There doesn't seem to be much love lost between hospital-based doctors, collectively, and the doctors and others in public health. "Public Health" by the way is concerned with the health of the public, not with insurance for poor people. The increase in life-expectancy in the US over the last 100 years was primarily due to public health measures, such as sanitation, regulation of the food supply, and provision of clean water. It had little to do with the vast hospital system (formed after World War II) and less to do with the use of antibiotics (which also occurred after 1945).
Despite those facts, if you read publicity blurbs from hospitals or the AMA, you'd think that hospital based high-tech devices, surgery, and drugs were responsible -- they certain take credit for the nation's health, where it has any.
The fact that "prevention" of illness is far more cost-effective than "treatment", heroic "life-saving" measures in hospitals gets all the great press, and efforts to keep the water supply germ-free are seldom reported at all. A regular oil change is far cheaper than a new engine for your car, but not nearly so sexy. This is the massive paradox of public health, and for that matter, all preventive maintenance services -- if you do your job perfectly, nothing ever breaks, no one ever gets sick, and the policy wonks decide they don't need your department any more and you get fired.
Still, as the costs of "health care" skyrocket and bankrupt not just individuals, but, increasingly, small and large business and the economy as a whole, these basic facts become more important and are grudgingly recognized.
The recognition doesn't mean, of course, that anyone would ever say that those pushing public health for the last 50 years were "right" --- it's as if these concepts were just discovered last week, by hospital-based doctors and the AMA. It's like the way Apple popularized the use of visual interfaces, dumped on repeated by IBM as stupid and childish and irrelevant, until suddenly IBM ame out with something called "Windows" and ... gosh.. invented the visual interface, I guess. I didn't hear a lot of "I guess Apple was right all along after all!"
So, we find the new President of the American Medical Association is a doctor with a long history of interest in Public Health. So far so good. But when the Institute of Medicine came out a month ago with a report on the Future of Nursing, with nurses having a much more visible and prominent role in caring for Americans, suddenly the AMA went knee-jerk blind again and reverted to attacks.
Now, to paraphrase, the IOM report said explicitly that the future of health care was going to require much more focus on prevention and the life-long care of people with chronic diseases outside of the "clinical" setting -- that is, at home, at work, in the lunch line as a diabetic selects what to eat, at the gym as a teenager decides to exercise, etc. This care also should, according to the report, deal with palliative care when "curing" or "healing" was not possible. It should deal with all of the other facets of human life that affect health, such as nutrition, social work, family interactions, child abuse, workplace abuse, etc. It should deal with everything that happens "BETWEEN office visits".
With the comprehesive view of patient health inside and outside "the health care system", and far more focus on prevention and home visits and community health than hospital-based acute-care by doctors, the IOM recommended that nurses partner with other clinicians and with suitable additional training, lead the teams utilizing experts from all areas to design improvements to the structure and process of American health care.
Furthermore, the report noted that nurses, [ note, not MD's] are the professionals who spend by far the most number of minutes actually talking to the patients, working in the areas that have been targeted so far for process improvement by the federal government, specifically delivering medications, avoiding infections due to all the inserts and tubing around patients, etc.
The AMA response was rapid, knee-jerk, and totally missed the point. It's hard to tell that they even READ the executive summary of what the IOM had to say.
Here's what the AMA website put as a response (highlighting added by me)
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AMA Responds to IOM Report on Future of Nursing
Physician-led team approach to care helps ensure high quality patient care and value for health care spending
For immediate release:
Oct. 5, 2010
Statement attributable to:
Rebecca J. Patchin, MD
Board Member, American Medical Association
“With a shortage of both physicians and nurses and millions more insured Americans, health care professionals will need to continue working together to meet the surge in demand for health care. A physician-led team approach to care—with each member of the team playing the role they are educated and trained to play—helps ensure patients get high quality care and value for their health care spending.
