1

                              T H E R E S E HIDALGO


                           Dr. Fitzhugh Mullan,
                                interviewer


Mullan:      Please give me your name.



Hidalgo:      Therese Hidalgo.



Mullan:      You're in the Presbyterian Medical--



Hidalgo:      Family Health Care in Belen.



Mullan:      In Belen, New Mexico, on the morning of February 21,

1996, in the conference room facility.

       Therese, would you tell me a little bit about your
background, where you grew up, and how you got interested in
nursing to begin with?



Hidalgo:      I was born in Las V e u a s , New Mexico, but I grew up in

Phoenix, Arizona.       I went to Catholic schools and Catholic high

school, then I moved back to New Mexico to go to college at the
University of New Mexico in Albuquerque, with nursing in mind.
You're probably wondering why I thought about nursing.          First of

all, my mom was a nurses' aide and raised eight children on that

income, which was difficult, but I think she always wanted to be

a nurse and so I thouuht, "Well, I can fulfiil her dream and

mine, t o o . "   I at one time thought about medical school, but in

those days, in my cultural background, family was first, being
                                                                        2

married and having a family.     I remember making that decision as
a sophomore in high school that I needed a family and the two
wouldn't work, and so that kind of helped me fulfill the decision
about nursing.     So I went to UNM, got a bachelor's degree in

nursing, and practiced in Santa Fe for about seven years.



Mullan:    When did you graduate?



Hidalgo:     I graduated in '79. I started as a general nurse on a
med surgical, and then my love was for obstetrics.


Mullan:    In Santa Fe?



Hidalgo:     In Santa Fe, at St. Vincent Hospital.   Then I moved

towards maternal child areas, and that was labor and delivery.          I
did several years in labor and delivery.     Then I did some
education.     I was an educational coordinator for the staff for
about a year.    Then I moved to Belen to work in a small hospital.



Mullan:    Was that a family move?



Hidalgo:    Family move.   My husband was born and raised here, and

we have property here, and we decided to make our move back to
raise our children.    I have to tell you, I was very fearful.      I

became very specialized in my career early on with maternal-

child, and to come back and work in a small hospital where an RN

was responsible for an emergency room, I had no experience in
                                                                     3

that, back on med surg, newborn intensive care, the whole gamut.

I had geriatrics.    Then I had to take care of men patients again
after taking care of primarily women.     So I was a little bit
nervous, because I was comfortable in my role, but I did it, and
it was probably the best thing that could have happened in my

development in my professional arena, because I became much more
broad in my scope, and I was a lot more challenged with the
diversity.

     So as I came here, let's see, I probably started in 1986,

August of '86, and then again, I quickly kind of was driven or
pulled toward labor and delivery again.    I became head of that

clinical department for labor and delivery and postpartum, and
pediatrics, actually.    It was maternal-child.   And served in a
supervisory role as well as a clinician.
     Then in '80--



Mullan:    Tell me a word about this hospital then.



Hidalgo:    It was Eastern Valencia Hospital, owned and operated by

Presbyterian.    It was a satellite hospital for that organization,
and they had several satellite hospitals around the state.    We
are thirty-five miles south of their main headquarters.



Mullan:    Which is in Albuquerque.



Hidalgo:   Which is in Albuquerque.   It was about a thirty-four-

bed hospital, closely affiliated with their mother hospital
                                                                       4

 thirty-five miles away.    We did have some acute-care-type

patients, but for the majority, let's say for an MI, those would
be transported to Albuquerque.     But we did full obstetrical
services; we did surgery in those days, C-sections.       We had a

surgeon here, we had an OB/GYN here, and family practice docs,
and a pediatrician.



Mullan:    That was pretty much the medical staff of Belen was all

on staff here?


Hidalgo:    Yes.   There were physicians outside of the ones we are

currently employing today that also admitted to the hospital,
that were mainly family practice.       There was an internist.   At
the time of the hospital, there were actually two internists

here, and a general surgeon, an OB/GYN, a pediatrician, but there

were other family practices.



Mullan:    It was, I gather, or became a troubled, rural hospital

in the sense of could it make it.



Hidalgo:   Yes.



Mullan:    Tell me a word about that.    It must have been tough for
the town and tough personally. As you saw the rural hospital

move towards closure, what took place?
                                                                      5

Hidalgo:     There was a lot of community discussion and some

division, even among the community about supporting the hospital,
because the issue became that Pres [Presbyterian] made a decision
because of continual financial losses, which was the trend around

the country for rural hospitals, that they were going to need

some support from the community.       We have a large Medicaid
population here and that's what our hospital served, is a lot of
Medicaid.     Because of reimbursement issues and things like that,

I think that's what drove the decision to make a change.      So a

mil levy [phonetic] was petitioned to the community and it

failed.



Mullan:     That was proposed, put on a ballot and didn't pass?



Hidalgo:    Yes.   Right.   It was an election.



Mullan:     This would have been like an add-on to the sales tax or

some such thing?


Hidalgo:    Yes, and I can't remember exactly how much.



Mullan:    But it would have raised a fund to support the hospital.



Hidalgo:    To support the hospital.



Mullan:    And the community didn't pass it.
                                                                       6

Hidalgo:    They didn't pass it.



Mullan:    Was it close even?



Hidalgo:    No, it wasn't close.    It was countywide.   The county is

divided into areas that, and I could understand, a large
population that is right next to the county line where
Albuquerque is.      As a matter of fact, it was closer for a lot of
those people to go to Albuquerque hospital--



Mullan:    So they weren't interested in supporting it.



Hidalgo:    Supporting it.    So I think some of that had to do with

it.   There was some campaigning, and I hate to speculate on tape
what I think happened, but there were some other providers in the
area, I think, who were campaigning in opposition to it.



Mullan:    The opposition because they would just as soon see the

hospital close?


Hidalgo:    Yes.



Mullan:    By providers, you mean physicians or not?



Hidalgo:    Yes.    Physicians.



Mullan:    Why?    What benefit was it to them?
                                                                   7

Hidalgo:    The reason why I say that is, I think, in a personal

level, I heard negative--well, I think they didn't want Pres to
continue to run it with taxpayer money.    They really wanted an

active board that was elected by the community.    The community
felt if they were going to pay--and this was one of the positions
of this physician--that the community should actually have more

control over it than what it had in the past, or what it was
intended to have.    It's interesting that after it didn't pass,

the physician resurrected, or attempted to resurrect, anotner
coalition to bring another hospital to the area.



Mullan:    Unsuccessfully?



Hidalgo:   Unsuccessfully, right. And that issue stayed at a

simmer for a while, for I would say a couple of years, with some
key people supporting it, some politicians and some other health

care providers and nurses who were very forthright in their

opinions about this.   It was more of an issue between the
organizations whether it was Lovelace or Pres, so it wasn't like
an individual type of endeavor, it was trying to hook up with
another organization like Lovelace.   There was a lot of talk
about Lovelace bringing a hospital here at one time.   I'm not
privy to all the meetings they had and what was said behind the

scenes, but as it appeared and what I knew, that's where I came

up with that opinion that I think that there was some opposition.
                                                                        8

Mullan:     How did the community respond to the closing of the

hospital?    Was it accepted?    How did you feel about it, too?


Hidalgo:    People were very opinionated about their loss of a

hospital.    They were opinionated about the need for twenty-four-
hour, especially emergency, care.       It affected me, because I felt
that those were the same people who wouldn't support it
financially on the ballot, obviously.       I didn't ever hear anyone

say that they were happy it closed, put it that way.       So a lot of
people did feel free to express their disappointment in it, and I
really believe that they were angry at Pres and not at
themselves, for it not being here, that they felt, "Well, why

shouldn't Pres keep it open?"



Mullan:    When was it closed finally?



Hidalgo:    It closed in 1990.



Mullan:    I want to pick back up on your story, but tell me a few

more things about your youth.       What did your parents do?


Hidalgo:    My mom worked as a nurses' aide in Phoenix, as a single

parent, because my father died when I was in third grade.



Mullan:    She raised you?



Hidalgo:    She raised all of us.    There are a lot of us.
                                                                        9

Mullan:    How many?



Hidalgo:    There are eleven children in my family.     She remarried

later and we have three half-sisters.



Mullan:    Did anyone else go into nursing?



Hidalgo:    Yes.   My brother became an LPN, and then did get his

RN.   We used to have these long battles about LPN and RNs, and he

used to get my goat.       So I just said, "GO back and get your RN."
And he did, and I was so proud of him.       I have a sister who has

an LPN and is still struggling with trying to go back to school
for her RN, in the administration track.

      My mom did start RN school.      She's probably sixty-five years
old, and she switched out of RN school and is still in college,
has an associate's degree in early child development in the

bilingual program, and is about to get her bachelor's.


Mullan:    Good for her.



Hidalgo:    Yes.   Who else?   Those are all the nurses in our

family.



Mullan:    When were you born?



Hidalgo:   December 11, 1955.
                                                                        10

Mullan:     So I guess there was general enthusiasm and your mom's

support when you went into nursing?



Hidalgo:     Yes.



