Oh, those pesky Nurse Practitioners. Held up as a savior of primary care in underserved areas, they are nevertheless under constant siege from uncomfortable doctors with one-hundred-thousand-dollar educations. The latest salvo comes from Dr. Brett Coldiron (I swear that’s his name), who published in the Journal of the American Medical Association a study that suggests nurse practitioners and PAs are billing for “surgical procedures” that they are not trained to perform. http://www.kaiserhealthnews.org/Stories/2014/August/18/nurse-practitioners-physician-assistance-dermatology-surgery.aspx
These are not major surgical procedures. Nurses are not doing low anterior resections or heart transplants. 50% of these procedures are dermatological. Oh, by the way, Dr. Coldiron is a dermatologist.
The definition of what constitutes a surgical procedure is pretty consistent: a medical procedure involving an incision with instruments; performed to repair damage or arrest disease in a living body (The Free Dictionary); Medical treatment in which a doctor cuts into someone’s body in order to repair or remove damaged or diseased parts (Merriam Webster); A procedure is considered surgical when it involves cutting of a patient’s tissues or closure of a previously sustained wound (Wikipedia). By those definitions, taking off a mole or a spot suspected of being cancerous on someone’s back does constitute surgery. Someone’s body is getting cut into. Merriam Webster says a doctor is the one that cuts into people. OK. I’m a doctor. I have no special training in dermatology, but if took a mole off someone, even though I have no idea how to do it, Dr. Coldiron would presumably be fine with it. But if I’m a nurse, with specific training in skin cancers and how to detect them and remove suspicious spots, and I took a mole off someone, I’m not properly trained. It doesn’t make any sense.
Coldiron said while the mid-level providers may have received extra training within a relevant specialty, many likely lack the expertise of doctors who have done a residency within the field. “If nurses are going to practice surgery, that’s not [nursing] – that’s medicine,” he said. You know what’s involved in taking off a skin tag? A pair of scissors and a bandaid. Removing a mole is more involved. Now you need a little novocaine and a knife, and a bandaid. Such a procedure demands some instruction, sure, but not a dermatology residency.
The issue at hand here is money. The authors of the study do not care about whether or not NPs can take moles off safely. In fact, the study says nothing at all about safety. They care about billing. If a nurse takes off skin tags, that’s money out of their pockets. This nurse vs. doctor thing has got to stop. Turf wars do our patients no good.
New flash: Doctors, in their role as providers of consumer goods and services, will soon start offering a new service! Coordinated Care is coming to a doctor’s office near you!
Medicare has decided to pay doctors to coordinate care. CMS is calling it a “new service”:
“As part of the new service, doctors will assess patients’ medical, psychological and social needs; check whether they are taking medications as prescribed; monitor the care provided by other doctors; and make arrangements to ensure a smooth transition when patients move from a hospital to their home or to a nursing home.” http://www.nytimes.com/2014/08/17/us/medicare-to-start-paying-doctors-who-coordinate-needs-of-chronically-ill-patients.html?ref=health&_r=0
Well, now it will. Here’s how it will work: Medicare will pay doctors a monthly fee to coordinate care of medicare patients with two or more chronic conditions (2/3 of all Medicare patients). The doctor drafts a comprehensive plan of care for each patient, using EMR, and provides 24/7 access to someone on the doctors’ staff. In order to be eligible the patient must sign up for the “service”. I can just imagine the conversation:
Doctor: “Mrs. Jones, I understand you have more than two chronic conditions.”
Patient: “Yes, doctor, I believe I do.”
Doctor: “Would you like me to coordinate your care for you?”
Patient: “Of course doctor. I thought that’s what you were already doing.”
Doctor: “Oh, no Mrs. Jones. I only assess your medical psychological and social needs, check if you are taking your medications, monitor the care provided by other doctors, and make arrangements to ensure a smooth transition from a hospital to your home or a nursing home. Things like that.”
Patient: “Oh. What does coordinated care get me?”
Doctor: “The same thing. But in electronic comprehensive care plan form, which I will draft and type up over the weekend during my kids’ soccer game.”