“Nurses are critical to the health care team, but there is no substitute for education and training. Physicians have seven or more years of postgraduate education and more than 10,000 hours of clinical experience, most nurse practitioners have just two-to-three years of postgraduate education and less clinical experience than is obtained in the first year of a three year medical residency. These additional years of physician education and training are vital to optimal patient care, especially in the event of a complication or medical emergency, and patients agree. A new study shows that 80 percent of patients expect to see a physician when they come to the emergency department, with more than half of those surveyed willing to wait two more hours to be cared for by a physician.
“The AMA is committed to expanding the health care workforce so patients have access to the care they need when they need it. With a shortage of both nurses and physicians, increasing the responsibility of nurses is not the answer to the physician shortage.
Research shows that in states where nurses can practice independently, physicians and nurses continue to work in the same urban areas, so increasing the independent practice of nurses has not helped solve shortage issues in rural areas. Efforts to get health care professionals in areas where shortages loom must continue in order to increase access to care for all patients.”
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OK, here's my read on this.
1) The AMA totally missed the point that health of Americans depends on many factors other than billable "care" time in hospitals. The AMA is very concerned that doctors, not nurses, should direct the in-hospital clinical medical and surgical "care" part of this picture. The IOM never said otherwise.
2) The AMA did NOT suggest that doctors, instead of nurses, should be the primary professionals who make house-visits, and who see how patients live and what they are up against as human beings besides their specific disease-category.
3) The AMA focused a great deal of attention on how many hours of education and clinical exposure doctors have, compared to nurses. They did not mention that, unlike nursing education, a typical doctor's education included zero hours, until very recently, on key determinants of health, such as "nutrition", "exercise", the role of poverty in making "compliance" with doctor's orders complex or impossible, the role of social support in maintenance of healthy behaviors and avoidance of hospital visits in the first place, etc. Doctor's education certainly didn't even mention topics such as the demonstrated value of "therapeutic touch."
Let's be clear about this. The term "health care", as bandied about in the last year in policy circles, generally translates to "insurance coverage" and has to do with the flow of money, not health. The majority of factors that can be controlled outside a hospital by a person who doesn't want to become a "patient" the main things people do to take CARE of their HEALTH, are not even part of "health care" as the term is used by the AMA. Pointedly, the huge "education" that doctors receive that they believe makes them qualified to lead the overall process doesn't include ANY of the factors that determine the health of people and PREVENT them from becoming "patients".
So, yes, medical doctors ARE the most qualified by far to make moment by moment decision regarding acute care in hospital settings and the ten percent, or so, of American's health which is determined that way. Sadly, the reality is that the doctors are vastly over-booked and don't have the luxury to even be present on a moment-by-moment basis, for the most part. Even in those settings, the doctors are not rushing to be the ones giving medications due to their "vastly greater education than nurses. " The doctors only order the meds, they don't deliver them, or deal with all of the problems patients have with taking the drugs as ordered. The nurses, not the doctors, are on the floor and are the first line of defense of the patient to notice adverse events, adverse effects of drugs, change in condition of the patient that is clinically important, etc. The doctors only come around "on rounds" at large intervals. Nurses need to make the moment-by-moment calls on what to do when a crisis occurs, until the doctors can be located.
Recent significant improvements in the safety of surgery resulted from implementing a procedure that FORCED surgeons to stop what they were doing and LISTEN to what nurses had to say about it for at least 30 seconds.
The fact that this made a huge difference in patient safety and avoidance of things like wrong-side surgery demonstrates that doctors are not, if left to their own judgment, good at taking input from nurses.
Also, the fact that this made a difference says that all of the huge number of hours doctors had were apparently NOT effective at getting doctors into a frame of mind where they could listen to nurses.
Very few of those hours, if any, were devoted to topics such as "How to run an effective meeting". Many studies and anecdotal evidence supports the idea that doctors do not, in fact, seem to be very good at actually listening to what patients are saying. The average time a patient can talk before the doctor interrupts and typically truncates the conversation is 18 seconds. ( data quoted by Groopman). For that matter, studies also show that patients typically leave the clinical setting with only a very vague idea of what it is they are supposed to be doing and why, so it appears doctors are also not well trained in how to communicate with, well, you know, lesser beings, mere mortals, "patients".
