaRocco and Rose first became acquainted at a Pine Bush medical office where LaRocco was a nurse practitioner, before striking out on her own. "A Middletown physician for whom I worked part-time encouraged me to do so," says LaRocco.

So, about a year and a half ago, LaRocco - a doctor of nursing practice and an adult nurse practitioner - opened a solo practice in Pine Bush.

Rose followed her, and now sees LaRocco regularly to monitor her blood pressure and check her levels of Coumadin, a medicine that helps reduce the formation of blood clots.

"There's no difference between a doctor and Linda," says Rose.

Not everyone would agree, though.

Just last week, LaRocco had the opportunity to see an elderly couple she had been treating, who were recently directed to a physician. They came into LaRocco's office for blood work with their daughter, who resides out of state. During the visit, LaRocco inquired about the change in providers.

"I told them I was perfectly OK with their decision, but I wanted to know if their new doctor was doing anything that I hadn't," LaRocco says. "The daughter responded, 'My parents need a physician. You're not a diagnostician. My husband is an internist, and his 12 years of education do not compare to your six.'"

LaRocco has another patient, also seen by a specialist, who was told to go to a "real doctor." Says LaRocco, "She told the specialist that she had no intention of changing."

About the nurse practitioner

The nurse practitioner has been an integral part of many communities for some 45 years.

"In the 1960s, pediatric nurse practitioners took care of the medically underserved in rural areas," says LaRocco.



At a minimum, there are four years of medical school and three years' residency, says Dr. Francis C. Imbarrato, a family practitioner in Monroe and a founder of Horizon Family Medical Group.

But whether as part of a medical group or the groundbreaking handful of independent practitioners, nurse practitioners add a critical element to the health-care team.

"There's no way we can replace a physician - and that's not what we want to do. We're not doctor wannabes," says LaRocco.

"We're different," says Nancy Laterra-Ferraro, a pediatric nurse practitioner in Goshen, who opened her practice, Chelsea Pediatrics Nurse Practitioner, in December. She and LaRocco are nurse-practitioner pioneers with private practices in Orange County.

"I've worked with three previous practices, and while I enjoyed working with the physicians and worked well with them - even though I thought I'd be flooded with patients by now - if I think about going back to where I was, no, this is my dream," she says.

Family and friends pitched in to create the child- and adolescent-oriented office that she's always envisioned. The drawings are hand-painted, and there are no beige walls in the waiting room. Instead, parents are greeted with a wall of educational materials, including a bulletin board, books and fliers.

"Nurse practitioners are known as educators who deal in prevention," she says. "I have my certification in teaching."

Education is also a layer in LaRocco's history. She is a diploma nurse who received her initial training in a three-year hospital program and acquired her bachelor's degree in nursing while her children were young. She then worked at the Orange County Department of Health in the tuberculosis control program.

LaRocco received her NP and master's degree from Mount Saint Mary College and became an adjunct professor before attaining a full-time post. To continue teaching, a doctorate was required. It was during her pursuit of that degree that she realized her interest was truly to practice as a nurse practitioner instead.

"I loved the autonomy and the ability to treat as well as educate patients," LaRocco says.

Nurse practitioners must have advanced education and clinical training to practice, according to the Nurse Practitioners Association of the State of New York. They must be registered nurses who graduate from a state-approved nurse practitioner program and have a master's degree before sitting for the national certification exam. NPs relicense every three years in New York state and update their national certification every five years through ongoing training and education.

"A nurse practitioner doesn't have the didactic theory or knowledge of a physician. But practically speaking, you don't need all of that knowledge all of the time," says Imbarrato, who also does foreign medical mission work in Third World countries. "Most patients don't care what you know - as long as they know that you care.

"Nurse practitioners are able to provide routine primary care as long as they remain humble, objective and focused on the patient's best interest," he says. "They can build a practice just like any other practitioner."

'It's all about the relationship'

Dr. Alex M. Joanow, another of Horizon Family Medical Group's founding physicians, is an OB/GYN with Horizon Women's Health Group in Goshen. He says his office is made up of two male physicians, a female physician assistant and two female nurse practitioners - so they're able to offer alternative providers.