Mullan:     Good.   Well, we got up to the mid-eighties and you were

describing your work here heading up the obstetrics unit.        I

wanted you to take your story forward from there.        Before we do
that, give me a little bit of a side on family.        You got married
and started a family, right?



Hidalgo:     I got married before I finished my RN school, two years
before, and then we had our first child in '80.        I was already
working as an F W in Santa Fe.       It was when I was pregnant with my
third son that we decided to make the move to the rural area.
It's so different from Santa Fe, but appropriate for our family

goals, for raising the boys in the country, and we have a ranch.

We raise cattle and are Santa Gurtrudis breeders.


Mullan:     What kind of breeders?



Hidalgo:     Santa Gurtrudis cattle.    It's a pure breed.   I think

they've got Brahma and Shorthorn, but they've been bred as a pure

breed.     They're registered--Democrats. So we do that with our

boys.     They enter in state fairs and we show them and we travel

and it's a lot of fun.
                                                                    11

Mullan:    In the early years of having kids, having a growing

family and working as an RN, was that tough?    How did you juggle
that?


Hidalgo:   What I will say about nursing is it's been good to me,

especially raising a family, because I've had a lot of leeway in
choices of shifts, taking a negative and making it a positive.
People think working graveyards and evening shifts can be a real

downer on family life, but actually, I used it to my advantage.

When I'd have a baby, I'd work night shift three days a week, so
I didn't need babysitters.   I really felt I was there with my
children in their early years.    Then when they got to a certain
age, then I worked three to eleven part-time.
     I primarily worked part-time, except for when I entered into

the administrative-type roles, then it was more demanding.      I

prefer to work part-time, and I'm still working part-time.      I
finally got back to part-time in my role now.    That's how I

balance.   That's how I balance, because as I was mentioning to
you at the beginning about why I decided to go into nursing, I
knew I wanted medicine, because it's challenging, it's exciting,
and it's a very caring field.    I've been able to keep my career
and make that balance with family, and that's how I've done it,
the part-time business, and being creative with my shifts and the

type of jobs that I'll do.   So I felt great that I ' d been able to

do that, and the profession's allowed me to do that, even as a

nurse practitioner now.   I feel like I've expanded my role, and I

can care for my patients in a more fulfilling way than when I
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worked in a hospital, and yet I can still be part-time.      So I
feel very fortunate that I achieved that personal goal.


Mullan:    Nursing has worked well for you, in both pre- and post-

advanced practice.    Let's pick up the story in the mid-eighties.

You were here as the obstetric nurse director.


Hidalgo:   Right.   In around--it must have been '89, I needed some

personal goals.     I served on a lot of organizational committees,
both here and in the local hospital, and also in the larger

organization in Albuquerque, and was giving a lot of my time and
commitment.    I decided to do something for me, so I decided to go
back to school and get a master's degree in nursing.    I'm not so

sure what I expected to do with a master's degree in nursing,
although it was always my dream to get a master's degree.
     When I graduated in '79, there was a nurse practitioner
program, but it was run by the medical school, and in '80 was the

last year that they had that program.    So actually, even though I

was getting my RN back in the seventies, I knew I wanted to be a
nurse practitioner.    But what happened is that in '80 was the
last year they had that program, so there was no opportunity in
New Mexico for ten years.    I tucked that away and I never let

that dream die.
     So in '89 I started to look around.    I knew I wanted to get
a master's, and I said, "I still want to be a nurse

practitioner."    I didn't have much of an opportunity for
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encounters with nurse practitioners.    It was a role I learned in
school, in the RN school, that I knew I really would like to do.


Mullan:    There weren't role models in the community to look to?



Hidalgo:   There were none.   I met one in Santa Fe, and I'd asked
her to come and talk at some of my educational things, and she
was probably the only role model I had, but I never worked

directly with her.
     So back in ' 8 9 I started looking around.   I was going to go
to Arizona and Texas, thinking about relocated myself and being a
part-time mom.
     Then as I was calling Arizona, they said, "Well, you know,
New Mexico's thinking of having a program."

     I said, "Really?" So I went and I started asking questions.
     They said, "Well, we don't have the grant money yet.      We are
planning it, but we're not funded.   So go ahead and enroll," and

I enrolled in just the general graduate program for nursing.
     It's interesting.   We'd go around, you know how you orient
in a new class, a new semester, and people go around and say,
"This is my background and these are what my educational goals
are for this program."   Mind you, there wasn't a program yet, but
I would say, "My name is Therese Hidalgo.   I work in Belen.    My

area of expertise is maternal-child, and I'm going to be in the

nurse practitioner program.r1 [Laughter]

     I think they felt sorry f o r me, so I was one of the first--
there were seven of us who were chosen for the pilot program, and
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so that next year I was accepted to that program and finished in
'91.



Mullan:    What was the program like?



Hidalgo:    Oh, it was haphazard.   I can't compare it to any other

program, personally, because that's the only program I went in,
and I had my undergraduate there, so I had a lot of the same
instructors. But there was a lot of room for growth, and there

were a lot of suggestions that our group as a whole made towards
improving the program.
       There were still no role models in our preceptorships, but
that's changed, because I serve as a preceptor for the college
and we assist students as a team, physicians and nurse

practitioners, because I think you need both, to help with that

role identity.    I had not much of an idea in actual practice with
a role model or mentor, and I don't know how I knew, but I came
away to my sites thinking I knew what a nurse practitioner should
be and what our roles were, and some of it was just ingraining in
our minds, this area of independence, because that was the
movement at the time in clinical areas.
       The physicians I came to work with in my last preceptorship,
which was here, they didn't know either.    They hadn't really
worked with nurse practitioners.    I think one of them worked

briefly in the family practice center at UNM when he was going

through his residency with a nurse practitioner, but they didn't

really know.   And the scope of nurse practitioners has changed
                                                                         15

over the years here in New Mexico, with the changes in the Nurse

Practice Act, so I think all of us evolved the role together.


Mullan:    Would you characterize it as more limited and modest

when you were in school and leaving school, and it's expanded
five years later today?



Hidalgo:     Yes.    My last year in school, the Nurse Practice Act

changed with sunset review.       But prior to that, nurse

practitioners worked under the supervision of physicians and they
worked under protocols.       That was how they were monitored and
what have you.       They could prescribe, we've always been able to

prescribe, but it was under supervision.



Mullan:    Limited prescription authority?



Hidalgo:   Right.      There were no narcotics, no scheduled drugs at

that time.     In '91, the Nurse Practice Act was reviewed, and
there were some changes. We were moving more towards
independence.       At that time there was language, independent,
trying to describe the different roles that were out there
already, because we knew that supervision was really
inappropriate to label what we did.      Because we're a rural state,

nurse practitioners were working in very rural sites, with only
phone consultation, so it wasn't really direct supervision.         So

what they wanted to do is they wanted to address all the

different levels of independence.      They had one that was still
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supervisory, and there was one that was interdependent, and one
that was independent.         There was still a connection with a
physician, and those affidavits had to be signed and determined

what level your relationship is.

     At that time, that revision of the Nurse Practice Act did

not include scheduled drugs yet.         It was two years ago that the
Nurse Practice Act was amended again, or regulations, I'm not
sure exactly whether it was--it was the Practice Act.         They got
rid of all that language about discrepancies between
interdependent, independent, and supervised, and cleaned it up,
and I was really happy about that, because that was a hassle,

trying to explain.


Mullan:    How did they leave it?



Hidalgo:    We're independent. The language is "independent in

primary care, chronic and acute, and will consult as needed."

And the opportunity to apply for a DEA number was also changed
two years ago.       So   we have that now.


Mullan:    So tha,'s      been an evolution in L e scope of practice.



Hidalgo:    Right.



Mullan:    In terms of the nursing school, what size classes have

they been producing?
                                                                       17

Hidalgo:    Oh, we were seven in our class.     I think they accepted

eight, but we ended up with seven, and the next year I believe
they had, I would say, twenty.       This year I think they've got

thirty-some.      So   that they've been increasing the size of the

class.



Mullan:    Are they most New Mexicans to begin with or do they come

from around about?



Hidalgo:    I can't tell you what ratio they are, but they do
accept people out of state.



Mullan:    Mostly New Mexicans?



Hidalgo:    I can't say that for sure.



Mullan:    How about where they go to practice?     Do most people

stay in New Mexico?       Can you tell?


Hidalgo:    In my class, I can tell you that most of them stayed in

New Mexico, or at the border with Colorado and New Mexico.       The
goal of this program is f o r rural health.



Mullan:    Is that an explicit goal?



Hidalgo:   Yes.    That's how they got their grant money.    It was

out o f a task force that looked at health care in New Mexico and
                                                                      18

the shortage areas.        So a lot of their money was linked to that.

I'm considered in a rural area.         I would say out of my class, 50
percent ended up in a rural area.         One of them in rural Colorado,
right at the border.        I still consider her within the New Mexico

area.      I know that the most recent class, it's probably about 50
percent.        It's probably still 50 percent where it's urban--



Mullan:        50 percent are--



Hidalgo:        In the rural areas.   Some did go to other states, back

to their home states.       One of them I know in the subsequent class
to mine, came from Arizona, the Public Health Service sent some

from Arizona, and their obligation was to go back and finish

there.