Patient: “Well, if it’s electronic and comprehensive…”
The fee for this “new service”? $42 dollars per month. Part of which Mrs. Jones will pay herself. All those care-coordinating doctors are rolling in money now. Especially after they pay their staff for that 24/7 coverage. Now, I understand that this fee is actually progress, in the sense that being able to bill for something you already do is progress. Being able to bill for something lends a certain legitimacy that doing the same thing for free does not. Forty-two dollars, while a bit insulting, is not nothing. However, doctors are going to coordinate care as best they can the same as they always have. But now they’re going to have to document it, code it, bill for it, prove the 24/7 coverage, draft the care plans, in short, do everything they already do plus a whole lot more. For the cost of a couple of Washington DC burgers with fries and a pickle.
Quality is very difficult to measure in healthcare. As I have said many times before, measures of quality tend to be things that can be easily quantified and put in a checklist. Whether or not these indices have anything to do with actual quality does not seem to matter to the Center for Medicare and Medicaid Services (CMS). One such measure, incidence of venous thromboembolism, has been called into question, most recently in Anesthesiology News, in which Christina Frangou reports on a study recently presented at the American Surgical Association annual meeting. Here’s Frangou quoting Dr. Mila Ju, one of the studies authors:
“Hospital may be unfairly deemed a poor performer for the outcome VTE measure if they have increased vigilance for VTE by performing more VTE imaging studies.”
If you look for it, you’re more likely to find it.
VTE is medical-speak for a blood clot in a vein, usually a large vein, often in the lower leg. These clots can occur for many reasons, but venous stasis caused by prolonged bedrest or immobility is one reason. Patients having hip surgery, for example, might be immobile for enough time for blood clots to form. The problem with these clots is that, in rare cases, they detach and float through the venous system to the lungs, causing a blockage of blood flow to a lung or part of a lung, causing oxygenation problems or even death. Most of the time they don’t. In many post-operative cases VTE is preventable using blood thinners such as Heparin, or devices that compress the muscles of the legs, like Venodyne boots. CMS has deemed the incidence of VTE to be a quality measure, that is, VTE in post-surgical patients should never occur because it is preventable. Medicare will not reimburse for the care of post-surgical VTE and starting in 2015 VTE occurrence will be tied to financial penalties. CMS apparently has a zero-tolerance policy on VTE.
Now, no one can argue that preventing preventable complications is quality care. There are several problems with using VTE as a quality measure, however. Problem number one is that VTE is actually pretty rare, in the 1% range, which limits it’s validity as a basic quality measure. Second problem is that to document the occurrence of VTE, you have to do a venous ultrasound or other imaging study. With a 1% incidence, there’s a lot of extra imaging going on that wouldn’t occur without the mandate to document. In fact, hospitals with higher rates of VTE also performed more imaging studies. Not only that, but the hospitals that did more imaging studies for VTE had also adhered most strictly to prophylaxis guidelines, even though a study in the Annals of Surgery in 2011 found that VTE rates failed to improve after implementation of guidelines that called for more aggressive pharmacologic prophylaxis. Translated, that means blood thinners don’t always work. Compression boots don’t always work, especially if applied incorrectly, something you can’t measure with a check box. Also, blood thinners come with their own risks, leading to complications potentially worse than VTE.
Maybe rate of VTE incidence really is a good quality measure. Maybe some patients get heparin and compression boots and early mobilization and aggressive PT and some don’t. But its also a terrible measure because it aggressive prophylaxis doesn’t always work. It doesn’t matter what you do, some patients are going to get VTE no matter how good the care is. It’s a terrible measure because all the care in the world won’t prevent VTE if the compression boots are hanging off the end of the bed because the patient won’t wear them. It’s a terrible measure because going looking for a problem usually ends in finding one.
Here’s Dr. Sam Finlayson, chair of surgery at the University of Utah:
“The problems that the authors [of Ju's study] have uncovered related to VTE rates strengthen the argument of those who believe that outcome-based, pay-for-performance programs are not ready for prime time.”
A very interesting post was brought to my attention on a website called Best Medical Degrees. The site has a lot of useful information with links to medical school degree programs and how to choose the best one. The post has to do with the cost of medical education, and I’m re-posting part of it here: http://www.bestmedicaldegrees.com/is-medical-school-worth-it-financially/.
