The Covert Rationing Blog

Getting Square With the Nurses

July 9th, 2008 by DrRich

Last month, DrRich wrote about how “doctor-nurses” are fixing to displace primary care doctors, and how the noble American Medical Association – champion, as always, of the American PCP – is mobilizing with decisive action to prevent this tragedy from taking place.*

One of the more remarkable responses to this article came in the form of a blog entry by DrRich’s colleague Annie, an entry which was, let’s say, critical.

DrRich is very sorry to have raised Annie’s ire, especially since Annie represents a combination of two of DrRich’s favorite kinds of people – nurses, and students of the Constitution. It is in this latter capacity that she writes for the blog Home of the Brave, a site that, if a bit leftward-leaning for DrRich’s tastes, is nonetheless dedicated to the very worthwhile goal of discussing “U.S. history, the state of the union, the state of the U.S. Constitution.” DrRich even gave top billing to one of Annie’s posts last week in Medical Grand Rounds – her nicely tuned article showing what the Founders might have said about the current sad state of the American healthcare system, an article which he now recommends again to everyone.

This public recognition of Annie’s obvious merits, despite the article she had written in response to DrRich’s posting on doctor-nurses, ought to attest to DrRich’s essential fair-mindedness and objectivity. For in that article Annie was less than kind to DrRich’s sensibilities. For instance, referencing DrRich, Annie said,

A few physicians are skeered of a new demon. They’ve got their Salem witch hunter judicial robes on, and they’re ready to order the press, the pyre or just a good old pompous piosity to their screed. What has their panties all in a bunch?

Doctorally educated nurses. I. am. not. making. this. up. They’re afraid of nurses.

What nurse bashing this is and based on what? Fear of competition?

Annie goes on some more about DrRich’s manhood and such (for the record, DrRich does NOT wear panties), but you get the idea.

More relevantly (more relevantly, at least, to everyone else if not to DrRich), Annie’s post points out that: a) nurses with doctorate degrees are not a new phenomenon; b) the vast majority of nurses are not out to displace physicians, or to usurp the title “doctor;” c) since there is an acknowledged shortage of PCPs, surely something has to be done to fill the void, and nurses – working in full partnership with doctors, as always – can help; d) the formidable Mary Mundiger (formidable, at least, to the lily-livered DrRich) does NOT speak for the large majority of nurses; and e) the organization that actually does speak for most nurses is the very reasonable American Association of Colleges of Nursing (AACN).

And the AACN is greatly disturbed by ideas, put forth by misguided paranoids like DrRich, that doctor-nurses may be getting ready to take over for actual physicians, and is distressed by the blowback that has already been experienced by the nursing profession as a result of such ideas. Indeed, Annie points out, the AACN is so alarmed by the resolutions being considered by the AMA (described here) - resolutions that, if passed, would potentially result in sending nurses a strongly worded letter - that it has issued a white paper itself urging the AMA not to take such drastic action.* This white paper passionately expresses

concerns regarding Resolutions 303 and 214, which are coming forward to the American Medical Association (AMA) House of Delegates. . .AACN is distressed by the tone of these resolutions, which may weaken the good working relationships established between many physicians and nurses….AACN requests that the AMA withdraw Resolutions 303 and 214, and if that is not possible, we urge members of the AMA’s House of Delegates to vote against these measures.

That is (Annie assures us, and the AACN certainly confirms), nurses, even most of the doctorally trained ones, want to play nice with physicians. And DrRich’s screed on the impending take-over of American medicine by hordes of aggressive nurses is both overdone, and very counterproductive.

In response, DrRich can only offer that he fervently desires that Annie, and any others who may have been offended by his earlier post, go back and read it again, but this time read it keeping in mind the following prompt: Irony. For DrRich’s comments were mainly aimed at satirizing the response of the emasculated and morally bankrupt medical establishment to the inevitable encroachment by nurses on what has traditionally been medical turf. DrRich was attempting to be ironic. (A colleague of DrRich’s, reading Annie’s posting, commented that those who miss the poorly-hidden subtleties of irony also may be likely to miss the well-hidden subtleties of difficult medical diagnoses. But this is unkind and likely incorrect, and DrRich chooses not to subscribe to it. Besides, this snide comment presupposes that DrRich does irony well, which may not be a good bet.)

Furthermore, DrRich would like to go on record to say that virtually everything Annie says (except for the personal stuff about his cowardice, Puritanical judgmentalism, exaggerated piety, panties, etc., much of which is simply not true) is pretty much correct. DrRich agrees that the large majority of nurses have no intention or desire to fundamentally displace American PCPs. And DrRich further agrees that doctors who resent nurses because they think they’re after their jobs are badly misguided.

