Last week I went to my primary care office and saw a nurse practitioner. She was great. Super easy, listened to my problem (a minor one), knew just what to do, didn’t press a bunch of tests on me that I didn’t need, and generally appreciated my goals for the visit and acted accordingly. It was nice. I didn’t ask this NP if she had a master’s degree or a doctorate. Until fairly recently I was unaware that a person could get a clinical doctorate in nursing. My professors in nursing school had PhDs in nursing.
About 10 years ago member schools affiliated with the American Academy of Colleges of Nursing (AACN) voted to endorse the Position Statement on the Practice Doctorate in Nursing, which called for moving the level of preparation necessary for advanced nursing practice from the master’s degree to the doctorate by the target year of 2015. On October 28th of this year, the AACN, an advocacy organization that has an independent program certification arm, published the results of a RAND corporation study about how far nursing schools have gone in transitioning advanced practice training from the master’s level to the doctorate.
Since I’m writing a book about medicine and nursing, and since this nursing doctorate thing seems to be happening, I took the opportunity to look into the matter.
Advanced nursing practice is defined by the AACN as “any form of nursing intervention that influences health care outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy.” (http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf). That’s kind of a broad definition and could be used for doctors as well. The AACN seems to want to emphasize the management, administration, and policy components of this definition, couched in the language of Improved Patient Care. The AACN has made curricular recommendations for the Doctorate of Nursing Practice (DNP) called DNP Essentials. They include:
Scientific Underpinnings for Practice
Organizational and Systems Leadership for Quality Improvement and Systems Thinking
Clinical Scholarship and Analytical Methods for Evidenced-based Practice
Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care
Health Care Policy for Advocacy in Health Care
Interprofessional Collaboration for Improving Patient and Population Health Outcomes
Clinical Prevention and Population Health for Improving the Nation’s Health
Advanced Nursing Practice
What does all this policy-speak mean? I don’t think anybody is quite sure yet. Do these eight points help you understand why you might want to do a DNP? Not really. Currently DNP degrees generally require an MSN, but the projected model is to go straight from the BSN to the DNP. Practically speaking, DNP programs are supposed to be the ultimate nursing clinical degree. DNPs are supposed to be three-year programs instead of two, with 1000 hours of clinical practicum, rather than 600. Rather than a research-based dissertation, DNP programs sometimes require some other form of final project, like a practice portfolio or a practice change initiative. It remains to be seen whether DNP programs grow in favor as the preferred preparatory path for nurse practitioners.
What did RAND find? Well, here are the key points as found on the AACN website:
- DNP programs – either at the post-baccalaureate (BSN-DNP) or post-master’s (MSN-DNP) level – are now offered at more than 250 schools nationwide.
- The study authors found near “universal agreement” among nursing’s academic leaders regarding the value of DNP education in preparing nurses to serve in one of the four APRN roles, specifically Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, and Certified Nurse-Midwives.
- Though the master’s degree remains the dominant route into APRN practice at this point in time, the educational landscape is changing. Approximately 30% of nursing schools with APRN programs now offer the BSN-DNP, and this proportion will climb to greater than 50% within the next few years.
- The national movement toward offering the BSN-DNP and closing master’s level APRN programs is expected to accelerate. Currently, up to 14% of schools with APRNs programs only offer the BSN-DNP as their entry-level option into advanced practice. An additional 27% of schools with or planning a BSN-DNP intend to close their master’s level APRN programs within the next few years.
- Student demand is strong for all types of programs – BSN-DNP, MSN-DNP, and the MSN – that prepare APRNs. Approximately 65% of schools with BSN-DNP programs also offer master’s level APRN programs.
- Many employers are unclear about the differences between master’s-prepared and DNP-prepared APRNs and could benefit from information on outcomes connected to DNP practice as well as exemplars from practice settings that capitalize on the capabilities of DNPs.
It is this last that I think is going to cause problems for the DNP advocates. Nursing educators and APRNs are themselves not sure what the differences are. But the DNP seems to be on it’s way, nevertheless.