Many of our best, brightest, and most ambitious students consider becoming doctors. Not too long ago, it would be crazy to question the choice. Yet a rising number of issues such as malpractice lawsuits, massive student debt, opportunity costs, and a changing medical landscape have made some question the worth of attending medical school. While most types of doctors trump opportunity costs within the decade in which they leave training, the opportunity costs of attending medical school are still massive; and for those who don’t truly want to practice, stress and debt can leave them wondering why they ever enrolled in the first place.
While the cost of medical school in and of itself is certainly high, the true cost of becoming a doctor is in years and years of your life. According to the Bureau of Labor Statistics, the average weekly earning of a bachelor degree holding American is $1,102. Extended out over a year, this is $57,304 that would-be doctors are missing out on (on average) for at least their first four years of medical school. Multiply the average lost earnings by four, and you end up with $229,216. This may not seem like a great deal when compared to the eventual salaries of doctors, but we haven’t factored in the other costs of the first four years of medical school yet.
The median four-year cost of medical school (including expenses and books) was $278,455 for private schools, and $207,866 for public schools in 2013 according to the Association of American Medical Colleges. While grants and scholarships account for some of this total, lowering eventual debt to an average of $170,000–interest accrues while doctors are still completing their residencies, sometimes adding as much as 25% to the total debt load. Added to the lost potential income above, and assuming a modest 10% increase in debt burden through interest during school, doctors are routinely $416,216 more in the hole when compared to the average college graduate. In other words, comparing doctors to average college graduates, doctors are half a million dollars behind in real and potential losses, all by their early thirties.
One thing it’s important to remember is that doctors are often some of the best, brightest, and most driven around. This often increases opportunity costs even more than our previously stated numbers. While the median salary of all bachelor’s-degree-only graduates evens out to around $25 an hour, those with the capacity to excel at medical school are probably prepared to excel more than others in the workplace. Given a modest increase to $30 an hour, lets take a look at the true cost of medical school by total hours spent.
With no fellowship and the shortest possible residency of three years, medical school graduates have already spent approximately 27,000 hours on their medical training. This is assuming 80 hours a week of studying and training, for 48 weeks a year in medical school, and 80 hours a week of studying and work, for 50 weeks a year during residencies. This may seem like a lot, but Medical school is hard and requires many more hours than most people work, particularly once long residency shifts are included. To put the amount of time many students are spending on medical school in perspective, working 40 hour work weeks, it would take another worker almost 13 years of work to equal the number of hours med students are putting in in 7. With the above assumption that those talented enough to get into med school would probably earn more than average bachelor’s degree only holders, potential salary losses swell to $674,400 through residency (even subtracting the average medical resident salary of $48,800). Coupled with average medical school debt of $170,000, the total cost of attending med school including lost opportunity is around $800,000.
Above we’ve fleshed out a ballpark figure of losses compared to the general degree-holding population, as well as to what we believe those who go to medical school are capable of if they chose another path. We’re still speaking too generally, however, as we haven’t accounted for the range of education requirements and benefits of different medical specializations. For example, to be certified in internal medicine, a doctor needs to graduate from medical school, complete a 3-year internal medicine residency, and pass board exams. To become a thoracic surgeon, one must graduate from medical school, complete a 5-year general surgery residency, complete a 2-year thoracic surgery fellowship, and then pass thoracic surgery boards. A difference of 4 more years in school (7 years vs. 11 years).
This difference is reflected in the eventual salaries of our example specializations. Pediatricians make an average of $210,678 a year, while pediatric thoracic surgeons make a whopping $762,846 a year. Speaking only in terms of finances (not focusing on individual passions, importance of work environment, and so on), very few specialization choices for those in med school face a meaningful financial loss due to additional years in school. In an example without taxes, the 6 extra years in which a pediatrician is out of school and working, and a pediatric thoracic surgeon is in school will net the pediatrician about $750,000 (once residency pay is included). Every year that the pediatric thoracic surgeon is out of training, however, will chunk over $500,000 off of previous comparative losses.
