It's something William Hodges doesn't have the stomach to do, but Janie Heath dives in without hesitation.
As Mr. Hodges closes his eyes and stretches out his legs on an examination table at the Downtown division of Department of Veterans Affairs Medical Centers, the nurse practitioner gently grasps his bare right foot and pokes his little toe with a long pin.
"Which one am I touching?" Ms. Heath asks.
"The little one," Mr. Hodges answers quickly.
"Good," Ms. Heath says, straightening up from the pale foot with thick gnarly toenails. "Excellent, you pass," she jokes.
"Damn I'm good," Mr. Hodges jokes back. "What's my prize?"
In this case, it is ongoing, coordinated care from Ms. Heath, who not only looks after his diabetes and heart problems but also sends him to specialists when he needs help with anxiety or depression. And there are the long, unhurried visits that allow him to talk to Ms. Heath about anything that is bothering him and her, in turn, to counsel him about his diet, medication and overall health.
And then she does something few of the 76,000 nurses in Georgia can do -- she writes him a prescription for an anti-inflammatory drug without calling in a doctor or sending him off to another part of the building.
Because Ms. Heath and a dozen other adult nurse practitioners work at a federal facility, they benefit from a federal law that gives nurse practitioners the ability to write prescriptions. Georgia law does not, and legislation to give nurses that power has been bitterly opposed by the Medical Association of Georgia.
"We ran up against MAG like a brick wall," in the last legislative session, said nurse midwife Judy of Atlanta. Georgia is one of only two states -- Illinois is the other -- that does not allow nurses to write some prescriptions.
Nurse practitioners did recently catch a break when Medicare decided to reimburse them for services. But only New York currently allows nurse practitioners to be listed as an option for those with managed care insurance, Ms. Heath said.
Physician organizations like the Medical Association of Georgia and the American Medical Association frame it as a public-safety issue.Daniel Johnson, AMA past president, discussed it during a visit with future physicians at the Medical College of Georgia in April.
"How many of you feel like the training of a physician's assistant or a nurse practitioner is equal to what you will have?" he asked medical students. No hands shot up. He called nurse practitioners "people who want to practice medicine without the training and legal right to do so."
But Ms. Heath, who has a master's degree and additional training as both an adult and an acute care nurse practitioner, said physicians shouldn't feel threatened.
"We're certainly not here to be little physicians," she said. "We're not competing with physicians; we are here to complement the health care delivery team. We are here as an alternative choice for patients."
And that's certainly how Mr. Hodges sees it. Assigned to the primary care team of nurse practitioners, it means he doesn't get bounced around from specialist to specialist and doesn't end up sitting around in a large waiting room for hours, he said.
"I don't ever feel short-changed," said Mr. Hodges, 48. In fact, it may even be better for him, he said. "I usually don't get to feeling good with doctors 'cause I don't trust 'em," he said.
To Ms. Heath, it's just a different way of approaching the patient.
"Nurses practice the art of caring, and physicians practice the art of curing," she said. Where a doctor may see a patient and write a prescription, a nurse practitioner is more likely to emphasize wellness and preventive changes in diet and exercise, she said. The examination of Mr. Hodges' feet, which even he doesn't like to touch, is part of Ms. Heath's monitoring of his diabetes, checking for numbness and poor circulation that can lead to ulcers, in addition to checking his blood sugar and prescribing him drugs to maintain his blood-sugar level.
But she still needs to be able to write prescriptions when needed, she said.
"As a nurse practitioner, that's not the biggest thing, but in order to do your job you need all those rights," she said.
Even within the VA, where nurse practitioners have been part of the primary-care clinic for four years, there is still some resistance among physicians, said Martin Grever, Ms. Heath's collaborating physician.
"There's been some friction and uncomfortableness with the concept," Dr. Grever said. "When looking at what their scope of powers and job description is supposed to be, I don't see any problems."
After about six years of trying, the nurses have figured out that if they are going to change laws, they'll have to bring to the table the same thing the doctors do, Ms. Fielder said.
"MAG has a lot of money they can put into campaigns and that seems to be what people listen to," she said. The Medical Association of Georgia has about 40 percent of the 22,000 Georgia physicians as members, while the Georgia Nurses Association's membership includes only about 4 percent of the 76,000 nurses, Ms. Heath said.
The association hopes to change that with a recruiting effort this summer, Ms. Heath said. Beginning this month, every nurse will get the group's publication, not just members, Ms. Fielder said. And nurses will be encouraged to get involved in campaigns, make their presence felt and vote accordingly, Ms. Fielder said.
"You've got to play the game or you're not going to get any points," she said.
Janie Heath, a nurse practitioner at the Department of Veterans Affairs Medical Centers, checks the circulation and feeling in the feet of William Hodges, who has diabetes. Federal law allows Ms. Heath and other nurse practitioners to prescribe medication at federal facilities.
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