Who Is Qualified and How: What Andrew Hacker Means

                                         Rugby Team
                                 Columbia College of Physicians and Surgeons

Would you be disturbed to learn the person taking care of your daughter, when you leave her in the hospital overnight with her fever and throat pain, the person writing the orders for intravenous fluids and medications is not a physician, but a “physician’s assistant,” who has never gone to medical school, or passed the licensing exams a resident with an MD degree has passed?   Would you be disquieted to learn the man holding the scalpel in the operating room, the man who has his hands, elbow deep in your chest, is a physician’s assistant or an operating room tech?

As MBA’s looking for cost savings have  driven hospitals to save money by hiring less expensive help, many jobs which once were thought to require the highest level of qualification are now done by less costly, less extensively trained people.

But is this a bad thing?

First, let’s consider what those more costly people were like.  They certainly made an investment in time and money and effort in their own training. They spent two years in anatomy labs dissecting cadavers, in biochemistry labs, in classrooms, not to mention the four years before that in organic chemistry labs, calculus classes, physics labs, biology labs and classes. They competed intensely for the few spots in medical school classes and they spent nights in the library and laboratory while their classmates partied and pursued the pleasures of the flesh adolescents and twenty somethings will do.

But did any of that make them more likely to be able to save your daughter or to be better in your chest when you needed it?

At  The New York Presbyterian Hospital/Cornell Medical Center, you can now be admitted, cared for and discharged by a nurse practitioner, without ever having seen, talked to or come into physical contact with a recipient of an MD degree.

And yet, when you have a colonoscopy, a procedure which requires no knowledge of biochemistry, physics, calculus, or even much anatomy, only a physician can do this procedure, which takes about three to six months to learn, and maybe a year to really master.

Before I became an intern, I had done six weeks on a ward as a third year medical student, and another 6 weeks as a “subintern.” I had done some elective courses in cardiology, endocrinology and I had a six week rotation in neurology and another in radiology.  All that was useful, but none of it prepared me for treating acute pulmonary edema.

When a patient bubbled over in pulmonary edema at 1 AM, what saved him (and me) was a single hour of training I had undergone in the first weeks of internship. The training session had been effective: I remembered what to do and did it, step by step, just as they had instructed and it worked and the patient was saved. I felt like a very sophisticated, competent young doctor. And I had learned it in an hour.  Would a physician’s assistant, who never did organic chemistry, passed a calculus exam or dissected a cadaver have been trained as well in an hour and been as successful? I have no doubt the answer is yes.

I learned to treat gram negative sepsis in patients with acute myelocytic leukemia, and that took about an hour. I could have told you the mechanism of action of the antibiotics involved, and I could have explained the physiology of how the glucocorticoids and fluids used in this rescue worked, and I’m not sure the nurses who worked on those wards could have delivered those explanations, but they knew what to do even if they could not have explained to the satisfaction of the professors the why of how it all worked. In practical terms, they were as good as I was, if not better, because they had been doing it for more years.

What has happened over the years, is each task I learned as an intern—lumbar punctures, phlebotomy, starting IVs, arterial sticks, placing CVP lines, placing Swan Ganz catheters, adjusting respirator settings, each of those procedures can be taught to specialized non physicians who can learn to do them quickly, and perform them just as well or better than any doctor. In fact, physician’s assistants can be taught when doing these procedures is warranted, which is actually a more difficult process. And, over time, nurses and PA’s can learn how to interpret the results of blood gases, lumbar punctures, CVP readings, Swan readings. CCU nurses learn to interpret heart rhythm disturbances just as reliably as physicians and they know which drugs are used to treat them.

Scrub nurses in the operating room hand the surgeon the exactly correct instrument before he even asks for it because they have watched him do a particular surgery so often, they have learned all the lines, just as stage hands often know the lines of dialogue the actors speak because they have hung around the stage during repetitive rehearsals.

Could we get away without doctors altogether?  Could we break down every problem into its parts and have people who have a year or two of training in the practical world do what we have always required people with 4 years of college and 4 years of medical school and 4 years of residency after medical school?

In fact, the English have been doing this for decades. They limit the numbers of MB’s (bachelor of medicine) and they severely limit the number of specialists. They had figured out the hospitalist system in the 1960’s—the same system we have only discovered over the last decade here in the USA. In England, a student goes from high school to medical school, and gets a bachelor's of medicine and being a GP (general practitioner) is not much more exalted than being a nurse practitioner here, with about the same social status and economic benefits. The number of cardiologists, endocrinologists, hematologists is severely limited--proportionately a much smaller percentage than we have in the USA. But they make the system work, and some would say better than what we have.

My son, who is doing a residency in surgery astonished me the other day, when he told me he was on call on Saturday, but he was home by 10 PM. He had begun his day at 6 AM and worked until 8 PM, when he was relieved by a “night float” to whom he signed out his patients. He spent two hours entering notes and data into the hospital computer and went home.  But he did not sleep overnight in the hospital, in some on call room where he would be awakened every 30 minutes or so by nurses on the phone wanting orders.

Who was the night float person who did this work? A physician’s assistant.

I was floored.

But as I thought about it, what sorts of problems were keeping me awake all night, when I was an intern?  Phone calls from nurses asking me to come down and do a blood culture on a patient, or to approve a sleeping pill for a patient or to draw a blood for some test which had been ordered to check at patient at 1 AM.  None of these things required much thought, training or education. That is why we didn’t kill many patients when we did those marathon 36 to 96 hour on call stints as interns. The tasks we were doing were mostly mindless.

Of course, interspersed among all those calls about trivial things or calls from nurses who could barely speak English or who did not understand that giving an order for  a pain medication over the phone required a physician to give that order some thought—what medications were being given to that patient? Was the pain med likely to cause respiratory arrest in this particular patient?  So among all the blizzard of calls were a few which required real thought, which might require a doctor, or at least a person who had spent a couple of years on the ward and could recognize the dangers of each order.

Among all those calls one night was a call about a patient who was found sitting in a bed full of her own stools. The nurse called, annoyed, not really with a question but more a complaint about having to clean it all up. But this particular patient had breast cancer metastatic to her spine and she had a metastasis compressing her spinal cord--a medical emergency requiring urgent radiation therapy and possibly neurosurgery. Putting all this together took neuroanatomy, neurology and some prior experience with cord compression. Could a physician's assistant have done that? I do not know. I'm not even sure what physicians' assistants learn or are required to know? Should a nurse or a nurse practitioner have recognized acute cord compression? I do not know.  

I’m not sure whether or not we have gone in the right direction when it comes to organizing the delivery of medical care: I think we likely have. But I am sure of one thing—the way we decide what education, what training we require for specific sorts of medical workers, particularly for MD’s has been rank stupidity.

We have allowed professor of math and chemistry and physics who depend on groveling pre medical students to keep their own graduate students and professors employed to bamboozle the medical powers that be into delivering pre medical students to their hands. We have done the same in the medical schools themselves, where professors of pharmacology and microbiology and biochemistry have taught the wrong courses to aspiring doctors and we have been smug and self satisfied while we did this, and we have failed in our responsibility—our obligation to our own country—as we have mindlessly done the easy thing of accepting without a murmur of complaint the nasty system we have allowed to fester all these years.