Pediatric thoracic surgeons are a rather extreme example, however, as they are one of the highest paid and most specialized medical disciplines. Taking another discipline that requires a great deal of school yet is more common, the financial benefits of becoming a geriatrician are somewhat less clear. Assuming, again, that a potential medical school student would end up making greater than average salary outside of medical school ($30/hour) soon after graduation, a geriatrician has lost a potential $930,000 in earnings (if they had worked the same amount out of medical school) by the time they’re practicing doctors. Assuming the opportunity cost of a potential geriatrician continuing to make $30 an hour slows down the recouping of loss brought about by a geriatrician’s average salary of $188,885, rendering an effective salary of $126,485 (not including taxes) with which to catch up from the million dollar deficit. School debt adds to the deficit, but generally it should take over a decade to catch up to what a geriatrician would have potentially earned. Meaning on average that a geriatrician breaks even in their early to mid 40′s. Factoring in a 33% tax bracket, and average interest accrual on student loans, the break even point can be extended almost a decade farther.
While the relatively high salaries of doctors invariably pay for opportunity and real costs of a long training period, the stresses of large debt loads, long hours of studying and residency, and sometimes extremely stressful work conditions take their toll. A recent report on American Medical News notes that nearly 90% of physicians feel moderately stressed, severely stressed, or burned out daily. For younger doctors in training, the burden of escalating debt and intense stress in training is often too much. Med students who realize they don’t really want to work as doctors have already taken on large loans, and often feel trapped. Unless you truly feel a calling for medicine, can cope well with the stress, or are highly motivated by the future pay off, medical school is often not worth it.
The take-home message of the piece is that to become a happy doctor you have to really really really want to be a doctor and be unable to imagine doing anything else with your life. If you want to make money, go to Wall Street. If you want to make a good living at a good job with good job stability, look elsewhere.
I’m about to get myself in big trouble here. In another excerpt from what is rapidly becoming a book-length project on choosing nursing vs. medicine, I’m going to try to tackle part of nursing’s image problem. Hold onto your hats.
Here’s a quote from a reader of this blog:
“I have done a semester of an RN program, but I’m starting to have an identity crisis. If I worked harder in the past, I would have been going to medical school today.”
What this person is really saying is: “Doctors are better educated than nurses. So if I’m smart and good in school, I should be doctor. If I don’t work hard or get good grades, I should be a nurse.” First of all, the term “better educated” is fairly meaningless. By “better educated” do you mean smarter? Good nurses are smart, and I know plenty of dim doctors. By “better educated” do you mean “spent more time training?” Time in training gets you more experience, not more education necessarily. By “better educated” do you mean “spent more time in school”? I spent a whole year sitting in Calculus and never learned a darn thing. Yes, doctors have more education, of a scientific and medical nature. That’s why they get to make medical decisions.
What the writer might really mean by “better educated”, “better” being a value judgement in this case, is “superior”. Herein lies one of the core sources of nursing’s image problem and it’s tendency towards defensiveness: the assumption that “Doctors are superior to nurses because they are smarter and better educated.” This is what people who say “You’re really smart. You should go to medical school” are really implying. I hope by now you know that I think that the decision to go into nursing or medicine lies in what you want the focus of your care for people to be, and not how smart or educated you are or want to seem. But the the assumption that doctors are smarter than nurses persists, in large part because of the barrier to entry.
Let’s compare the academic bar set for various degree programs.
Admission requirements for a typical ADN program:
1. Be high school graduate or have passed the high school equivalency GED (General Educational Development) Test.
2. Have a high school grade point average (GPA) of at least 2.5.
3. Have completed one-year courses in high school algebra, biology and chemistry with “C-” or higher in each.
4. Have a negative 7-panel urine drug screen and complete a criminal background check. Students will not be allowed to enter the program until cleared by GRCC police.
5. Score at least 75% on the HESI test. This test assesses knowledge in reading, vocabulary, grammar, and math.
Admission to the BSN programs typically require:
1. High School GPA of 3.00 or higher (on a 4.00 scale)
2. ACT score – 20 or higher or SAT score (CR+M) – 930 or higher
Here are the entrance requirements for a typical state medical school:
1. High school diploma with average science GPA of 3.7 and total GPA of 3.8
2. College degree with all the required science and math courses (grades of C or below don’t constitute completion of any any course), average GPA 3.7
3. MCAT scores of at least 27
The existence of an entry point into nursing that does not require a college degree, or even a high school diploma, really, and that only requires the student to barely pass their coursework, pulls professional nursing into the realm of being more of a job or a trade than a career, requiring more brawn than brains. An ADN-prepared nurse might be a great nurse and a smart person, but such a low barrier to entry fuels the assumption that nurses are not smart. Nursing policy makers would really like to make a college degree a requirement, but there is also a strong argument being made that removing the ADN as an option will discourage people from becoming nurses at all. Professional nursing will have to decide whether it wants to maintain this inclusivity at the expense of image and credibility.
