Monday, October 25, 2010

Doctors Versus Nurses: Let’s Root for the Nurses

This month the Institute of Medicine (IOM) released a study titled: The Future of Nursing: Leading Change, Advancing Health. The report summary included this statement.

“With more than 3 million members, the nursing profession is the largest segment of the nation’s health care workforce. Working on the front lines of patient care, nurses can play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act, legislation that represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. A number of barriers prevent nurses from being able to respond effectively to rapidly changing health care settings and an evolving health care system. These barriers need to be overcome to ensure that nurses are well- positioned to lead change and advance health.”
The report indicated the following as its four key messages.
“Nurses should practice to the full extent of their education and training.”

“Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.”

“Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.”

“Effective workforce planning and policy making require better data collection and information infrastructure.”

These messages sound harmless enough until the implications of the report are spelled out. The cover story of the October 11, 2010 edition of “Modern Healthcare” magazine discussed the issues under the title: “Fueling the Turf Battle.” The IOM report is in favor of considerably enhancing the role of nurses in setting policy and in dealing with patients.

One of the interesting results presented by the IOM involved data derived from experiences at the Veterans Affairs Department (VA). In the late 90’s the VA faced a large number of new enrollees.
“In response, the VA moved away from a system of hospital-based acute care and toward community-based delivery emphasizing primary care and chronic-disease management—roles filled by registered nurses and skilled nurse practitioners, the IOM said.”

“The result? Studies showed that higher proportions of veterans received appropriate care relative to comparable Medicare enrollees, and spending per beneficiary rose more slowly—30% cost growth for VA patients between 1999 and 2007, compared with 80% for Medicare beneficiaries over the same period, according to the Congressional Budget Office.”
The message the IOM is sending is that nurses should, with the proper training, be granted considerably more leeway in diagnosing disease, and prescribing medicines and treatment—with little or no physician oversight. This extension of responsibility is not always legally possible at present, depending on state restrictions. The IOM findings and recommendations were not welcomed in all quarters.
“But for skeptics and apathetic readers, the IOM presents this urgent picture: in a time when 32 million more Americans are about to get health insurance, skilled nurses are cheaper than physicians, they are easier to produce in large numbers, and they can prevent costly mistakes and perform with essentially the same rate of errors as doctors once they are established in the workforce.”
The comments on the influx of new patients and the experience of the VA remind one of another area of growing concern. We are becoming an older society. I suspect that the type of care provided by the VA is exactly the right approach for serving our senior citizens. If we can save money and provide better healthcare results, let’s go for it.

Apparently many physicians are not thrilled with the implications of the IOM report. The fear is that the better-organized doctors will lobby state legislatures to keep restrictions on nurses’ responsibilities. Clearly, the doctors were better organized in the past, but I believe nurses are moving towards national unionization and the ability to speak with a single voice. If they aren’t, they should be. I know they are a political force in California. Meg Whitman was foolish enough to make them mad at her.

As for the doctors who are concerned about their incomes and their privileged positions—welcome to the marketplace!

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