Mullan:        Tell me about entering the practice again, now as a

nurse practitioner, coming back to your same hospital or your

same community.       How was that?


Hidalgo:       Positives and negatives.   It was comfortable on one

respect to know the physicians.        I worked with the same
physicians when it was a hospital, as a nurse, and some of the

nursing staff, the LPNs, were left over from the hospital

staffing   .

Mullan:     When you came back, it had now gone from a hospital to

being--
                                                                       19

Hidalgo:     A clinic.   It had been a year history of a clinic.



Mullan:    When you got back.



Hidalgo:     When I got back.   But at the same time I felt a lot of

pressure, even when I came from my preceptorship, I thought,

"Well, they knew me as a nurse," and like I said, I felt

comfortable in my role, especially in OB.     Matter of fact, I felt
like I taught them a few things, because they were rural, and I
had been in a larger institution doing OB.        So I brought a lot of

experience with me, but coming back, then I felt the pressure of,

"Gosh, I'm supposed to know a heck of a lot more, 'I and I don't
know if you remember your residencies and internships that you

think, "I don't know anything."      So I put expectations on myself

that I thought they would have for me.      They'd been very
nurturing, the physicians here.
     You talk about evolving the role, I think I tried to teach
them about the role.     I was blind, mind you.    I didn't really
have any true role models.      I came in with a clinic need.   They
needed someone to help them with urgent care, so that's how I
started.     It was a very welcomed addition to the clinic staff,
because our physicians were doing appointment care and taking
turns doing urgent care or non-appointment coverage as well
during the week and in the evenings.     That is very, very

difficult.    They weren't real happy with that.
                                                                      20

     So when I was about to finish, and it was Steve, actually,

while he was out running on this area that I also ride horses and
stuff, asked me, "Are you almost done with school?"
     I said, "Yes, I'm almost done.       I'd like to come over and

work back at the hospital."

     He says, "Well, you go talk to so-and-so," the administrator
at the time.
     So    I felt welcomed when I came.    I think I helped a lot.    It

was hard for them at first because I was a new graduate, and I
did need a lot of time at first.    They made a great investment in
me for their future benefit.



Mullan:     This is in terms of consultations?



Hidalgo:    Consultations. Yes.   Right.    So I did the urgent care,

that really freed them up.     They still did the evenings and were

available for consultations during the regular working hours.         I
worked Monday through Friday.     I'm trying to remember how long I
did that.    It might have been for two years.
     I had the goal to not just stay in urgent care.      I wanted
to--this is my phrase I use--it wasn't fulfilling for me.      It was
challenging and exciting, and I loved coming up with those
differentials and the diagnosis and treatment, but I didn't have

any continuity.    I wanted to know how they did afterwards.    And

although this was an ideal setting for getting as much as you

could, being an urgent care provider, I could ask the docs and

get the chart, I had access to the charts, but I didn't have the
                                                                        21

time.     It was constant patients from the minute you got here
until way after you were supposed to leave.       So   the volume was
really a lot for one person.
        But I didn't feel fulfilled, because I wanted to develop

relationships with patients, and that's why a lot of us go into
it, this Marcus Welby, as you mentioned, relationship.         I felt
working in urgent care was like loving and leaving them.         It
didn't feel fulfilling, so I proposed to the staff that I would
like to move into primary care, and we could hire the nurse

practitioner student that I was precepting.       I sort of had it all
planned.     We did that.   They agreed.   Again, I think it's because
I was trying to teach them what my role could do, and I pushed
it, pushed it, pushed it.     They went along with it.     I felt at

that time I was really the only one in the system that was really

having her own patient load.      I mean, officially on insurance
forms, I can't, and that's one of the barriers, is I still am not
listed as a primary provider for billing and through HMOs yet,
but I do have my own patients, and pretty much they're
exclusively mine, unless they go to urgent care or can't get an
appointment.


Mullan:     This has developed.



Hidalgo:    This has developed over time.



Mullan:    How did you select or did they select who became your

patients?
                                                                     22


Hidalgo:     It's self-selection. Patients and myself, and I've

learned a lot.    I've learned how I need to, for my own level of
skill and experience, need to know that I don't really want to

take care of this type of--1 don't feel like I'm the best
provider for this patient.     I can think of some pretty

complicated ones.    They really wanted me, because they wanted
that role.    They wanted that person that they felt that they

could talk to and wouldn't talk down to them.     One I'm thinking
of is this COPD female who has a lot of health problems, and had

polypsythemia [phonetic], and she had a lot of things,
depression, a lot of things.     She was fed up with the traditional

providers that she's had in the past, and she's talking about

physicians.     I'm not sure if it was a gender thing, but she

wanted me desperately, and I knew at the time that she was very,
very complicated, and I would work with an internist, a female

internist here, and we'd consult a lot on her.
     Then the internist retired, and so I felt like I didn't have

that link, and that was the type of patient that I've learned
that I need to direct patients to another level of care, and it
can be through a specialist or it could be to one of the family

physicians here.    So   up until that point, patients would self-
select, and I'd try to refer, but that really became apparent to
me what some of my limitations were, and that's just part of the

growing process, the learning curve.



Mullan:    Over time, has that been comfortable? Are there people
who discover you're a nurse practitioner say, "Well, I want a
                                                                      23

doctor," or contrariwise, are there people who say, "I want you

because you're a nurse practitioner"?      I gather that's the case

in some of these.



Hidalgo:    Yes.    Because they know I'm a nurse practitioner.
        Let's go back when I first started in urgent care, because

see, of course, they're not selecting me when they come through

urgent care.       So that was a different scenario than what I'm

doing now.    When they make an appointment, they're selecting.      So

it's a lot easier.      But I'll tell you, when I first started, it
was hard, because the physicians didn't know quite what a nurse

practitioner was, the public surely didn't, and, of course, you

have to think about their health-care-seeking behaviors.      Very
interesting in this town.      They use a lot of non-appointment;
that's just been their tradition.      So there was a lot of learning

that needed to take place as far as that.
        But then having a nurse instead of a doctor, that was really

hard.     I got a lot of older people especially, that would say, ''1
want to see the doctor.       I thought I was seeing the doctor."

They would say it in so many ways.      Some were point blank that,

''1 don't want to see a nurse."     Some would say, "Oh, I thought I
was seeing my doctor."      Before I came, that's what they expected.
If they came on that doctor's urgent care day, they wouldn't

bother making an appointment, because they would see him through

urgent care, and it would be their provider anyway, their doctor.

        But that changed, and I can say that after the first year,
that was probably the roughest, I still had a number of people
                                                                      24

say, ''I don't want to see you, I want to see my doctor."    By the

second year it dramatically declined, and by the third year, I
hardly ever see it.    But that's because I also moved into primary
care, so that may be just a skewed representation as to what

really was the attitude out there.



Mullan:    At the outset you're talking urgent care setting?



Hidalgo:    It was urgent care setting.   But now we have a nurse

practitioner in urgent care doing it primarily, and we get your
occasionals, but those are those who never worked with a nurse
practitioner before, so they don't know.     They see this mental
picture of a nurse and a physician, and how they've been

socialized into those roles through television, through their

experiences in hospitals years ago, and so their whole frame of
mind about a nurse is totally different.

     I did an experiment.   I did a talk at the high school.      I
believe they were freshmen--no, they were juniors.     It was a
Career Day, and they had different guest speakers, and one of my
patients wanted me to go talk about nursing, and the advanced
practice role as well.   So I went, and what I did, I went around
the room and I asked each of them to give me a response to the
word "nurse," develop a mental picture and just tell me the first

thing that comes to your mind.   And our societal opinions or

attitudes about nursing haven't really changed much, and that was

disturbing, although I expected that.     They're still looking at

soap opera types, handmaiden, assistant.     I didn't hear anything
                                                                       25

that let me believe that people at this point are seeing nurses

as independent care providers with their own little bag of
tricks.    So that confirmed it.      I could see that in the adult
world as well, what I was saying before, is that you just said

the word "nurse," that just kind of blew any credibility that we
could be totally responsible for their care.        I had co-workers
who would say, "Therese, can't we call you something? Like the
doctor is called a doctor, and that makes people feel

comfortable.        Can't we call you something instead of your name?''

Because people are used to not calling the doctor Rick--


Mullan:    Yes, a title.



Hidalgo:     Yes.    We joked around about that, but those were

probably very valid points about how the public sees u s , when
they've not had much exposure to us.        They want something to hang
some security blanket on, and they thought maybe a title would be

appropriate.    But I go by my first name, probably as most nurse
practitioners that I can think of, and that's the down side, is
that security that a title makes people feel more secure.         But at
the same time, the flip side is, people feel more comfortable.


Mullan:    The title puts a distance.



Hidalgo:   Right.      I think that's what we market to people through

ourselves.
                                                                    26

Mullan:    Well, let's pursue this.   This is very interesting, and

in Washington, a much debated point, far away from the actual
laying on of hands.    In your judgment, do nurses bring to the

primary care arena, and let's focus on primary care, which I also
want to get your thoughts on, but I've skipped over that for the
moment.    Do nurses bring to primary care qualities that are
different than physicians bring to primary care?     Is the product
a term that you offer ultimately now a well-trained, experienced,

nurse practitioner substantially different than or even different
than what a physician brings?