I don’t know if any of you have heard of James Clear. He is a self-improvement writer and, of all things, a body-builder. The gym and I don’t generally get along, although I have been known to bow to its torturous demands in my youth. Mr. Clear (an awesome and improbable name), despite his sweaty bonafides, is surprisingly good at breaking down the process of getting better at anything. My favorite phrase of his is “The aggregation of marginal gains.”
With this phrase Mr. Clear beautifully describes an attitude I find difficult to the point of impossible to adopt: enjoyment of the process of becoming. A self-confessed serial accomplisher, I have no problem setting goals but tend to suspend my day-to-day happiness until the goal is reached, thus missing a good portion of my life. The process, which Clear calls The System, is really what gets us to the goal. The system is the series of marginal, 1% better, aggregate steps needed on a regular basis to produce improvement. These steps an be almost impossibly small: eating 50 less calories per day, increasing your running mileage by 100 feet, managing to get a note in tune 1% more often in tune. 1% times 100 is – well, 100% better.
This concept, while simple and cognitively understood by most of us, is very difficult to put into practice because marginal gains are hard to see. What is the gain to be seen in getting one note more in tune when a thousand are out of tune? Why do I care if I take two more steps when I run? Americans don’t want marginal gains. We want the big score.
Why am I talking about this on a medical policy blog? Because the knee-jerk reaction many of us physicians have to bad habits is: “You need to stop smoking.” You need to stop drinking.” “You need to check your blood sugar more often.” These statements, while perhaps true, are unhelpful at best and discouraging at worst. The fact that doctors are judged and paid based on results of things likes smoking cessation and blood sugar control doesn’t help. Blanket statements about major changes in habits don’t work. My violin teacher could say “You need to learn how to control your bow better.” Unhelpful. I’ll spend a year tightening my grip and digging into the string until I can’t play at all. Instead he says “lower your shoulder when you come to the base of the bow, and move faster and with more bow hair as you move toward the tip.” If I practice this, the result is that my ability to play one long note may be 1% better. It feels doable. What about those other 100,000 notes? Over time, they all get better. A doctor could say “You need to quit drinking.” Unhelpful. The patient will not drink one day and binge the next. If the doctor says “You need to drink one-half a can of beer less once a week”, it sounds doable. The doctor will not be rewarded for such marginal improvements, but the patient will be, if the aggregation of marginal gains is allowed to proceed in it’s own time.
This approach works for everything. Say you want to get into medical school, but organic chemistry is like a fog that descends upon your brain, so thick you feel like you are swimming through oil-infested gulf water. Instead of quitting that molecular biology and biochemistry major in favor of environmental sociology, figure out how a carbon and a hydrogen fit together. That’s more than 1 % of orgo. That’s like 90%. The aggregation of small advances from that basic knowledge, done systematically and regularly, will get you through.
Marginal gains. You can do it.
Dear reader, you have not heard from me for awhile. I apologize. I have been practicing the violin. I recently got a teacher, whom I call The Crazy Russian, who insisted that I had talent and then proceeded to completely dismantle my technique. Now I can barely play at all, there are so many things to remember. But I practice, with the hope the changes will make my playing better.
The careers of doctors and lawyers are often called “practices”. A doctor will say “I don’t do this in my practice” or a lawyer will say “I practice mostly corporate law”. Why are doctors, lawyers, and musicians, even the seasoned and successful ones, still practicing? Is it just to keep up our current skill level, or is there something we still need to learn? Do doctors’ work, like my violin playing, occasionally need dismantling and overhaul?
The word “practice” originated as a medieval Latin word c.1400 meaning “to do, act”. In the early 15th century the meaning included “to follow or employ; to carry on a profession,” especially in medicine, and “to perform repeatedly to acquire skill, to learn by repeated performance”. This means that when someone sets out to practice he could have several goals in mind. A musician might want to improve his performance or he might simply want to maintain his skill level. A doctor might also want to maintain his skill set, to “carry on a profession, to do, to act”, but any good doctor, as any good musician, is constantly striving to get better at what they do. Doctors and musicians are not finished products when they come out of school. Each encounter with a patient, each introduction to a new piece of music, demands that we take what we know, apply it to the patient or music in front of us, and tailor our approach according to the unique problems of the person or music we are dealing with. During this process, we use what we have learned from that patient or piece and apply it going forward.