Medicine, of course, has an incredibly high barrier to entry, both in terms of time, money, and academic ability. Notice I don’t say intelligence. Medical school is more about persistence than smarts. But to become a doctor you have to perform at a very high level for a very long time from a very young age. And it’s very expensive. It almost seems designed to discourage people from becoming doctors. The resources, both external and internal, required to actually complete such a road are beyond what most people think they can come up with. This lends to medicine a mystique and unreachability that results in a superior image.
I’m not saying that nursing should require everyone to have a PhD. Nor am I in any way saying that doctors are smarter than nurses. Nor am I saying that ADN-prepared nurses aren’t good nurses. I’m saying that the standards set by educators and administrators in any field should reflect the image that field wants to portray.
We humans have a tendency to judge and compare. We can’t help it. We look askance at the mother with the screaming child in aisle 7 while our 6-month-old sleeps angelically, or look pityingly at the shivering soul smoking just outside the “no smoking” sign, snow piling up against their shoes. We see our friend from high school who’s still working retail at Charlotte Russe and think our BA in basketweaving is pretty awesome. Student violinists compare their seat in the back of the second violin section and think resentfully that the guy who’s last chair in the first violin section is no better than they. My five-year-old tells my four-year-old that her dress is prettier. That person got into a better school, landed a more lucrative job, married a prettier wife, on and on it goes.
We are especially obsessed with numerical values. We look sideways at the person on the spin bike next to ours and gloat that we are on a higher setting. (Oh, come on, you know you’ve done it.) High school students compare SAT scores, medical students try to weazle other peoples’ MCAT scores out of them. We want data on other peoples’ numbers, be it income, weight, houses, awards, etc. because we need to know where we stand in relation to everyone else. Dan Ariely, in his book Predictably Irrational calls this “relativity”, and it is a powerful motivator for how we make choices.
Governing bodies of all types, charged with maintaining standards, love numerical values. Numbers can be charted on a graph and trended. Judgements can be made on the basis of numbers in a seemingly objective manner. Here’s Mr. Ariely:
“..there’s one aspect of relativity that consistently trips us up. It’s this: we not only tend to compare things with one another but also tend to focus on comparing things that are easily comparable – and avoid comparing things that cannot be compared easily.”
This is why most of the “quality” measurements in medicine concern things that can be counted, like pre-op antibiotics, the presence or absence of documentation about vaccinations or smoking history, percentage of patients on statins, etc. Its why check boxes are so popular. The binary “yes the box is checked” or “no the box is not checked” is super easy to analyze. But the analysis is meaningless. My colleague at The Medical Bag, Skeptical Skalpel, puts it this way: (http://www.kevinmd.com/blog/2013/05/problem-basing-physician-pay-quality-indicators.html)
“How quickly patients are discharged [as a quality indicator, as NYC's Health and Hospitals Corporation wanted to do last year]: Does this mean the time from admission to discharge, or is it the time from when the decision to discharge a patient is made until he actually leaves? If it’s the latter, again there are many forces at work. Does the patient want to go home? Can he get a ride? Is the bed ready at the nursing home or rehab center? If he’s being transferred by ambulance, will it arrive promptly? Is the nurse too busy to do the paperwork? Is the doctor, who may be a resident, too busy to do the paperwork?”
The ability to easily quantify is at the root of the standardized testing and ranking of quality of teaching, and quality students, in education. It doesn’t work in this setting either. Here’s Anna Bahr in the New York Times: (http://www.nytimes.com/2014/07/30/upshot/when-the-college-admissions-battle-starts-at-age-3.html?ref=education&_r=0)
“The admissions criteria for New York’s specialized public high schools are much simpler. Schools like Stuyvesant High School, Brooklyn Latin School and the Bronx School of Science admit children based exclusively on their Specialized High Schools Admission Test score. The student who is a prodigious cellist and a terrible test taker won’t stand a chance.”