Hidalgo:    I'll answer it more directly, but let me just give you

a little example on that issue.   When Ford brings out the new

Power Stroke truck, which I'm going to go pick up in about a

week, that's why that one comes to mind, when they're advertising
this new model, they put it on this little revolving table for
the cameras, and they show you pictures from the side, and they
show you pictures from the front, pictures from the back, so that
you can get a feeling for the whole vehicle.
     I see health care providers in our different domains, seeing
the patients from different perspectives, that the physician may
have a perspective of the patient and their needs different than
the profession of nursing.    I know that's been said and debated

over the years, and it's probably getting more blurred, but I can
tell you from my early nursing experience, physicians were more

the medical model, a disease perspective, and nurses have always

seemed to have always seemed to be health perspective.
                                                                      27

     Now because of the market change in health care, we're all

trying to work towards disease prevention and health promotion,
and so those lines are getting more blurred, because I do think

primary care physicians are better at it than specialists and

subspecialists as far as looking at the patient with more than
the disease, the organ, the organ system, and looking at it more

as a complete person.    But what nursing can bring is educators
and communicators with their patients.      I think that that's one
of our strongest points, is that we will educate, and I believe

that more money needs to be spent on education and the services

that can be rendered and billed for, to prevent disease.

     So I'm not looking at it so much from a person who's already

got COPD in stage and focusing a lot of our energies and
attention on medicines to help them and treatments to help them,

but more to prevent them from getting there, number one, with
spending a lot of energy and time educating, but also, when they

are in that level of disease stage, that we work and focus on how

does that affect their life, their daily living things.      How does
the medicine affect that?   More of a case management type of a
perspective.


Mullan:    So your answer would be, yes, that nurses bring--



Hidalgo:    Something different.



Mullan:    Something different.    Is that measurable, in your

judgment?    Is that scorable?
                                                                          28

Hidalgo:     I once read an article about how most of us measure

things with financial reimbursement and things like that.          They
were talking about how does a nurse practitioner bill, I guess,
for some of these functions that I mentioned a minute ago.         Right
now there's not a system in place to do much of that, and that's

what I'd like to see change, if everybody really put their money
where their mouth was.     We all talk about disease prevention and
health promotion, but no one is willing to pay for it.

     On a personal level, I can tell you that I do a lot of
counseling and weight management and diabetic education, and this
is the arena that's separate from what the physicians are doing.

Matter of fact, they refer to me for those.        I can see two
patients that with weight management and nutritional advice,
consultations on a regular basis, were able to be taken off their
medicine.     That's always like the buck talks.    So we don't have

to pay for medicines repetitive screenings and things like that.

I think that's a victory.     I don't have any hard core, bigger
studies, but I can tell you from my practice, I've seen a
difference.


Mullan:     I like your image of the Power Stroke truck from the

different perspectives.    If a patient has those different
perspectives, and a nurse can see a somewhat different side than

a physician can see, in the primary care domain, how does one

rationalize having one set of patients seen by a person with one

perspective, and another set of patients seen by a person with
another perspective?
                                                                     29

Hidalgo:     I'm glad you asked that, because part of the talk that

I did for a site visit from an organization in Atlantic City,

this was my point, too, I used the Power Stroke as an example.



Mullan:     I'll have to find out about the Power Stroke truck.

It's a good truck, I gather.


Hidalgo:    Oh, yes, it's a diesel.

        Presbyterian has a logo that looks like this, and these are
supposed to be mountains, and this is supposed to be a sunrise.

Okay?    What I did is I talked about nursing and medicine, and how

we worked together as a team, and I used the logo.    The way I see
it is this is medicine, this is nursing.    There are a lot of
things--and there might be more overlap there--there's an area of
overlap in tasks that we do.    That's why I wanted to focus on a

perspective of a patient.    This is the patient up here.   What I

added also is these are the rays of the sunrise or sunset.       This
is family and community, and this is an area that's been nursing.
     The nurse practitioner program has developed out of the
community nursing tract in our school of nursing.    So this is

very, very important from where we come from, where our
perspective is, because we don't just want to l o o k at the
patient, we want to l o o k at how that patient is affected or

affects the family, and then the family within the community.

Those are different levels of care, but that is part of our

perspective on a patient.
                                                                      30

     Anyway, so these are the areas that we share certain tasks,

but these are areas that are distinct.    This is where that
different perspective comes from.    I'd looked at it as a team,
and that was what I was alluding to earlier this morning, is that

I would like to see it in this kind of a model, where you have
both of us looking at a patient that we share, and we bring our

different perspectives for the betterment of the patient.      This

area where we share some tasks can be done by either, but if we
want to look at cost effectiveness, why don't we let the nurse
practitioner do some of this, and free up physicians for some
other things.


Mullan:    Which would be high level of acuity, by and large?



Hidalgo:   Higher level of acuity.   I always say you don't need a

bazooka to shoot a rabbit. A BB-gun will work just fine.       Not

that one is better than another, but only in terms of acuity.
You don't need that much velocity to get the rabbit.    So when

we're talking about health care shortage or access to health
care, especially--and that's one of our biggest issues here, when
patients who are prepaying for health care cannot get in to see
their primary provider, because that's just the way our model is
being set up, you have a primary care provider, but they can't

see that provider for two weeks, something's wrong.
    As a consumer, I'd be really upset, and I've been in that

situation, and I have been upset.    That we could improve access

with looking at a model like this, where you actually have the
                                                                  31

health care provider team, and that we could market it, but it
has to come from the marketing standpoint when they're selling
HMOs to people, because just like we need to change people's idea
of what a nurse can do, it's not Bobby what-ever-her-name was

that was on "General Hospital," but that they really are trained
and have expertise in areas of health care that you never thought
of in the past, that if our marketers can go out there and market
that, that when you sign up, you're signing up for a provider,

but not a provider, you're signing up for a team of providers

that are sharing the responsibility of your care.    That's how I'd

like to see it evolve.


Mullan:    Do you see yourself as more of a nurse or more of a

doctor?



Hidalgo:    Oh, I'm a nurse.   I do some of the things that doctors

do.   If I didn't believe in a different domain of perspective on

health care, then I guess I would say I was more like a doctor.
That's why I can't say that, because I do believe that we bring
something in addition to what medicine offers patients, but I do
some of the things that doctors do.


[Begin Tape 1, Side B]



Mullan:    This is Therese Hidalgo, side two, continued.

      Is this because of your schooling in the sense that you are
acculturated as a nurse, your identity was a nurse, your maternal
                                                                    32

identity was a nurse?    Obviously that's a powerful influence on
anybody, how they get to where they are, it's certainly true of
physicians.    Or is it because of what you do daily is

substantially different than what you're co-practicing physician

is doing?     If I came from Mars and walked into that pod where you

and Steve Cohen [phonetic] work side by side, would I say, "These
are people from two different traditions, two different
histories, two different educational systems," would I conclude

that, or would I conclude, "These are two variants on a theme"?


Hidalgo:    This is the essence of how it's so difficult to measure

the differences.    I think it lends itself--I'm not sure, to

answer your question, that a person from Mars could tell by
dropping in on our pod that these are two different perspectives
and ways to treat a patient.    It's more subtle than that.   I
think it gets more subtle depending on the individual who's

providing care, number one.
     I've seen some physicians who my impression is nursey, and I
will do that to help acculturate not only that physician I'm
talking to, to my perspective, that it's a value--1 think we're
talking about value perspectives, that I wanted him to know that
I value that in him, even though I don't feel that the community,

because we can't see such distinctions, and we don't place any

value, well, where it counts, the pocketbook, on some of these
subtle distinctions. But I remember telling a physician, "Gee,

that was just so nursey, the way you intervened on that patient.
                                                                    33

I'm really impressed."    I'm just trying to shed some of those old
stereotypes and visions of who we are in our professions.
     Just like today, I got a letter from Presbyterian Health

Care Services, who I work for, addressed to T. Hidalgo, M.D.       The

same physician--I've been working at this same physician--is that
when he saw something in my door that had Therese Hidalgo, M.D.,
and this was his bias, he said, "Oh, my, look at that Therese.

Gosh, doesn't that make you feel good?''

     I said, "Absolutely not."    You know what I'm getting at, is

that I have to train people that I don't feel that what I'm
bringing is lesser and that I am continually trained to achieve
the role of an M.D., that I'm happy being a nurse doing what
physicians do.    That goes back to telling you my perspective on
that question you asked me, do I consider myself a nurse or a

doctor.



Mullan:    Let's pursue a little bit the political side of it.

Have you been involved with that as well to some extent?


Hidalgo:   Yes.



Mullan:    First, on the political side, physician acceptance of

your work here, as well as nurse practitioners in New Mexico.