Some examples: If I am playing the Sibelius violin concerto, which has a lot of arpeggios (broken ascending and descending scale passages in which only every other note of each scale is played), I will recognize them but I might want to pull out my scale book and review arpeggios in different keys, or find an etude that focuses on arpeggios. Thus, not only do I learn the concerto, but I learn to play all arpeggios better. If I encounter a patient with a rash, I might recognize the rash, but will probably pull out my dermatology textbook or online equivalent and review similar rashes, as a way of confirming my diagnosis. In the process, I learn more about rashes in general.
Suppose, however, I approach the Sibelius concerto convinced I know how to play arpeggios, and have only to apply what I already know. This might work if I really do know how to play arpeggios, but such an attitude will limit my ability to refine my technique and grow in this area. Thus my practicing has limited effect. Doctors who shut down their minds to the suggestions and opinions of others, convinced they know best, are depriving themselves of the opportunity to learn, and their practice can stagnate.
Good doctors, like good musicians, are learning all the time. They are applying what they know and seeking to increase and refine their knowledge. May we never be convinced that we know everything.
There comes a time in every writer’s life when she realizes someone else said it better. A fellow blogger, John Mandrola, pointed out a piece in the New England Journal of Medicine that I am happy to say is better than anything I could have written. Called “Invisible Risks, Emotional Choices – Mammography and Medical Decision Making”, written by Dr. Lisa Rosenbaum, it can be found at http://www.nejm.org/doi/full/10.1056/NEJMms1409003. Dr. Rosenbaum talks about the ways in which patients make decisions, and how at odds those decisions can be with the scientific evidence. Here is what what she says:
“We do not think risk; we feel it. As research on risk perception has shown, we are often guided by intuition and affect. For example, when our general impressions of a technology are positive, we tend to assume that its benefits are high and its risks are low. We estimate our personal risks of disease not on the basis of algorithms and risk calculators, but rather according to how similar we are, in ways we can observe, to people we know who have the disease. And when we fear something, we are far more sensitive to the mere possibility of its occurrence than its actual probability.”
Decision-making pitfalls are extremely common sources of poor choices. We have to be able to predict how we will feel at a later date, for one thing. As Dan Ariely says in his book Predictably Irrational, “To make informed decisions we need to somehow experience and understand the emotional state we will be in at the other side of the experience.” We also have to understand the availability heuristic. Here’s Barry Schwatrz in The Paradox of Choice, talking about a study in which people looked at newspapers and then were asked to estimate the risk of death for various scenarios.: “People mistook the pervasiveness of newspaper stories about homicides, accidents, or fires – vivid, salient, and easily available to memory – as a sign of the frequency of the events these stories profiled. This distortion causes us to miscalculate dramatically the various risks we face in life.” We must also be aware of the influence of our emotions, our assumptions, who we talked to last week, prior experience, and a host of other very personal factors.
In the case of medical decision-making, fear is a powerful motivator. Fear can turn all of us into irrational beings especially if, as Schwartz points out, it causes us to miscalculate the actual risk of something we fear coming to pass. The current Ebola outbreak is a perfect example of this. Every new Ebola case is covered extensively in the news, governors get on TV reassuring large populations, thousands of people can’t get into the US without someone sticking a thermometer in their mouths, and two- to three-week quarantines are instituted for everyone who knows every victim. The fact that the incidence of Ebola in the US is currently on the order of 4/330,000,000 and that in order to get the disease you have to have had physical and intimate contact with the bodily fluids of an infected person has no bearing at all on people’s fear.
It is important for doctors to understand these pitfalls to good choice, because it affects many areas of our practice, including vaccinations, mammography, cancer screenings of all kinds, cardiovascular risk management, and even flu shots. Read Dr. Rosenbaum’s article. She says it better than me.
Alright, now that I’ve officially offended all the anesthesiologists I know, let me try now to convince my readers that I’m actually a big advocate of physician anesthesiologists. They just need to be used in the right way.
The American Society of Anesthesiologists (ASA), the governing body for the specialty, has recently responded to the growing popularity of having people other than anesthesiologists give anesthesia by proposing what they are calling the Perioperative Surgical Home. This is a terrible name for something that might turn out to be a good idea. Here is what the position statement says:
“The ASA is currently developing the Perioperative Surgical Home (PSH) model of care. The PSH model is a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience, from decision for the need for surgery to discharge from a medical facility and beyond.”