Here’s what Lily Eskelsen Garcia says in Salon.com: ( http://www.salon.com/2014/07/30/stupid_absurd_non_defensible_new_nea_president_lily_eskelsen_garcia_on_the_problem_with_arne_duncan_standardized_tests_and_the_war_on_teachers/
“The years I taught at the homeless shelter, I had different kinds of students than the year I taught at Orchard Elementary [in Utah]. Also, there was the year I had 24 kids and the year I had 39 kids. You can’t put that in a value added formula. It doesn’t work. Then there was the year I had three special ed kids with reading disabilities, and I did a bang-up job with them. So the next year they gave me 12. I had all of the special ed kids that year. No other teachers had any. Just me. So in a class of 35 kids, 12 had reading disabilities. Now I’m guessing if we had just used test scores back then to evaluate me, you maybe would have thought that I had suddenly become a really crappy teacher that year. Test scores alone wouldn’t have told you what happened. They wouldn’t have given you an analysis of why.”
A test score, a check box, a yes or no answer, these are all stand-ins for real evaluation. They are easy, they are quantifiable, and they mean nothing.
Here’s an excerpt from a project I’m working on about the choice between nursing and medicine. I’d love to know what you think.
Barry Schwartz, in his book The Paradox of Choice, asserts that most good decisions involve the following steps:
Figure out what your goals are
Evaluate how important each goal is
Gather all your options
Evaluate how likely each option is to fulfill each goal
Pick a winning option
Reference here: Schwarz, Barry. The Paradox of Choice: why more is less. HarperCollins, NY, 2004.
These steps sound simple enough. You know these steps. You run these steps a thousand times a day in small ways. Here’s the problem. Step number 1 involves figuring out What You Want. Step number 1 can take your whole life to complete. Figuring out What You Want involves all your prior experiences with good and bad choices, how you expect future experiences to feel, and the experiences you’re having now.
Let’s take a simple example. You go to the library to choose a book to read. The decision to go to the library for your book is based on prior experience with the library and a glance at your overburdened bookshelves. In the library, you can choose to go to the “new book” section or upstairs to older fiction. But wait, maybe your prior experience with fiction was unpleasant. Or maybe you like fiction but the work of fiction you’re currently reading is unpleasant. So you decide to go to the biography section, for something different. You don’t know if you will like biography, having had no experience with it. You anticipate you will like it because you liked History 101 in college. Once you’ve chosen biography, you still have no idea what you want because you have no experience with the different authors. So you choose a book about Abraham Lincoln because you just saw the movie. You leave the library, hoping you made a good choice, but not knowing for sure. Your chances of having made a good decision for yourself are fifty-fifty at best.
Schwartz says that knowing What You Want means that you have to be able to anticipate how you will feel if you choose different options, which in the case of health care is very difficult to do. And the ability to accurately predict how you will feel is even more important when the thing being chosen, as in medicine, is years away from actually happening. Here are two seemingly contradictory conclusions drawn by people who do research into decision-making:
Most people don’t know what they want.
We have to see things in context and comparison. What we see tends to change depending on what things are next to each other and how we judge each. My car looks great next to that old jalopy but it looks like a bucket of bolts compared to the Jaguar on the other side. Nursing looks great next to my high school friend working at Starbucks, but maybe doesn’t look so great next to your other friend who is transplanting hearts.
What other people think also has a great impact on what we think we want. When somebody says “You’re so smart. You should go to med school”, they are imposing their judgements, values, and stereotypes on the decision. But you’ll care about what they think, and as I said above, it will influence how you decide.
Most people know what they want
This is why a simple list of pros and cons doesn’t work when it comes to these kinds of decisions. Gut feeling is a powerful indicator of what we really want. Most of the time our gut is drowned out by social structures and expectations, but it is a very important piece to pay attention to. For example, if you are making a decision about whether or not to buy a new car you might make a list of all the good things and bad things about buying a new car vs. keeping the old one. What you might not factor in is the gut feeling that says “I want a new car. Now.” So you end up buying one even if your list concluded it wasn’t a good idea. We are not completely rational creatures.
It is clear that, using Barry Schwartz’s steps to good decision-making, you have to get step number one right. No amount of information will help if you don’t know yourself and what you want. Not just what you think you want, or what you think you should want, or what someone else tells you is the right thing to want.