Doctor and Nurse Replacement

Medscape recently commented on the case of Natasha Valle from Clarksville, Tennessee (1). Pregnant and scared she went to the local Tennova Healthcare hospital because she was bleeding. She didn't know much about miscarriage, but this seemed like one. In the emergency room, she was examined then sent home. She went back when her cramping became excruciating. Then home again. It ultimately took three trips to the ER on three consecutive days, generating three separate bills, before she saw a doctor who looked at her bloodwork and confirmed her fears. The hospital declined to discuss Valle's care, but 17 months before her three-day ordeal, Tennova had outsourced its emergency rooms to American Physician Partners, a medical staffing company owned by private equity investors. APP employs fewer doctors in its ERs as one of its cost-saving initiatives to increase earnings, according to a confidential company document obtained by Kaiser Health News and National Public Radio (2).

This staffing strategy has permeated hospitals, particularly emergency rooms and intensive care units, that seek to reduce their top expense-physician labor. While diagnosing and treating patients was once their domain, doctors are increasingly being replaced by nurse practitioners and physician assistants, collectively known as midlevel practitioners, who can perform many of the same duties and generate much of the same revenue for less than half of the pay.

However, a working paper, published by the National Bureau of Economic Research, analyzed roughly 1.1 million visits to 44 ERs throughout the Veterans Health Administration, where nurse practitioners can treat patients without oversight from doctors (3). Researchers found that treatment by a nurse practitioner resulted on average in a 7% increase in cost of care and an 11% increase in length of stay, extending patients' time in the ER by minutes for minor visits and hours for longer ones. These gaps widened among patients with more severe diagnoses, the study said, but could be somewhat mitigated by nurse practitioners with more experience.

From the hospitals’ perspective, the extra cost, length of stay and increased admissions could add to the bottom line as long as the patient or third-party payer pays the extra costs. However, in many cases the patient is unable to pay and insurers have been looking for cost-cutting in other areas. If third party payers were to refuse to pay for the extra costs or increased litigation resulted from the hospital’s staffing decisions, it seems likely these practices would quickly end.

In the intensive care unit (ICU) corporations and government agencies are replacing physicians with nurse practitioners (NPs) or physician assistants (PAs) sometimes collectively referred to as physician extenders (4). While these entities argue that they have been forced to hire physician extenders due to a supposed physician shortage, the truth is that physicians are being systematically fired and replaced by lesser qualified clinicians on the basis of profit. Although advocates claim that studies show that physician extenders can provide comparable care to physicians, they fail to acknowledge that this research has always been done with supervised NPs. The truth is that there are no studies that show nurse practitioner provide similar safety and efficacy when practicing independently (4). Furthermore, most of the studies that purport to show NP safety have been of retrospective, nonrandomized, and followed patients over very short time frames. These studies were not appropriately designed to show whether NPs, especially practicing independently, can safely and effectively care for critically ill patients. Newer studies have revealed concerning gaps in the quality of care of some nurse practitioners, including increased unnecessary referrals to specialists (5) and increased diagnostic imaging (6).

Strained by the demand for more graduates, training programs for NPs are accepting less qualified applicants and no longer requiring nursing experience to become a nurse practitioner (7). Despite legislation allowing unsupervised nurse practitioners the right to provide medical care to patients, case law has repeatedly demonstrated that NPs are not held to the same legal standard as physicians in malpractice cases (4). Moreover, organizations are not being held responsible when they hire nurse practitioners to work outside of their scope of training (4).

Another concern is the effect of NPs and PAs in the ICU on resident and fellow education. With hours restrictions imposed for trainees the need for meaningful training experiences has never been greater. Studies utilizing NPs have examined patient outcomes which appear comparable to residents and fellows (8). The effect on resident and fellow education remains unknown although the trainees are often satisfied with less work but there may be future costs due to less well-trained physicians (9).

We have already commented on substituting nursing assistants for nurses (10). Not surprisingly, replacing registered nurses with less qualified nursing assistants or licensed practical nurses leads to a lower quality of care with increased mortality (11,12).

The bottom line is that when money is the bottom line, substituting physician extenders for physicians or nursing assistants for nurses makes a great deal of sense in the ER or ICU as long as third-party payers are willing to pay any potentially increased costs and there is a low concern over quality of care and patient outcomes. It is becoming increasingly hard to see a doctor anymore. The effect on resident and fellow education remains unknown although the trainees are satisfied with less work.