There are a couple of ways in which anesthesiology is currently practiced in the hospital setting that are detrimental to the status that physician anesthesiologists fear they are losing. The first is that patients are assigned to anesthesiologists the night before. This practice is unique among physicians. Usually patients go to a specific doctor, develop a relationship with that doctor, and both parties develop some ownership of the perioperative course. Most patients don’t come to a specific anesthesiologist, have no relationship with the one they are assigned, and do not consider the anesthesiologist “their doctor”. It is like a nurse being assigned to a group of patients for the day or a waitress being assigned certain tables. You own it for the day but tomorrow you’ll have a different assignment, maybe in a different building or a different town, doing cases that are completely different. This makes anesthesiologists look like employees.
Secondly, there is the matter of breaks. My husband is one of the anesthesiologists at my hospital that “runs the floor”, meaning he coordinates all the rooms and anesthesiology providers to make sure things get done in a timely manner and that room is left for emergencies. The worst part of his job is getting all the people working alone breaks and lunches. Anesthesiologists, when they are working alone in a room, that is, they aren’t supervising two or more rooms with residents or CRNA’s, expect to be given a 15 minute morning break and a lunch break. These breaks might be a nice thing to have, but they reinforce, in a very powerful way to everyone in the room, that anesthesia providers are interchangeable. They can all do the same thing. It doesn’t matter. The surgeon certainly doesn’t consider himself interchangeable, and doesn’t expect to be broken by another surgeon. The internist in the office doesn’t expect that in the middle of a patient visit another doctor might pop in and continue the interview to give the other doctor a break. Getting breaks makes us look like employees.
And if we are all just employees and can all do the same thing wouldn’t hospitals choose to hire the ones they can pay the least?
What if anesthesia was run in a different way? After a surgeon and patient decide that surgery is required, what if the surgeon said: “you’re going to need an anesthesiologist for your surgery. Here are the ones that practice in the hospital in which your surgery will take place. All are good but I have worked a lot with X and Y and would definitely recommend them.” The patient then selects an anesthesiologist, just as they selected the surgeon, and makes an appointment with that doctor. Patient and anesthesiologist meet, perhaps in a pre-op clinic, discuss the options for anesthesia, get to know each other, and agree on a plan. Then the booking office schedules patient, surgeon, and anesthesiologist at a mutually agreed-upon time. When the patient then comes for surgery the conversation between the anesthesiologist and the patient, instead of introductions, goes something like “Hey! There’s my anesthesiologist! How you doin’ doc?” “Great, good to see you again. How’s the dog? Any questions about the things we discussed at our last meeting?” The doctor can assess the patient while talking to him, noting changes from the last time, different breathing patterns, changes in anxiety level or level of consciousness. The patient has had time to process what the doctor has said and can now ask any questions he may have or discuss changing the plan.
During the operation the anesthesiologist may have more than one patient, in fact he usually does, for revenue and educational reasons. Here’s where the CRNA comes in. The CRNA “does the case” in the sense that he is present and monitoring the patient throughout the case. But the anesthesiologist is frequently in and out of each room and always present during critical times. He has agreed with the CRNA on how to take care of the patient and they do it together.
After surgery, instead of dropping the patient off in the PACU and relying on the nurses, the PACU resident, and the surgical staff to manage his post-operative pain medication, fluid management, etc. the anesthesiologist continues to be in charge of the patient’s care. That anesthesiologists time is scheduled in such a way that he can see the patients he has anesthetized that same evening and again the next morning, looking for complications or assessing whether his pain management strategy is working for this patient that he now knows fairly well. During the whole period the doctor has not relinquished ownership of any part of the patient’s course. The patient is his patient. The patient knows that the anesthesiologist is his doctor. If the patient needs help once he has gone home, he knows he can call his anesthesiologist. If he needs surgery again, he can call up his anesthesiologist, whom he now knows and trusts.
If anesthesia worked this way we wouldn’t need rhetoric and regulation to defend our profession. It wouldn’t need defending.