How much resistance, how much support? What has that been like

in general?
                                                                     34

Hidalgo:   On the state level, because it's a rural state, nurse

practitioners are very well accepted.    They are, I would say.
Most recently, being part of the organization, not in our clinic

per se, I think we're accepted here, but I've been told that as
far as the Presbyterian organization, not the other clinics are

as accepting as ours, and I think part of that's because they

didn't know.   But I'm a nurse practitioner and I did.     I admit
it.    I went full force.   I saw an opportunity to help the role,
and I saw some naive physicians who were not tainted with maybe
some of the resistance that I'll share with you, with some of the

nurse practitioners in Albuquerque within our system. Money h a s

not been attached to that as far as our positions are concerned
here, that what I do doesn't take from their piece of pie per se,

because these are employed physicians.    So   that has an undertone,
too.



Mullan:    That makes it easier.



Hidalgo:    It makes it easier for us to be accepted.



Mullan:    In a salaried setting.



Hidalgo:   Yes, in a salaried setting.   In Albuquerque, I went to

a meeting within the Pres organization, and I did hear a
physician who's family practice, sounding very resistant to the

role of nurse practitioner within her practice as a team,
because, I think they're trying the team concept, sharing
                                                                  35

patients, not in the level that I'd like to see, but to a certain

degree, but compensation as being attached to that position, and
she's feeling threatened that her numbers are being affected by
having a nurse practitioner.    So it's not the nurse practitioner

per se that she's being resistant to, it's that her numbers are

dropping because people are seeing the nurse practitioner when
they could be seeing her, and her paycheck is based on that.
There's different levels of agreements in the organization.



Mullan:    That's an economic competition.



Hidalgo:    That's an economic competition.



Mullan:    What are nurse practitioners recompensed in the

Presbyterian, roughly?



Hidalgo:    Right now, the twenty-fifth percentile for a nurse

practitioner is $50,430, something like that.


Mullan:    Twenty-fifth percentile of all in New Mexico?



Hidalgo:    No, of their range within the organization.



Mullan:    Within Pres.



Hidalgo:   Within Pres.
                                                                         36

Mullan:    So that means the fiftieth percentile might be up at

$60,000, and you might have people make $70,000, $ 8 0 , 0 0 0 ?



Hidalgo:    Currently not in our Pres system, but that's the

potential for growth.     We don't have anyone in those.      Of course,

nurse practitioners are new to Pres.       I was the first one, and

that was in '91.    We have probably ten mid-levels total within
Pres, and now I'm talking about some PAS.       I'm trying to think.
I think we might have six nurse practitioners in the system.            So

for four years' time, I guess I would have expected it to be a
lot more expanded, but I think we're on the brink of that.          I
think we're on the brink.


Mullan:    What are the economics in terms of volume seen?         If

you're sitting in the Pres front office talking primary care

coverage, traditionally, nurse practitioners see less patients

than physicians?


Hidalgo:    That's what the literature says, and that's probably

true with certain physicians and certain nurse practitioners,
that probably is true.    I've read the literature where they think
we're more economically advantageous, but yet we don't see as
many patients.



Mullan:    The calculus I've seen is, in simple terms, if you put a

primary doctor at 100,000 and a nurse practitioner at 50,000, the
                                                                    37

nurse practitioner sees half as many patients, their economic

pulling power is equivalent.


Hidalgo:    Right.



Mullan:    Then you get to the question of quality and acuity and

so.forth. I think it's those kind of formulas that are
ultimately going to have a reality in the employment pattern,

particularly when you have managed organizations.    But I think

they're in their fairly primitive phases most places as people
explore this.    But it's certainly inexorably true as the nurse
practitioner salaries rise, they will make themselves a less
attractive commodity in the sense that the gap, the putative
savings become less.



Hidalgo:    Well, you're right, and I agree with that statement,

because that's a risk.    That could be our detriment in the next
few years, because the salaries really have changed.


Mullan:    Well, it's kind of a Catch-22 for the nurse

practitioner.


Hidalgo:    It is, and that's why I think we need to change a few

things here.



Mullan:    It also may medicalize her, in the sense that if the doc

is spending less time doing education and counseling and moving
                                                                   38

the patiznts quicker, if the nurse practitioner wants to be

economically more successful and be seen as such in an
organization, then they've got to have similar productivity, the

nursey qualities that do take time often and may fall by the
wayside.



Hidalgo:   That is really, really true.   That's why some things

have to change.    With managed care, I think, and this is where
we're at in this clinic, is that we need to have appropriate

appointments.     I've worked urgent care, and I know that if I had

a thoroughly complicated patient who has a big chart, it's going
to take me a lot longer to sift through that problem.    At the
same time, when you have a physician filling up his schedule with

ear checks and otitis, I'm not saying that that's all theirs, but
that sure helps the numbers, if we're playing a numbers game.
     I think we need to get away from the numbers game and I

think that we all have to be committed to getting the right

patient in the right appointment slot, because we're talking
about access, too.    For all those little ear re-checks that's

filling up a pediatrician's schedule, you have four people who
probably have a higher acuity type of problem, maybe a little
more urgent, who can't get in to see their provider, because he's
tied up with that, and they're coming through urgent care and

that's affecting the nurse practitioner's numbers, because it's

more complicated. Besides, the patients aren't even known to us.

It's more start from square one to really do a thorough job.      So
I think we need to get away from the numbers.
                                                                       39

        If how we're going to measure productivity--and that's what

this article was about, I couldn't think of that word earlier--
are we going to measure productivity by the number of encounters,
or do we need to weight the encounters that we have?     An   ADD exam

is very time-consuming, so the pediatrician will be penalized for
an ADD evaluation when it's done right with family and
everything.     It takes a long time.   But that's his expertise, and
he should be the one doing the ADD assessments.      But his numbers

will be lesser.
        It's still the same thing as I mentioned earlier about if we
can get away from actual numbers and putting people in the right
slots, triaging them--to me, that's a program we're going to
embark on probably at the beginning of the summer, hopefully, to
help with our own access issues, and that is to utilize either a
nurse or a nurse practitioner that have a set of protocols, and
it's a computer system that can actually be more responsible for

triaging.    Does this appointment have to be done today?     Can it

be done two days from now?    Should this appointment really be
home care instead of taking up a slot?     Because in managed care,
if we're not available to give the product that people have
already paid for, we're going to have problems, and spend the
money that doesn't need to be spent with capitated services.

Think of all the colds that waste our resources.     They waste

them.    We had an internist here who worked here.   I could only
feel her frustration, working even in her appointed care and

urgent care, she still does urgent care on the weekends, the

number of colds that come in.
                                                                     40

Mullan:    Let me go back, if I could, on an issue between the

nurse practitioner and physician.     With medicine becoming more
feminized as in the number of women doctors entering the work
force, certainly what--let me not say certainly--it has been

characterized by some that one of the things that nursing brings
to the health care work place is a more feminized, more caring
model, built into the profession, but a profession that's always

been close to entirely women.     I mean, nursing, the very concept,
relates to mammaries and nursing.     As medicine moves towards 50
percent women, does that bring into the field of medicine more
qualities that would be nursey in the sense that you've raised

them, or not?    Do women doctors work more comfortably with the
nurse practitioner model in your experience, or not?


Hidalgo:    I think it's the male physicians, in my experience,

that have a more compatible relationship with the two roles, and

it's the male physicians that I see doing more of the nursey
things, at our clinic, and they were all trained in the same
school.    It's interesting.   I found that it was more the males.
Since I've been here in this clinic, there have been three male
physicians that actually had more of the nursey art of medicine,
nursing, whatever.   And it's been the females, except for this

one female internist, but she was motherly to a lot of patients
by nature of her age and what have you.    But I can tell you that

the other female physicians that I've experienced, I don't think

they brought that to the role.
                                                                    41

Mullan:    Would you conclude, and I realize this is highly

anecdotal, but would you conclude that a woman entering medicine
and moving through the process of medical education moves to a
different model or has some of the feminine qualities suppressed?



Hidalgo:    I think that's it right there.    I think that there's a

potential to bring feminism to the role as a health care
provider, but I think it's squelched because of the

competitiveness and the nature of the medical school and

acculturation.


Mullan:    Let's move, if we could, to Santa Fe.    Tell me a bit

about what sounds like a very positive evolution of the Nurse
Practice Act.      You mentioned before that elements of moving
towards more definitive practice, more prescriptive authorities.
How does that come about, and with what supporters and with what

resistance, and what is your role in that?


Hidalgo:    The Nurse Practice Act that evolved to the point of

independent practice was voted unanimously by the Congress.


Mullan:    By the legislature.



Hidalgo:   Yes.    By the legislature.   So that was really

interesting.      There was a lot of lobbying on the part of our
state Nurse Association, and unfortunately that lobbyist is now

in Washington, for future issues we may be at a standstill.
                                                                      42

Mullan:    Who was that?



Hidalgo:     Deborah Walker.   She was also a nurse practitioner.

I'll tell you that I think the nurses took the AMA [American
Medical Association] by surprise, is what happened.



Mullan:    This being the state Medical Society.