But it’s not because ascendant nurses aren’t about to displace them that they’re misguided. They are indeed about to be so displaced. Rather, they’re misguided because most nurses don’t want any part of it either, just like Annie says.

Anyone who had read DrRich’s earlier articles on the plight of the PCP would understand that he does not consider the prospect of nurses encroaching on the turf of PCPs to be evil or bad, but simply the normal pattern in a modern society wherever advancing technology enables lesser-trained individuals to do things that in the past required highly-trained specialists. DrRich would never bash nurses for simply playing their natural part in the evolution of a technological society. He would sooner criticize a grizzly bear for dining on the entrails of an elk which had died of the mange.

The quotation Annie provides from the AACN white paper, protesting because the AMA is accusing nurses of doing what nurses are, in fact, doing (however involuntarily it may be) is quite telling. The train is leaving the station. The writing is on the wall. While it is clearly not Annie’s intent, or the AACN’s intent, or the AMA’s intent for nurses to replace PCPs, it’s happening just the same, as the night follows the day. Neither the PCPs, nor the nurses who may be startled and intimidated by the prospect, can ultimately stop it.

Those doctors who do view the encroachment by nurses as an unadulterated evil deed will see the protestations of innocence by the AACN - while events on the ground so clearly contradict them - as something similar to the soothing murmurings of the Japanese Ambassador while preparations for Pearl Harbor were in their final stages. They will see it as disingenuous at best, treachery at worst. But viewing it this way is simply wrong.

The posting by Annie and the white paper of the AACN are actually indications that most nurses are as apprehensive as are the PCPs they are displacing. And why shouldn’t they be? Look at the new responsibilities and risks the nurses will be acquiring - medical, moral, legal, financial and otherwise. Historical upheavals like this are often unkind to all parties involved, even the supposed “winners.”

If further evidence is needed that DrRich is correct (beyond simply studying the history of technological societies), simply read the July 2008 Update of the Hospital Outpatient Prospective Payment System issued by CMS. This document (if you can get through it) among other things removes language from the Medicare Benefit Policy Manual that had required that “services furnished in provider-based departments of hospitals must be rendered under the direct supervision of a physician who is treating the patient.” That is, non-physician care providers are now allowed to provide care for Medicare patients in a hospital outpatient department without any supervision by any physician who is caring for the patient.

CMS is already there, and is very obviously clearing the path for the inevitable. Everybody needs to get ready for this - the PCPs, and the patients, and even the reluctant nurses.

* This is an example of irony.

Posted in Primary Care in America

5 Responses to “Getting Square With the Nurses”

1. Annie wrote on 07/9/08 at 1:18 pm :

   Annie humbly requests that Dr. Rich not take personally any panties references, as her comments, ad hominem as they were - were generally intended to poke fun at many of the self identified physician commenters of both genders on the WSJ Health blog. The irony and most excellent opining of Dr Rich is duly noted, but the response wouldn’t have been as much fun or as barbed if it had been taken into account. Oh, and for your colleague - I am NOT a DNP graduate or an advanced practice nurse, so you won’t find me making any diagnoses, let alone a diff. =^} My critical care clinical nursing is now very out of date, and except for the rare good sam first responder aid, me no practice clinical anything anymore. ;^)

   Two points (not barbed this time):

   The numbers of DNP graduates will be small. The DNP is not the sole type of doctoral degree in nursing (the EdD and PhD are other options, and if I recall, the PhDs lead the pack by far).

   Second - patient quality and outcomes will be measured. If they are found lacking in any way, regardless of the credentials of the person providing primary care, then appropriate safeguards and sanctions must be taken. I’m not referring to the excrescent Press-Ganey hotel service satisfaction questionnaires, but rather, objective measures of degree of accuracy of diagnoses, treatment and outcomes.

   One thing that Mundinger said which struck me (I couldda had a V-8!) is that nurses are attracted to DNP and advanced nursing programs because they want more control over their interactions with patients and with their practice environments.

   That’s exactly what drove me to enter graduate study in nursing administration: the horrendous degree of dissonance between the responsibility without concomitant authority and autonomy over acceptable patient case loads and working conditions. I wanted to find better ways to put authority for nursing practice directly with clinical nurses.

   And that’s why I am convinced that any model of practice for nurses and physicians which involves working as an employee rather than as an independent contractor or member of a professional practice group allows power over practice to remain with non-physicians and nurses (the payers, the employers and the regulators).