"They function almost completely as we do," he says. "The nurse practitioners are requested and have their own following and practice within the practice."

"They are licensed," says Imbarrato, "and within the scope of their ability, they can do what they would like, such as suturing, if they're comfortable and confident.

"Patients who have been seeing me for 20 years sometimes are initially reluctant to see a nurse practitioner," says Imbarrato. "But after the first visit, they're at peace. They're happy with the quality of care and open to seeing them again. It's all about the relationship."

LaRocco chooses not to do minor surgical procedures in her office; however, blood work, EKGs and spirometry to gauge respiratory health are typical components of her practice.

"NPs vary in the office procedures they perform. They do what is comfortable for them," she says.

"They need to know what they don't know," stresses Imbarrato.

"A smart physician knows when to ask a question; a smart nurse practitioner knows when to ask a question as well," says Laterra-Ferraro. "If I'm over my head, I'll consult."

Imbarrato says he's been working with nurse practitioners for the past 25 years. In his office now, there are three physician assistants and one nurse practitioner.

"The ability to make a diagnosis and prescribe the correct medication or treatment are a given," he says. "When I choose staff, there also has to be an intrinsic sense of respect, an inherent ability to take care of a person."

They were nurses first

Along with the number of years of education, the initial chosen path also distinguishes a nurse practitioner from a physician.

"Doctors work from a medical model; we are RNs with advanced training and education," says LaRocco, whose office is located between two senior citizen complexes. And she does house calls.

"I visit Medicare patients for whom transportation is a problem or who are not well enough to go out," she says. "Nurse practitioners also tend to spend more time with patients."

"We learned differently, and we need to have that valued," says Laterra-Ferraro. "Nurse practitioners work with a different philosophy. We blend medicine and nursing, and while there are constraints, I believe my background in nursing (working since 1975 as an RN and for the past 10 years as an NP with three pediatric practices) gives me an enormous advantage."

She provides this simple example of how she blends being a nurse, woman and mother into her practice.

"I don't just say, 'Take this three times a day.' I incorporate the family's lifestyle," she says.

She'll talk about the obstacles to compliance and then provide solutions - so her prescriptions often ultimately include specific hours, based on the family schedule.

She also treated three patients last week without compensation, either because of a recent job loss or not yet being credentialed with a particular insurance company.

"It's an ethical issue for me," says Laterra-Ferraro.

"Historically, the role of the nurse practitioner was to spend more time and be a liaison in terms of clinical education - and to impart greater information," says Imbarrato. "Realistically, that doesn't happen in a busy practice. They complement and supplement what we can't do because of time constraints."

Joanow says the nurse practitioners in his office are a huge benefit in that they also enhance different services provided.

"One nurse practitioner, for example, runs the urinary incontinence program," he says.

Joanow also brought two other specialists into the office, although they're not part of the Horizon group. Nevertheless, each - one specializes in reproductive endocrinology and fertility, the other in high-risk pregnancies - has nurse practitioners.

"At Horizon, midlevels (the term applied to nurse practitioners and physician assistants that some, such as LaRocco, take exception to) are used in a variety of settings and are always sought out," says Joanow.

Joanow says that NPs sometimes do post-surgical and postpartum rounds at the hospital. The work they do and the patients they see allow Joanow and his partner to focus on more dramatic and complicated situations.

"I'm a big believer in them, and I only see their scope expanding in the future," he says.

Physician shortage predicted

Local and national experts foresee that the need will only grow in coming years. The aging population - which includes doctors from the baby-boomer generation who are poised to retire in record numbers over the next decade - is predicted to result in a shortage of physicians, according to various websites. Couple the increased needs of an aging population with the uncertainty of health-care reform and the result could be a void - which might very well be filled, at least in part, by nurse practitioners.

"Nurse practitioners are positioned to fill that gap," says LaRocco.

"Many nurse practitioners are capable of practicing on their own and independently," says Imbarrato, "based on their confidence level, training and what they're trying to accomplish."

"We're not usurping physicians; we're enhancing the field," says Laterra-Ferraro.
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Amazon.com: Reproductive Endocrinology Infertility Nursing
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