Hidalgo:     The state Medical Society, yes.   There have been some

responses that were not positive to what happened here.     What
happened here?    The osteopathic society, I'm not sure what it's
officially called, has written some letters that felt that the

legislation that was passed was, in a nutshell, was done not up
front, didn't give enough opportunity for rebuttal and things
like that.    It slipped past them.   So they've made a formal
letter regarding that.     I believe the state Medical Society also
has made some comments.    Pharmacy--you know pharmacy is trying to
evolve, too, into health care primary care providers.     They, too,
have raised a lot of flags.
     We're preparing for this next coming legislature session,
because this one was primarily financial, but the long session
coming next year, because I'm not the Advanced Practice Committee

for the Board of Nursing, and we're trying to decide what issues

we want to raise in relationship to advanced practice.     We're

worried that we made a lot of headway towards independence as a

profession, but I think we're not going to be surprised if there
                                                                    43

are some bills that will come to take back, three steps forward,

that may bring us back.    I don't know.


Mullan:    Have there been any incidents or issues that have

provoked that medicine is saying, "Here is a situation where a

nurse practitioner botched it"?



Hidalgo:    No, there has been no complaint as of my last meeting

with the Board of Nursing Advance Practice Committee.    There have
been no complaints about care issues that require any kind of--



Mullan:    To your knowledge, it's been the osteopathic community

that's raised some issues.


Hidalgo:    Not about care, but just about--



Mullan:    Principles.



Hidalgo:    --the legislative--



Mullan:    Principles.



Hidalgo:    --legal.



Mullan:    The family physician group in New Mexico hasn't--

traditionally, those are the people who feel the most heat.    They

have not, to your knowledge?
                                                                     44

Hidalgo:    Not formally.   Not that I know of.



Mullan:    Let's talk a bit about primary care as a concept, which

we really haven't, and that's the theme of what I'm exploring,

actually.    With a nurse practitioner educated as you've been, and

as nurse practitioners as I understand it are in general, primary
care is at the focus of what they do.    When interviewing
physicians where primary care there's been this sidebar or this

much maligned part of medicine, it's more important to kind of

tease out how a person chose one way or another.      I would

presume, as a nurse practitioner, the concept of primary care
came naturally to you and you're comfortable doing it.     How do
you see it?    What is primary care in your view as practiced by a
nurse practitioner or a physician?



Hidalgo:    Well, primary care is the entry into health care.   It

doesn't always come the way we expect it, and that's how we use
urgent care, especially in our facility and our community here.
Sometimes people will access what really is primary care through
urgent care because it is--


Mullan:    Is this facility devoted to urgent care?



Hidalgo:    Yes.



Mullan:    There's no specialists?
                                                                       45

Hidalgo:     There are visiting specialists that come, that we have

just for referral purposes.        That's what it's for.


Mullan:    Or on occasions you'll refer out if somebody needs a

specialist?



Hidalgo:     Right.



Mullan:    But basicall r what you've done here in primary care.



Hidalgo:     Yes.     Primary care and non-appointment urgent care.   So

some people may enter the system through the urgent care mode, or

they may do it through appointments.       Let's talk appointment and
non-appointment.       So I see primary care is a person's entry into

health care for whatever reason.       Then primary care, as opposed
to what we're calling urgent care, which is a role I was in, and
that's where I can make the difference, is that this is ongoing,

a relationship type of care where you develop that relationship
with the new patient history and physical, and the relationship
where both of your are identifying needs to maintain or improve
health care health of that patient, and this is the ongoing
surveillance of that.       We're talking about health promotion
things, we're talking about screening, and along with that is the

episodic care in between, but it's more than just having a

relationship with somebody just every time they get a sinus

infection.    It's more than that.     And it's more than just coming

in for an annual pap.       It's looking at other areas of health care
                                                                      46

needs, other than cancer screening.     The pap smear encounter is

not just a cancer screening, but it's really looking at all their
other health care needs as far as promoting health.



Mullan:     Is that model comfortable in terms of this community?     I

would presume people come here understanding that.



Hidalgo:     I think it's a learning process.   As I mentioned, the

population here, and I don't know how different or how similar it

is to other places, I think the older residents have had a
different type of health, because that's what's changed over the
years.     People would show up at a doctor's office, I can say for

Belen, and they just want the medicine.     They've been
acculturated that way that you've got a cold, and that's why
we're dealing with it, if you've got a cold, you go in and get a
shot.     They don't know what the shot was, but they got a shot,

and that's going to take care of them.    But they didn't go in for

screenings, consistent follow-up for a particular problem like
hypertension, that sometimes requires labs, depending on what
some of the health care issues are.     So there's a big population
here that is very episodic, and that's all they want out.



Mullan:    But they're not particularly specialty oriented?



Hidalgo:    What do you mean by that?
                                                                      47

Mullan:    That they want to see a cardiologist because they have a

chest pain, or they want to see a dermatologist because they have
a rash.    Do you encounter that? Actually, let me back up.     The
people you see are either part of the Presbyterian Health Plan or

Medicaid, or other?



Hidalgo:    Medicare, Medicaid, and part of the plans that we've

got contracts with.


Mullan:    "We" Pres, or "we" this facility in particular?



Hidalgo:    Well, it would be Presbyterian.   So there is a certain

population that doesn't come here, if it's a different health

plan that we don't service.


Mullan:    Having passed two other facilities on the way here, the

private offices next door, and the Belen Health Center.      What is

it called?


Hidalgo:    There is a Belen Center there that's a nursing home.

There's a private practice here with two physicians and I don't
know how many mid-levels, but I think they have one or two mid-

levels there.



Mullan:    What kind of physicians, primary care?



Hidalgo:    Family practice.
                                                                     48

Mullan:     Who comes to you as opposed to them or other doctors in

town?     Are you seeing an economic cross-section of the community?
Are you seeing poor folks, better than poor folks?



Hidalgo: No, we're seeing a cross-section.       We have a lot of

Medicaid, they have a lot of Medicaid.     Medicaid asks people to
pick a primary care network where they maybe picked for that

office even though they're Medicaid and it's not a HMO, so to

speak.    At one time they were the only Lovelace providers here in
town, and I think they still may be.      Lovelace went to them, but
they also have Health Plus, and they also have Blue Cross/Blue
Shield.    Actually they had more of a cross-section because they

had E'HB Lovelace, that we didn't have.
     Some of it is choice of providers, because before all this

happened, that's why it's exciting to have been part of this,
because when I first entered in the picture here, there may have
been Health Plus and that kind of stuff, FHB.     Yes, there was, it

was the hospital.    But what I was able to observe about the
community was that it's not so much economic background that made
them choose a different physician as their primary physician, it
had a lot more to do with the style of care.     I would say, and
honestly speaking, the physicians that I work with here are more
primary care oriented, and more of a gatekeeper type, and primary

care meaning screening, ongoing continuity care, not just
episodic type of care and referrals to specialists.     I think that

they do more of that, and that was the style before we really

kind of got into this picture of HMOs and referrals and all this
                                                                    49

stuff.     Then there's one other physician who spoke of retiring

but hasn't retiring, who is strictly--1 think his type of care is
really archaic, the old model.



Mullan:     But you don't have a lot of specialists in Belen to make

that an issue.     The core issue is practicing primary care as you

do here, does the negative side of gatekeeping, the perceived
negative side, are people concerned because they have to go to
you and they can't go straight to the dermatologist or the

gastroenterologist, etc.?



Hidalgo:     I think that is an issue. Actually, I've seen a change

in the behavior in the referral process over the last couple of

years.     I can see it as a consumer before I got into this picture
and before it got so tight with managed care and all this stuff,
that I felt it was a barrier.    I know I need an ophthalmologist.
Why do I have to go to a primary care provider first?      I can tell
you as a consumer before, that was my perspective, and I do
believe a lot of people still share that.    But I've also seen the
practice of some of these physicians that they've kind of rolled
with the punches, too.    I think at the beginning when they were
given that responsibility of gatekeeper, they took it very

seriously, and it was to keep costs down and really not use a
bazooka when you can use a - 2 2 , for the same problem.   But I

think their actual practice and referrals is multiplying.     I

think the gates are looser, put it that way.    That's just my

perception.
                                                                    50

Mullan:    Because?



Hidalgo:    Because I think it's the demand of the patient.



Mullan:    As opposed to there are certain kinds of things that

they are now comfortable sending through?    For instance, in many

cases it's been argued that dermatology is best seen directly,
that a dermatologist is so efficient and so quick that if
somebody calls up and says, "I've got a rash,'' and if there's a
dermatologist available, it's more efficient to send him to it.
At least some primary care docs and others are concluding that.
That's different than patient demand saying, ''1 want to see a
dermatologist," or whatever.    But as primary care sort of sifts
itself out, there are reasonable arguments even in an efficient
mode that direct access to certain kinds of specialists makes

more sense.



Hidalgo:    Maybe that's it.



Mullan:    But it's certainly the former, that is that there is a

steady demand, a steady patter of patients to want to see
specialists.



Hidalgo:    Oh, yes.