   It’s no surprise, then, that health care “cost-cutting” is aimed directly at physicians’ and nurses’ salaries and reimbursement rates. “We” - the global aggregate of US registered nurses and physicians - would be a much more powerful and influential force if we worked within self-governed professional practice group iterations and contracted services directly to patient care organizations. Unions do not and cannot address the needs of autonamous licensed professional nurses and physicians. So instead of power through numbers, hospitals, other patient care institutions and payers use the divide and conquer approach to deal with individual and small groups of nurses and physicians, and essentially, the professional is at the mercy of the employer and payer. That’s backwards and serves the patient ill, as well, since it makes advocacy doubly difficult.

   We have many more critical and essential commonalities in goals, aims and ethics than we have essential differences and competing interests. But we have a long way to go to learn about and understand the practice demands and professional ethos which are peculiar to our professions, and even farther before nurses and physicians sit down at the same table and craft a meta plan to provide essential medical and nursing care to Americans.

   Thanks for reading and commenting and making me think! (That’s always the painful part)

2. Bob wrote on 07/10/08 at 12:53 pm :

   “..non-physician care providers are now allowed to provide care for Medicare patients in a hospital outpatient department without any supervision by any physician who is caring for the patient..”

   Dr Rich - I don’t believe this is an epochal change (if any). Medicare has always considered the physician “treating the patient” (a phrase which you reworded) to mean the patient’s personal attending MD - the MD ordering the services.

   Would you want a hospital to refuse to perform infusion, or cardiac rehab, or OT on one of your patients unless you personally showed up at the hospital to observe the process??

3. Dan wrote on 07/11/08 at 2:47 pm :

   So, You Want To Be A Doctor…..

   Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason stated and speculated for this decline of this health care profession that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training, as the annual salary of a PCP is around 130 thousand a year. This includes payers such as Medicare.
   Yet considering the additional attention of shortages of students in some medical schools as well, one may ask the question as to whether or not people want to be any type of doctor in the first place in the United States. About one third of their lives are spent achieving the requirements of this profession. Reasons for not choosing to enter this profession are several and valid and include the following:
   There is the issue of long hours- with primary care in particular because of the apparent lack of doctors of this specialty. Such doctors may be over-worked without an expected pay reflecting the work they do. Furthermore, those doctors employed by health care systems are required to see a certain number of patients a day, and receive a monetary bonus if this expectation is exceeded. It seems that most doctors are members of such health care systems. So burnout never anticipated certainly may occur. And I consider such a requirement mandated by health care systems demeaning to this profession, and leave the doctor without the control that the doctor is entitled to due to their training and experience, and this competes with the other adversary of doctors, which is managed care. In fact, even government healthcare programs provide financial incentives in relation to the pay-for-performance system to improve the quality of care.
   However, the recent increase in hospitalists, who are those doctors that are usually Internal Medicine doctors who care for patients presently under hospital care, and they have lessened the load for all doctor specialties for the work they do that the admitting doctors would have to do without their presence. This in itself makes a doctor possibly more effective and efficient in their practice outside of the medical institution. Yet still, PCP medical school training has decreased about 50 percent in less than ten years not long ago.
   All doctors, I presume, face a high degree of emotional and physical stress associated with their profession, as stated in the previous paragraph, for example. And this is not to mention the incredible stress associated with patient care in the first place, with some patient cases causing more stress than others. Patient care duty is a noble and great responsibility.
   Doctors, due to the changes that have occurred recently in the U.S. health care system, not only have the issue of money to deal with, but also a loss of autonomy regarding patient care combined with loss of respect that may be due in large part to the others previously mentioned who dictate how they practice medicine. Ironically and often, these others who direct these doctors are not as qualified as the doctor in the first place. This is complicated by the perception that the public, with some who view doctors as having the easy life with their pay and profession, which does not seem to be the case presently. Another frequent occurrence is the doctor’s patient directing their care with their doctor from either DTC ads or researching medical disorders on the internet themselves.
   There are also reasons of malpractice insurance, which is why doctors choose to join health care systems, it is believed, to pick up the tab for this necessity, along with eliminating the concerns of running a practice in a private manner, which historically has been the case, as their offices are owned by the health care system as well. Yet having another pay their malpractice premium does not eliminate their concern about being sued for error perceived by one of their patients. To protect against this, defensive medicine is implemented by doctors, which basically involves copious amounts of documentation and ancillary diagnostic testing regarding the doctor’s adherence to recommendations and guidelines.
   It has been said that up to 90 percent of malpractice cases against a doctor are baseless and without merit, so they are unsuccessful for the plaintiff, yet this still affects the rate the doctor or another system has to pay for malpractice insurance of a wrongfully accused doctor. This is combined with the amount the doctor has to spend to defend themselves in such cases, which separates them from their focus on the restoration of the health of their patients completely. Furthermore, malpractice lawsuits cost about 100,000 dollars over the course of about 4 years for such cases. A tort reform in Texas in 2004 resulted in annual malpractice premiums reduced by about a third of what they were. Soon afterwards, claims against doctors remarkably dropped by about 50 percent. Some specialties of doctors pay more premiums for malpractice than others. For example, OB/GYN doctors have been known to pay around 300 thousand dollars a year for this insurance. Certain types of surgeons experience a similar high rate of malpractice premiums. Malpractice flaws are catalysts for doctors to practice the inappropriate defensive medicine mentioned earlier to avoid potential litigation, which is a waste of health care resources with ordering unneeded patient methods or procedures to cover themselves against such lawsuits.
   Also, about a third of the U.S. is insured by Medicare, which progressively has lowered what they will reimburse a doctor for regarding the care doctors give a patient they treat. This fact is recognized by other insurance companies who will eventually follow the recommendations of Medicare, usually, regarding the reimbursement issue, so it seems. This will lead to a doctor having to see even more patients in order to make it financially with their profession, as this has resulted in the overall income of a doctor experiencing a decline of about 10 percent over the last decade or so.
   Further complicating the financial state of a primary care doctors is that doctors normally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed. About 20 years ago, that debt was only about a fifth of what it is today. Paying this debt off is typically about 2 thousand dollars a month that doctors on average is what the doctors choose to pay in order to eliminate this debt in a timely fashion.
   Conversely, there are some who believe that doctors in the U.S. are over-paid. This may be true, but they are not absent of financial concerns as with any other profession. And as mentioned earlier, clearly doctors accept more responsibility involved with human health than other vocations, so this should be kept in mind perhaps more by others.
   Most doctors do not recommend their profession to others for such reasons stated in this article so far presently, and perhaps other reasons not mentioned. This is somewhat understandable, yet extremely unfortunate for the health of the public in the future. There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state of mind that occurs as a doctor in today’s health care system, which is expressed by them at times in apathy, cynicism, and vexation regarding their limitations coerced by others.
   Then again, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession. Personally, I believe that the intentions of most physicians are bonafide. Yet in time, due to the nature of the current health care system, doctors frequently and really do become cynical, demoralized and apathetic. This may be considered a significant concern to the well-being of those in need of restoration of their health, understandably.
   Not long ago, the medical profession that has been discussed had overt honor and a clear element of nobility. Such traits are not as visible or recognized anymore, which saddens many intimate with the profession and importance of public health that is needed by many. It seems that our own government is not supportive of this profession as well, and this is disappointing.