So, I'm with the IOM on this one. I'd rather have policy and health care review sessions led by trained nurses than by doctors. Leading does NOT mean dictating the outcome -- it means doing a good job of asking and listening and getting all of the experts in the room, from doctors to nutritionists to social workers to nurses, providing good feedback about the area in which they are the experts. If doctors act as the meeting "leaders" for such meetings, our experience to date makes it seem very unlikely that the viewpoints of the other experts (outside medicine and surgery) will be heard at all, let alone taken seriously.
The AMA does not recognize that what doctors do is less than ten percent of what matters in the care of the health of people. That fact alone makes their members unwise choices to "lead" discussions about keeping people from becoming patients. Most doctors never visit patient's homes. Again, thier opinion of what goes on at home, for all their education, seems less based on actual observation than the nursing professions' experience would be.
In reality, it is not a "patient-centered" electronic record of hospital-based events which is missing today, for all the money flowing that direction by the immediate beneficiaries of it -- the insurance companies. What is needed more is a "person and family and community centered" record of events BETWEEN visits, OUTSIDE the clinic or hospital.
We need less in the way of "decision-support" for doctors in ordering drugs, and way more "decision support" for people that help them avoid needing any drugs in the first place.
This is basically the point of the Institute of Medicine. Doctors, for all their very specialized training, have obtained enormously good DEPTH of perception by having an every decreasing and narrow WIDTH of perception and field of view.
They have become, in a way, "idiot savants" -- knowing a vast amount about a tiny area, at the expense of being almost totally ignorant of anything outside their tiny specialization area. One example -- the accident rate in civilian aviation (small planes) is tracked by profession, age group, etc. The only group that has a worse accident rate than MD's is ... teenagers. In my mind, this strongly suggests that doctors (a) are used to an environment where their mistakes are picked up and fixed by others, and (b) are very bad at knowing the limits of their own capabilities in an objective fashion. (Other interpretations of the data? Comments?). In aviation by the way, there is not a category for accidents "caused by weather" -- there are only accidents caused by the "pilot's decision to continue into conditions beyond their skill and experience." Fog does not cause accidents. The existence of mountain tops does not cause accidents. A decision by a pilot to fly really low in fog MIGHT cause an accident.
Nurses certainly know less about medical niche specialization areas, but have a much broader view of human beings and the nature of the factors that go into health.
Doctors in the American system really have little choice -- by the time they are through medical school their debt load is so high they have an enormous pressure to keep on specializing into something that might someday get them back out of debt. They become fantastic, say, at removing prostates without damaging nerves -- at the expense of pretty much everything else, including, say, triple billing the Navy for plane tickets. It's sad.
I agree entirely with the IOM -- nurses are a far better choice to lead the charge in designing the future of how Americans care for their own health, despite what doctors know about "health care."
A good nurse, by the way, is NOT "simply a poor doctor-extender". Nurses are professional at many things that doctors are clueless about. Nurses are not "poor doctors" -- they are, one hopes, great NURSES. The fact that doctors think of nurses as "doctor extenders" reveals how little doctors know about what goes on in hospitals, etc.
Here's one last example: Jerome Groopman, M.D., wrote an excellent book titled "How Doctors Think". He discusses the various ways doctor make cognitive mistakes in diagnosis, and how the medical record and handoff system propagates and strengthens that stereotyping and error. He talks at length about things patients might do in talking to doctors to catch such errors and reverse or mitigate them.
One might think such an open-minded physician would have a lot to say about the role nurses could have, and have have in "time outs" in surgery, in catching doctor's mistakes. One would be wrong -- the book doesn't even have the word "Nurse" in the index.
One pictures the New Yorker's famous picture of the USA, with Manhattan being most of the country, New Jersey being another smidge, and 'everything else' being one more almost invisible smidge.
I recall one comment a nurse made -- "I've worked here 17 years, and every day I say "Good morning Doctor X", and he mutters something. He's never learned my name."
That, to me, says worlds.
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