Anesthesiology used to be a job that was attractive for people who don’t like patients very much. The drill was: meet patient 5 minutes before surgery, do case in OR without interruption, drop off in PACU, done. Minimal need for personal interaction with patient, no need to listen to complaints about back pain and demands for antibiotics for a cold, no risk of getting called in the middle of the night with a fever. Early anesthesiologists were on the cutting edge of medical innovation, nobody else could do what they did, and patients were just glad anesthesia existed. Anesthesiologists like to think they still are on the cutting edge, but the old drill is no longer enough. Health care providers who are not anesthesiologists now do the meet-patient-do-the-case-drop-off all the time. Nurses do sedation and CRNA’s do all kinds of cases up to and including heart surgery. This scares the folks at the American Society of Anesthesiologists (ASA) and results in the turf wars I have talked about on this site before. It also results in questions from med students, who wonder (again) about the stability of the field.
Looks like anesthesiologists are going to have to become real doctors.
Of course I don’t mean by this that anesthesiologists aren’t doctors, in the sense that we all went to med school, did residency, and take care of people during surgery. But we have paid a lot of attention to the technical aspects of patient care and been glad to hand the patient part of patient care to others. Being a doctor means caring for a patient body and mind, throughout health and illness. Anesthesiologists want to “do the case”. We have to come closer to “caring for the patient.” The best of us already do. The rest of us must.
Here’s a typical example of an outpatient surgical case. Patient has a problem of some kind. Surgeon meets patient, examines him, decides he needs surgery, discusses the pros and cons with him and his family, schedules the procedure and any pre-operative tests the surgeon thinks the patient might need. Patient is healthy and so the surgeon waives the need to go to the pre-op clinic, where nurses and anesthesiologists see patients in preparation for surgery. Patient arrives on day of surgery and is greeted by a nurse, who does all the initial work of making the patient feel comfortable and screening for potential problems. At this point the nurse is now caring for the patient, no doctor in sight. Now comes the anesthesiologist. He reviews the information the surgeon and nurse have compiled in the patient’s chart. “Hi, How are you? I’m your anesthesiologist. Anything to eat or drink today? Any problems with anesthesia in the past? No? Great! I’m going to put your IV in and then we’ll get going.” So far this doctor has said Hi, read some paperwork, and done a minor procedure that nurses can do just as well. The anesthesiologist then gives the patient a sedative and wheels him to the OR, where the anesthesia is done. Here is where the ASA gets nervous, because it is in the OR that “midlevels” are gaining favor as a cheaper alternative. Then the anesthesiologist wheels the patient over to recovery, gives report, and that’s the end of it. The nurse again takes over, only calling the anesthesiologist if there is a problem. The nurse decides when patient is ready to go home. The nurse calls whoever is in charge of anesthesia, who comes over and signs a form that says “yes, indeed, this person can go home safely.” Next case.
Is there any part of that that demands four years of medical school and four years of residency? Yes, knowledge of anesthesia is required, but nothing in the previous paragraph suggests that a doctor, trained with the medical knowledge to care for body and mind throughout health and illness, has to do any of it. The problem is the old paradigm (I hate that word) no longer applies, as nurses get advanced training and anesthesia gets safer. As Jason Whang , author of The Innovator’s Prescription: A Disruptive Solution for Health Care, says “You can’t defend a profession by putting up regulatory and payment barriers to stop the barbarians at the gates.” Anesthesiologists have to start to truly care for the patient through the whole process. The anesthesiologist has to be The Doctor. The Guy. The one everyone, including the patient, looks to as directing the care of the patient body and mind, in health and illness. The person who, when she walks by, leaves whispers of awe in her wake. We are doctors. We need to doctor. Then the world will know that we are still needed.
I owe the Rev. Jesse Jackson a congratulatory card and a graduation gift. He has apparently gone all the way through medical school since last time we spoke. Maybe I’ll get him a nice Littmann cardiology II stethoscope. How else to explain his sudden expertise in international infectious diseases? The relatives of Thomas Eric Duncan, the Liberian who died of Ebola in a Dallas hospital, have, with the assistance of “Dr.” Jackson, decided that the treatment he received was substandard and that it was because he, the patient, was African.