   “In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero

   Dan Abshear

   Author’s note: What has been written has been based upon information and belief.

4. Jonathan Dee wrote on 07/11/08 at 9:45 pm :

   I don’t think we can avoid using non-physician providers as a part of the solution for a primary care shortage. In most cases, however, this results in a compromise in the quality of care. I don’t mind the nurses or anybody else getting a “piece of the healthcare pie”, just make sure they’re educated (med school) and trained adequately (residency). I think the longterm fix needs to be an increase in the number of med school slots and a real financial incentive for students to choose primary care specialities.

5. Red Baron wrote on 07/17/08 at 10:49 am :

   @ Jonathan who said “In most cases, however, this results in a compromise in the quality of care. I don’t”.. Where on earth do you come up with absolute tripe like this? While I agree with your overall poit, saying things like this does not help it, especially when it is not true: Mid-levels have LOWER med mal rates and HIGHER patient satisfaction rates than physicians do (it has to do with the acuity of patients they see).

   When will people uderstand this issue comes to simple mathematics. The basic questions you/they should be asking are:

   1. How long does it take to produce something (in this case a healthcare provider)?
   2. How much does it cost to produce something (again, in this case a healthcare provider)?

   If you are going to put a nurses in an expensive shool for 4 years after college (to get their nursing degrees + M.S. or whatever degree they want) AND then have them in some kind of ‘residency’, they will cost as much as a physician to produce– do you think it really matters whether they call themselves MD or whether they call themselves RN + MS or PhD?

   The salary required to justify the financial outlay and times spent training will still need to be recovered either way. Changing something as simple as a title does not change this simple mathematical fact.

   And playing around with finances by asking the governement to fund the education/training doesn’t make the process any cheaper either– all it does is push the cost onto someone else.

   They key is, always has been, and always will be educational productivity.

   Please wake up and smell the coffee

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