One wonders why regulatory organizations such as the Joint Commission, Centers for Medicare and Medicaid, ACGME, etc. have taken no action. Regulators need to address policies that place patients at risk. Physicians should support NPs and PAs as well as nurses when appropriate. However, the use of these physician extenders or nursing assistants to replace physicians or nurses may have untoward consequences. The administrative personnel who perceive financial benefits by eroding physician direction and autonomy need to be held accountable for their actions.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Kelman B, Farmer B. Doctors Are Disappearing From Emergency Rooms as Hospitals Look to Cut Costs. February 13, 2023. Available at: https://www.medscape.com/viewarticle/988196?src=WNL_trdalrt_pos1_230214&uac=9273DT&impID=5165828 (accessed 4/5/23).
2. Lender Presentation-Public Side. American Physician Partners. November 2021. Available at: https://www.documentcloud.org/documents/23605675-american-physician-partners-redact (accessed 4/5/23).
3. Chan DC Jr, Chen Y. The Productivity of Professions: Evidence from the Emergency Department. National Bureau of Economic Research. October 2022. [CrossRef]
4. Bernard R. The effects of nurse practitioners replacing physicians. Physicians Practice. Jan 30, 2020. Available at: https://www.physicianspractice.com/view/effects-nurse-practitioners-replacing-physicians (accessed 4/5/23).
5. Lohr RH, West CP, Beliveau M, Daniels PR, et al. Comparison of the quality of patient referrals from physicians, physician assistants, and nurse practitioners. Mayo Clin Proc. 2013 Nov;88(11):1266-71. [CrossRef] [PubMed]
6. Hughes DR, Jiang M, Duszak R Jr. A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits. JAMA Intern Med. 2015 Jan;175(1):101-7. [CrossRef] [PubMed]
7. NurseJournal Staff. Nurse Practitioner Career Overview. NurseJournal. March 3, 2023. Available at: https://nursejournal.org/nurse-practitioner/ (accessed 4/5/23).
8. Landsperger JS, Semler MW, Wang L, Byrne DW, Wheeler AP. Outcomes of Nurse Practitioner-Delivered Critical Care: A Prospective Cohort Study. Chest. 2016 May;149(5):1146-54. [CrossRef] [PubMed]
9. Kahn SA, Davis SA, Banes CT, Dennis BM, May AK, Gunter OD. Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents' critical care experience. J Surg Res. 2015 Nov;199(1):7-12. [CrossRef] [PubMed]
10. Robbins RA. Substitution of assistants for nurses increases mortality, decreases quality. Southwest J Pulm Crit Care. 2016;13(5):252. [CrossRef]
11. Aiken LH, Sloane D, Griffiths P, et al. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf. 2017 Jul;26(7):559-568. [CrossRef] [PubMed]
12. Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nurse staffing and quality of patient care. Evid Rep Technol Assess (Full Rep). 2007 Mar;(151):1-115. [PubMed]

Cite as: Robbins RA. Doctor and Nurse Replacement. Southwest J Pulm Crit Care Sleep. 2023;26(4):72-75. doi: https://doi.org/10.13175/swjpccs019-23 PDF

VA Administrators Breathe a Sigh of Relief

On May 30, Eric Shinseki, the Secretary for Veterans Affairs (VA), resigned under pressure amidst a growing scandal regarding falsification of patient wait times at nearly 40 VA medical centers. Before leaving office Shinseki fired Sharon Helman, the former hospital director at the Phoenix VA, where the story first broke, along with her deputy and another unnamed administrator. In addition, Susan Bowers, director of VA Veterans Integrated Service Network (VISN) 18 and Helman’s boss, resigned. Robert Petzel, undersecretary for the Veterans Health Administration (VHA, head of the VA hospitals and clinics), had resigned earlier. You could hear the sigh of relief from the VA administrators.

With their bosses resigning left and right, the VA leadership in shambles and the reputation of the VA  soiled for many years to come, why are the VA administrators relieved? The simple answer is that nothing has really changed. There for a moment it looked like real reform might happen. Even President Obama in announcing Shinseki's resignation said the "There is a need for a change in culture..." (1). Shinseki’s resignation would indicate that any action to change the culture is unlikely. Sure a few administrators, like Helman, will lose their jobs, perhaps a few patients will get outsourced to private practioners, but nothing is being done or proposed to change the VA culture. A new interim VA secretary was named and his tenure is likely to be lengthy since no confirmation appears to go unchallenged in the US Congress, and who would want the job?

I was at the VA, when then undersecretary for VHA, Kenneth Kizer, made the fundamental change that resulted in the present mess. Kizer had come to the VA with a program he called the “prescription for change” (2). Indeed, Kizer made several changes but the one that really counted was that the chiefs of staff, doctors who ran the medical services in VA hospitals, were replaced by the head of the Medical Administration Service, usually a business person. This made the VA director the monarch over their own little kingdom, and we all know “it’s good to be the king”. Furthermore, we all know that power corrupts and now with absolute power, the VA director was absolutely corrupted. The hospital directors eliminated any sources of potential opposition. Physicians who did not “play ball” could suddenly find themselves as a target of an investigation (3). After being found guilty by a kangaroo court, their names would be turned over to the National Practioner Databank as bad doctors making it difficult to find a job outside the VA. Those cooperative physicians were rewarded, often for limiting the care of patients. In other words, putting the VA administrators’ interests before the patients’ (4). Lastly, the long-standing relationship with the Nation’s medical schools was destroyed (remember VA dean’s hospitals?). It was argued that the medical schools used the VA to serve their needs. Although this had some truth, it is part of the two-way street that makes cooperation possible. No VA administrator wanted a bunch of doctors and academics telling them what to do.