Mullan:    And the primary care docs are getting a little more

relaxed about that after initial tough stance.
                                                                        51

Hidalgo:    I think so.    I mean, as I told you this morning, my

medical assistant helps Rick Madden's nurse with referrals,

because it's just too much.      I'm talking stacks of referrals,

multiple referrals for the same patient.       That's so different
from what I was told when I first entered into the picture of
primary, when they were acculturating me to the system.        When I

came as a nurse practitioner student, if I wanted to make a
referral, I was taught very early on that, "Oh, no, no.        We need
to keep those down to a minimum."      That's what was communicated

to me by the same providers.      As I got to working here, I began
to say, "Well, I don't refer but it seems as though for the same

problem you've changed your tune."       I think.   I think it would be
interesting to look at that.



Mullan:    Let me ask about your view of the future, where the

primary care portion of the system is headed.       Much speculation

about will it become more prominent, less prominent, the role of

non-physicians working with physicians, will they capture the
field, will they be squeezed out of the field, will there be
multiple types of primary care providers in the future as there
are today, some coming out of medicine, some coming out of
nursing, some coming out of PA?



Hidalgo:    Pharmacy.



Mullan:    Pharmacy.    If you l o o k twenty years down the road, what

do you think's going to be out there?
                                                                   52

Hidalgo:     I don't think primary care is going to be squeezed out,

because I think even though consumers feel that there are
barriers to get the level of care they think they need, I don't

think they want to be seen as a liver, as a skeleton, as a heart.

They want to be seen as a whole person.     And I think that's what
primary care and the health care team, with physicians and non-
physicians as a team, I don't like the hierarchy, I think that's

old stuff, and I think that if we can sell that concept to the
consumers, they may feel better cared for, and not feel this need

to reach for the specialist after they've had the time for
education of the system.
       I think we need to spend more time in community education
projects to help people understand their perception of illness.

For instance, in working in this other committee on the
organizational level, it's an access care team.     One of the loop
process with feedback, and the issue is access.     How do we
improve access? Why are we feeling that it's a negative right

now?


Mullan:    Access is a negative?



Hidalgo:     That patients are viewing access negatively, that they

are not feeling we are accessible to them as their primary care

providers.



Mullan:    This a Presbyterian committee?
                                                                    53

Hidalgo:    This is a Presbyterian committee.   One of the things is

that they feel that it's the patient's perception of level of
illness that needs education.    Of course, that's us the providers
wanting to tell them, but I think a lot more time needs to be

spent on that, educating people, appropriate access, so that we
don't plug up the holes with things that are inappropriate.     I
think if we could spend more resources on educating communities
on different things.    For instance, how many holes are plugged by
me doing diabetic education one on one?    It's expensive.   That's

very, very expensive, when programs should be initiated that
you're out in the community hitting larger groups of people for

less money, actually.    So I think community education needs to be
a seller for a plan.    If we're going by plans, the plan's got to

sell to employers, and I think these are some of the things that
they should be investing in.    I think triaging the appropriate
level of access of a patient into the system is going to save a

lot of money and actually provide better care for these people.
I still feel that the health care team, as a team provider, needs
to be marketed.


Mullan:    So you would think that twenty years from now we will

see people practicing primary care whose origins are medical
school and medical concepts, and people whose origins are nursing

school and nursing concepts?



Hidalgo:   Yes.
                                                                       54

Mullan:    How about PAS?



Hidalgo:    PAS, well, actually, we're going to start a new PA

program here.     I'm not sure if it actually started yet.



Mullan:    At UNM?



Hidalgo:   At UNM.    They're bringing back a PA program.    I think

we're going to see PAS, too, because there's a lot of controversy
over who's more efficient, a PA or a nurse practitioner, lumping
us together.


Mullan:    I think the margin again would have a hard time

distinguishing.      In our minds, the PA who doesn't come out of

nursing tradition and is also a latecomer to the medical
tradition is kind of neither fish nor fowl, and yet by all
measures when properly trained and put into the situation, works

pretty well, with a slightly different spin or twist or attitude
or world view.
     This is your interview, not mine, but I'm struggling with
this question.    I don't think primary care is going to be a
potent part of our system, that the multi-headedness of it,
currently--you've got pediatricians, family physicians, and

internists just within medicine, and then others like OB/GYNs

claiming the same, too, then you've got a set of nursing

traditions, you've got PAS, and then you got the pharmacists.        If

you were marketing toward cars or trucks, you'd consolidate.        You
                                                                      55

wouldn't have five different pickups that essentially did field

work, you'd have one or two.
      So that historically one understands how these various

streams have fed into the health care work place that we have

today, but it seems to me that the market and reasonable

educational approaches of things will work to achieve some kind
of consolidation or simplification.       I don't know what it is,
it's instinctive, so I'm sort of plumbing people's ideas trying

to figure out what they think.       Because we sort of funny-fit

different traditions into a work place which is okay, but if it
really is going to be a constant foundation of our health care
system, an important element of the whole system, it's a little
wobbly when you've got all these different things feeding into

it.   I suppose you can make the argument that it's also rich,
because it has different traditions, but it's wobbly.
      So   you don't see any driving forces that NPs are going to

take over and primary care physicians are going to disappear or

vice versa?


Hidalgo:    No, that won't happen.    Nurse practitioners have been

in New Mexico a long time.


Mullan:    I told you, my nurse, in 1973, Gloria [unclear], went to

the first generation of the program at the medical schools, so

that's twenty years.



Hidalgo:    Did she work for Allison The1 Gonzalez, too?
                                                                      56

Mullan:    Was she in Albuquerque?



Hidalgo:     Yes.



Mullan:    She might have.    She went to Albuquerque and went to

work.



Hidalgo:     I think you must have shared the same nurse

practitioner.       This other proponent for--she's within our system,
came from Lovelace, she's a family practice doc, and she's
working with the same--1 almost feel like you had talked to her,
because we talked about the very same issues when I met her.
     When I was schooled in nursing for the nurse practitioner

program, those people in the ivory tower were moving me in the

direction to be very independent, almost in a competitive sort of
manner, but over the last five years, I have changed my
viewpoint.    I've developed my own, put it that way.    I've

realized that I don't want to compete with a physician, because
in this state a nurse practitioner could, and have, developed
independent practice.       But of course, physicians aren't even in
independent practice anymore.      They're being employed because of
economics, and that would be foolish to do that.      Although that
was one of my original goal.      But over the last view years, I've

developed the team approach and feeling very comfortable with it,

with is totally different from how I was set free from school.

So I think there's a mind-set changing.
                                                                   57

Mullan:    That's interesting.



Hidalgo:    I think it's, to be honest, for survival, because I

agree with what you and Allison said.



Mullan:    One sees in Washington a fair amount, particularly

during the health care reform, I thought, when there was a good
deal of opportunism on all sides, people saw the opportunity to
make leaps ahead, and particularly since nursing politically was

well positioned with the [Bill] Clinton White House, there were

enormous demands made about independent nurse practice and the
new efforts to make a national law to just sort of preempt state

laws, which I think state laws, to use your word, are archaic
practice acts, but they are very much a part of the texture of
the countryside.   States wouldn't take kindly to having the
federal government preempt those laws.   But there was this

effort.

     One had a sense, and I speak, I suppose, as a physician, a
little defensively, nowhere near as defensively as some of my
colleagues, that this was nursing's final revenge on medicine, or
final effort to kind of get medicine back.   "We're going to be
doctors of our own sort and have our own, etc.," which looking at
the history of medicine and nursing and the way medicine both

historically and interpersonally has been an overbearing

colleague or non-colleague, one could understand that.

     Functionally what it means for nursing, advanced practice
nursing, in a tighter marketplace, somehow physicians and nurses
                                                                     58

are going to have to work out a combination to where there are
professional benefits or professional distinctions that allow for
more effective or salubrious delivery of services, is where I
think the gain is to be made.       But the irony of nursing both

pushing its scope of practice and its cost ahead, is going to run

right into the buzz saw of physicians' salaries coming down, more

physicians in the country, and it's going to be, I think, a very
difficult situation.


Hidalgo:    I think you're right.     I think even at the state level,

I felt like that's what I was pursuing when I came here, and I

wasn't making a lot of headway for the role, kind of blindly

taking opportunities.    I wanted to carve out something before it
was carved for our role, and I think I took a lot of
opportunities.
     But now I feel that I'm at a level and I think our role

should be at a level where it's not worth it to try to compete.

It doesn't make any sense.   You're going to lose a lot more
opportunities and that to figure out how we're going to work
together but still maintain an identity and not go back to, "I'm
your boss and whatever medical order I give, I'm the only one who
can give the orders and you carry them out."      I don't think
nursing needs to go back to that.      They don't, because they're

intelligent professionals who can make decisions based on their

level of education and experience.      I would like to see that

continue.
                                                                     59

Mullan:    What do you see yourself doing twenty years from now?



Hidalgo:    Well, I don't know about twenty years from now.     I

won't be practicing twenty years from now, but in that interim I
see a lot   of opportunity to provide care not necessarily on an
encounter level as we're seeing it traditionally today, people
coming in for this and that.     That may be part of my practice.

I'd like to develop educational programs for, say diabetics, in
an entrepreneurial sense, and I'd like to hit the market of HMOs
to recognize that as something that they're willing to pay for

and to be able to demonstrate cost savings.     I still have my love
in prenatal care, I love it.     I tried to stay pretty general for
the first few years out of nurse practitioner's school, but I'm
drawn to it.    I also see developing programs in that level,
community-based.