Yeah. Because that’s what we do. We healthcare providers just decide to give substandard care. Of course we do.
Dr. Jackson is, naturally, aware of what Ebola is. It is a virus, which means antibiotics don’t work against it. The US, and the world, have no effective treatment for Ebola. Here is what Ebola (EVD) looks like on presentation, according to the CDC: http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html
Patients with EVD generally have abrupt onset of fever and symptoms typically 8 to 12 days after exposure (incubation period for current outbreak has a mean of approximately 9 to 11 days). Initial signs and symptoms are nonspecific and may include fever, chills, myalgias, and malaise. Due to these nonspecific symptoms, particularly early in the course, EVD can often be confused with other more common infectious diseases such as malaria, typhoid fever, meningococcemia, and other bacterial infections (e.g., pneumonia). The most common signs and symptoms reported from West Africa during the current outbreak from symptom-onset to the time the case was detected include: fever (87%), fatigue (76%), vomiting (68%), diarrhea (66%), and loss of appetite (65%).
OK let’s stop there. The ER in Dallas has been roundly castigated for sending Mr. Duncan home with a fever of 103. Given the viral news coverage for Ebola, and the fact that Mr. Duncan was from Africa, the ER should have included Ebola in it’s differential. But remember Ebola is really very rare, with an incidence in the US of 3/330,000,000 so far. My last bout of the flu looked just like it.
Patients can progress from the initial non-specific symptoms after about 5 days to develop gastrointestinal symptoms such as severe watery diarrhea, nausea, vomiting and abdominal pain. Other symptoms such as chest pain, shortness of breath, headache or confusion, may also develop. Patients often have conjunctival injection. Hiccups have been reported. Seizures may occur, and cerebral edema has been reported. Bleeding is not universally present but can manifest later in the course as petechiae, ecchymosis/bruising, or oozing from venipuncture sites and mucosal hemorrhage. Frank hemorrhage is less common; in the current outbreak unexplained bleeding has been reported from only 18% of patients, most often blood in the stool (about 6%). Patients may develop a diffuse erythematous maculopapular rash by day 5 to 7 (usually involving the neck, trunk, and arms) that can desquamate.
Translation: From looking like the flu, Ebola progresses to diarrhea, vomiting, abdominal pain, chest pain, trouble breathing, confusion, headache, bleeding from gums or rectum, seizures, and rash that results in skin peeling off.
Patients with fatal disease usually develop more severe clinical signs early during infection and die typically between days 6 and 16 of complications including multi-organ failure and septic shock (mean of 7.5 days from symptom-onset to death during the current outbreak in West Africa).
Dr. Jackson, as an infectious disease expert, has a healthy fear of multi-organ-system failure (MOSF in ICU lingo). What generally happens in severe cases is that patients get so dehydrated from diarrhea, vomiting, and bleeding, that the amount of blood in their veins can no longer provide a blood pressure that sends adequate oxygenation to the vital organs, which start to shut down and die. In West Africa the fatality rate is 71%. Almost three-quarters of people who get Ebola and aren’t treated adequately die. Why aren’t the African patients treated adequately? Because the resources required to save the life of one patient with MOSF include the following:
ICU-level nursing, multiple blood transfusion of red blood cells and clotting factors, one or more intravenous medications to support blood pressure, large-bore intravenous access, preferably into the subclavian vein or internal jugular, warehouses full of protective gear for caregivers, ventilators for lung failure, dialysis for renal failure, intravenous nutrition, gallons of IV fluids, sodium, potassium, arterial blood pressure monitoring, and state-of-the-art monitors.
In the US doctors are five per square foot. In Africa they are five per 1000 square miles. Approximately.
Did Mr. Duncan get all the treatment US medicine could throw at him? I don’t know, but I bet he did, at significant risk to the nurses and doctors who waded through his feces, blood, and vomit to care for him. Because it turns out that when someone is dying we forget the color of his skin, how much they can pay, or what perceived value to the world they have. Maybe the Rev. Jesse L. Jackson and Mr. Duncan’s family should stop assigning blame and start thanking the Dallas staff members for doing their best against a nasty disease. Mr. Duncan died because Ebola kills people.