After eliminating any possible oversight from the physicians or the medical schools, an insulating administrative layer had to be placed between the hospitals and VA central office. Therefore, the Veterans Integrated Service Networks or VISNs, were created. Although ostensibly to improve oversight and efficiency (2), only in Washington would they believe that another layer of bureaucracy would do either. As more and more patients were packed into the system, the numbers of physicians and nurses decreased (5). Not surprisingly, wait times became longer and there was no alternative but to hide the truth. The administrators, the VISNs and VA Central office were all complicit in these lies. Their bonuses depended on it and even when it was discovered by the VA Office of Inspector General (VAOIG) nothing was done.

Congress, who supposedly also provides oversight, was swift to propose action that does not change the VA culture and accomplish little. In this election year Congressional cries to throw those VA bums out have been consistent and loud. However, plenty of clues were available to know that the wait time data was false. First, the concept that you can cut the numbers of physicians and nurses and improve wait times defies common sense. Second, the VAOIG had repeatedly reported that wait times were being falsified. Helman had already been accused of this when she was the director at the Spokane VA (6). This week the Senate passed a bill allowing veterans to see private doctors outside the VA system if they experience long wait times or live more than 40 miles from a VA facility; make it easier to fire VA officials; construct 26 new VA medical facilities and use $500 million in unobligated VA funds to hire additional VA doctors and nurses (7). The VA already is able to do the first two, and as the present crisis illustrates, funds can be diverted away from healthcare. It seems likely this is exactly what will happen unless additional oversight is provided.

Kizer and Ashish Jha authored an editorial on this crisis in the New England Journal of Medicine this week (8). They made three recommendations:

1. The VA should refocus on fewer measures that directly address what is most important to veteran patients and clinicians-especially outcome measures.
2. Some of the resources supporting the central and network office bureaucracies could be redirected to bolster the number of caregivers.
3. The VA needs to engage more with health care organizations and the general public.

All these recommendations are reasonable. Outcome measures, not process of care, should be measured (9). Paying bonuses to administrators for clinicians completing these process of care measures should stop. Many of these measures serve mostly to increase administrative bonuses and not improve patient care. By giving administrators supervisory authority over physicians, healthcare providers were forced to complete a seemingly endless checklists rather than serve the patients' interests.

Bureaucracies should be reduced. VA's central-office staff has grown from about 800 in the late 1990s to nearly 11,000 in 2012 (8). VISN offices have reflected this growth with over 4500 employees in 2012 (10). This diversion of funds away from healthcare is the source of the present problem.

The VA needs to re-engage with the medical schools and with its patients. Reestablishment of the Dean's Committee or other similar system that provides oversight of the VA hospital directors and administrators may be one method of achieving this oversight. The association of the medical schools with the VA served the VA well from the Second World War until the 1990s (11).

Poor pay and micromanagement of physicians to perform meaningless metrics makes primary care onerous. Appropriating funds might improve the salary discrepancy between the VA and the private sector but will not fix the micromanagement problem. The VA may find it difficult to recruit the needed physicians and nurses unless a more friendly work environment is created. How do we know that any appropriated money will be spent on healthcare providers and infrastructure unless additional oversight is put in place? Without oversight the VA positions will become VA vacancies and the VA hospitals will become administrative palaces. Local oversight by VA physicians, nurses and patients is one method of ensuring that appropriated monies are actually spent on healthcare.