Mullan:    Teaching?



Hidalgo:    Teaching, yes.   I see teaching as an area.



Mullan:    The final area and final question.   We talked a little

bit about your family to begin with.    How has your career, as

it's developed, intersected with family life?    Do they

understand?    Does your husband understand what you do?   Is he
supportive? How about the boys, how do they see it?
                                                                        60

Hidalgo:   And how about extended family.      Yes.   What I'm trying

to sell, what makes me different or how much alike, because
that's what all people know, is what a doctor does.       Okay?
Teaching my family what I did was hard enough, and teaching the

distinction between a nurse practitioner and a doctor, it's just

so much easier to say, "She does what a doctor does."       Well, that
gives you a focus point to start from, and I don't like that

focus point.    I would rather be described as what I do, but not
using a physician as a reference point.       That's what I meant, a
reference point.    But they still do that.    They do understand
what I do, and my husband has been the biggest promotor of what I

do and what I can do--this is his family here, his extended
family--about how exciting my job is, and how elevated it is from

what they see as a nurse.    It's taken time for them, just my own
extended family, to gather--"Well, what does that do?       How much
does she really have authority to do?"    It goes to both issues.
But I think they understand, the younger generation.
     My mother-in-law, God bless her soul, I think she's just now
figuring it out.    Attitudes are hard to change.     They see a nurse
is a nurse is a nurse.    That's why when you get people's
perspective is, "What's the first thing that comes to your mind
when you think of a nurse?" it hasn't changed that much.       It's
changing, hopefully, and I want to be the influence to help that
along, not to be a doctor, because I'll be the first one to tell

you, "NO, I'm not a doctor," but to promote nursing in and of its

own entity.    My mother-in-law will still say things like, "Well,

heck, I saw the nurse practitioner," at some other clinic,
                                                                      61

because of her health care plan, "and shoot, I wanted to see the
doctor, and I told them, well, I could have just seen you."
     "Yes, you could.     There's nothing wrong with it."
[Laughter]

     So    some of those attitudes do come through.   But they've

been very supportive, and they sacrificed a lot when I went to
school.    So   I think they've had just as much commitment to this
change that I have.     They really have.   They've been very

supporting.



Mullan:    Another question.   Hispanics in nursing in the United

States are at a low number, something I actually studied in my
last job and worried about.     The numbers are very, very low.
You've obviously gone that route and gone that route fairly well.
Any observations about what motivates or doesn't motivate young
people, particularly women in the New Mexico community or the

Arizona community to not get into nursing or to get into nursing?
HOW'S it been being a person of Hispanic origin going through the
system?


Hidalgo:    That's a real good question.    I'm glad, because I want

people to know this.     I went to a Catholic high school in
Arizona.    There were a lot of barriers, and it's because of our

ethnic origin.     It was interesting.   I have to tell you a little

bit of this background, because I think it's pertinent.     My

original last name was Lopez.     I was adopted by my stepfather and
I was Bloyd, but looking at me, I am Hispanic.     Coming from
                                                                    62

Arizona, the Hispanic population is different and treated
differently than in New Mexico, and I've had the opportunity to
feel both, and it's been very rich.



Mullan:    New Mexico is more long-term part of the land, whereas

in Arizona there's much more transience?



Hidalgo:    Discrimination is what I'm talking--and prejudice.

When I went to this Catholic high school, it was mostly white,
middle-class, very few Hispanics.    But the rest of the Hispanics
came from--1 don't know, they had other barriers that they had,
well, they had Spanish last names, they had accents--



Mullan:    Which is a barrier?



Hidalgo:    Which is a barrier.   In Arizona it's very

discriminatory.    They had accents that stereotyped them.   Well, I

was a good student, and I didn't have an accent, I didn't even
have a Spanish last name, but I was Hispanic.    People would
always ask me what I was.    When it was time for me to make a
college decision, or a decision after school, after high school,
I had an Anglo, white nun, who was the career counselor, told me,

"NO, don't go to college."



[Begin Tape 2, Side A]



Mullan:    This is Therese Hidalgo, first side of the second tape.
                                                                       63

Hidalgo:    So I was at the point where I was being counseled on

what my after high school decision should be.       She knew I wanted

to go to college, and she said, "Oh, Therese, I don't know.        I
think that college wouldn't be right for you.       I think that you

ought to be a secretary."    Well, she said that to the wrong
person, because as soon as she said that, that made the hairs on
my neck stand up.    So that was a barrier.     That was one of the

barriers that is probably not affecting me, but affecting a lot

of other Hispanic women and men.

     So I went to school, and when I was in my undergraduate
program, you're right, I can count the number of Hispanics, and
this is in New Mexico.    It was interesting.    Then in my graduate
program, there were eight of us originally, and two of them were

Hispanic.    That's such a small size.   That may not be a fair

statement, because I don't think that--1 can tell you in the rest
of the graduate school level nursing, that was a big percentage

of the whole graduate program, for that one class.      But that was
because this was a federal grant for rural New Mexico.      They
wanted Spanish-speaking people, and I think that's why the
percentage was actually higher in my nurse practitioner class.         I
don't really know what the statistics are for the most recent
classes are as far as the makeup of the ethnic background.



Mullan:    Do you have a sense that that's changing, that more

Hispanic people are getting into nursing and health professions

or not?
                                                                     64

Hidalgo:     Just a guess, I would think that more of them are

getting into it, but getting to the advanced practice level, I
still think is going to trail.       It'll come.   My guess is that the

undergraduate levels is accepting or cultivating more Hispanics.

At UNM, there's a lot of opportunity once you get there, but

having somebody put an obstacle before you before you even get to
that college, maybe that's still going on at the high school
level.     I don't know.   Because there are a lot of minority

studies there at UNM, and a lot of minority programs.        I can
remember this, tutoring programs for minorities at UNM

undergraduate level.



Mullan:    The affirmative action concept and/or programs, did that

have any bearing at any point along the way on things that you
did?


Hidalgo:    I always wondered, and I don't know that for sure, but

my hunch is it probably did, getting accepted to the nurse
practitioner school.       I hate to think that, because I would like
to know that I got it on my own merit, but there were hundreds of
applicants.    Or maybe they j u s t felt sorry for me because I
already said I was in the program when even that was going on,

with my charm.    I thought maybe that was it.      [Laughter] I

always wondered if that was really an issue when I was in that

program, when j u s t eight people were selected out of hundreds of

applicants.    So I'm not sure.
                                                                     65

Mullan:     How about in terms of role modeling?   Have you done any

work on high schools or elsewhere trying to get young women
interested in nurse practice careers?



Hidalgo:     Any patient that walks in my door.    [Laughter] And

it's not a matter of what their ethnic background is, but I do a
lot.     I have done guest speaking at the high school level for
their Career Day.     I have been asked to be their mentor for a
day.     They have a program where they mentor with someone they are
interested in their career, here at the clinic.
        Here's an interesting one.   This one young woman asked me to
mentor her in my role.     This is interesting.    I said, "Oh, so
you're planning in going into nursing.     This is what nursing can

do.
        "Actually, I want to go to medical school," she told me,
"but I feel more comfortable if I would mentor around you at the
clinic."    She knows this one other physician here very well.

It's a small community, so we all know each other real well
outside of the clinic.    But that was a very interesting remark.
Still talked about values of the different professions.      I still

think there's that attitude, and that kind of hurt my feelings,
because I thought I made such headway with, "Nursing is valuable,
too."    So I know I kind of took that a little personally, but we

got through that okay.    And I also took it as an opportunity to
really show if she should become a physician in the future, that

she could see the value of our roles together.      She is in college
                                                                       66

right now out of state.       This is probably her second or third

year undergraduate.      So   I'll be curious to see what happens.


Hidalgo:    What about your boys?     What are they going to do?



Hidalgo:    They're really ranch oriented.     My oldest still feels

like he wants to be a professional baseball player.



Mullan:    He's thirteen?



Hidalgo:    No, he's sixteen.     He's playing for the high school.

But ranching and farm science.       I'd like to help direct him in
that way, to work in the economics business of ranching and
farming.    He wrote a paper when he was in eighth grade that, "I'd
love to be a rancher, but I know that nowadays you have to have a

degree, and I feel that business and agriculture together would

be a good combination."       That was really pretty good.
     My second one still wants to be--they still are in the
sports arena, of thinking that--their dreams.       But none of them
have talked about medicine.       None of them have talked about
health care.      I'll be interested to see.   I thought I could get
one of them to be a vet, because things are changing in medicine
of veterinarians, as far as use of drugs.       This would be a good

investment.



Mullan:    Yes.   I bet you as they reach maturity, when they have

to start making those decisions, their mind at least passes by
                                                                    67

you as a role model, I'm sure.   Well, you've been terrific.

Anything else you want to say or you'd like to leave with me?



Hidalgo:   No, I think I gave you a lot.   I'll just look forward

to seeing your book.


Mullan:    Thank you.



[End of interview]