VA health care is at a crossroads. New leadership can help the VA succeed but only if the administrative structure is fixed changing the VA culture. Until this occurs the same administrative monarchs will continue to rule their realms and nothing will really change.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Cohen T, Griffin D, Bronstein S, Black N. Shinseki resigns, but will that improve things at VA hospitals? CNN. May 31, 2014. Available at: http://www.cnn.com/2014/05/30/politics/va-hospitals-shinseki/ (accessed 6/7/14).
2. Kizer KW. Prescription for change. March 1996. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf (accessed 6/7/14). 
3. Wagner D. The doctor who launched the VA scandal. Arizona Republic. May 31, 2014. Available at: http://www.azcentral.com/longform/news/arizona/investigations/2014/05/31/va-scandal-whistleblower-sam-foote/9830057/ (accessed 6/7/14).
4. Hsieh P. Three factors that corrupted VA health care and threaten the rest of American medicine. Forbes. May 30, 2014. Available at: http://www.forbes.com/sites/paulhsieh/2014/05/30/three-factors-that-corrupted-va-health-care/ (accessed 6/7/14).
5. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54. Available at: http://www.swjpcc.com/editorial/2012/5/5/va-administrators-gaming-the-system.html (accessed 6/7/14).
6. Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9. Available at: http://www.swjpcc.com/editorial/2014/5/26/va-scandal-widens.html (accessed 6/7/14). 
7. O'Keefe E. Senators reach bipartisan deal on bill to fix VA. Washington Post. June 5, 2014. Available at: http://www.washingtonpost.com/blogs/post-politics/wp/2014/06/05/senators-reach-bipartisan-deal-on-bill-to-fix-va/ (accessed 6/7/14).
8. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med. 2014 Jun 4. [Epub ahead of print]. Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1406852 (accessed 6/7/14). [CrossRef]
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353(17):1860-1. [CrossRef]
10. VA Office of Inspector General. Audit of management control structures for veterans integrated service network offices. March 27, 2012. Available at: http://www.va.gov/oig/pubs/VAOIG-10-02888-129.pdf (accessed 6/7/14).
11. VA policy memorandum no. 2: policy in association of veterans' hospitals with medical schools. January 30, 1946. Available at: http://www.va.gov/oaa/Archive/PolicyMemo2.pdf (accessed 6/7/14).

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado, or California Thoracic Societies or the Mayo Clinic.

Refence as: Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. doi: http://dx.doi.org/10.13175/swjpcc077-14 PDF

Questioning the Inspectors

In the early twentieth century hospitals were unregulated and care was arbitrary, nonscientific and often poor. The Flexner report of 1910 and the establishment of hospital standards by the American College of Surgeons in 1918 began the process of hospital inspection and improvement (1). The later program eventually evolved into what we know today as the Joint Commission. Veterans Administration (VA) hospitals have been inspected and accredited by the Joint Commission since the Reagan administration.

The VA hospitals often share reports regarding recent Joint Commission inspections and disseminate the reports as a "briefing". One of these briefings from a recent  Amarillo VA inspection was widely distributed as an email attachment and forwarded to me (for a copy of the briefing click here). There were several items in the briefing that are noteworthy. One was on the first page (highlighted in the attachment) where the briefing stated, "Surveyor recommended teaching people how to smoke with oxygen, not just discuss smoking cessation". However, patients requiring oxygen should not smoke with oxygen flowing (2,3).  It is not that oxygen is explosive but a patient lighting a cigarette in a high oxygen environment can ignite their oxygen tubing resulting in a facial burn (2,3). A very rare but more serious situation can occur when a home fire results from ignition of clothing, bedding, etc. (3).

A quick Google search revealed no data for any program teaching patients to smoke on oxygen. It is possible that the author of the "briefing" misunderstood the Joint Commission surveyor. However, the lack of physician, nurse and respiratory therapist autonomy makes it easy to envision administrative demands for a program to "teach people how to smoke on oxygen" wasting clinician and technician time to do something that is potentially harmful.

Although this is an extreme and absurd example of healthcare directed by bureaucrats, review of the remainder of the "briefing" is only slightly less disappointing. Most of the Joint Commission's recommendations for Amarillo would not be expected to improve healthcare and even fewer have an evidence basis. The Joint Commission focus should be on those standards demonstrated to improve patient outcomes rather than a series of arbitrary meaningless metrics. For example, a Joint Commission inspection should include an assessment of the adequacy of nurse staffing, are the major medical specialties and subspecialties readily accessible, is sufficient equipment and space provided to care for the patients, etc. (4-5).  By ignoring the important and focusing on the insignificant, the Joint Commission is pushing hospitals towards arbitrary and nonscientific care reminiscent of the last century. These poor hospital inspections will undoubtedly eventually lead to poorer patient outcomes.

Richard A. Robbins, MD*

Editor

References

1. Borus ME, Buntz CG, Tash WR. Evaluating the Impact of Health Programs: A Primer. 1982. Cambridge, MA: MIT Press.
2. Robb BW, Hungness ES, Hershko DD, Warden GD, Kagan RJ. Home oxygen therapy: adjunct or risk factor? J Burn Care Rehabil. 2003;24(6):403-6. [CrossRef] [PubMed]
3. Ahrens M. Fires And Burns Involving Home Medical Oxygen. National Fire Protection. Association. Available at: http://www.nfpa.org/safety-information/for-consumers/causes/medical-oxygen (accessed 3/12/14).
4. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002 Oct 23-30;288(16):1987-93. [CrossRef] [PubMed]
5. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14(8):499-511. [CrossRef] [PubMed]

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. Questioning the inspectors. Southwest J Pulm Crit Care. 2014;8(3):188-9. doi: http://dx.doi.org/10.13175/swjpcc032-14 PDF