Friday, October 29, 2010

Doctor Nurse

It occurred to me many years ago that to the extent medicine is a science, we don’t need doctors.

Science is the means by which we identify what we are willing to accept as facts. Lab results are one example. When the lab reports that my fasting blood sugar is 200 mg/dL, we don’t need a doctor to decide that it is higher than normal. Neither, in a smaller but still large number of cases, do we need a doctor to decide that it means that I am diabetic. Evidence-based protocols lay out what is to be done about it and so we don’t necessarily need a doctor to figure that out either.

In other words, medicine begins where science leaves off. It is when the lab and the evidence are unable to make a definite determination of diagnosis or treatment that we need the judgment of trained and experienced professionals.

With the passing of years and the advancement of science, the ability to establish facts has greatly increased, thereby reducing the incidence of the need for professional judgment in health care. It would seem logically to follow that a larger portion of the work of patient care could be done by people other than physicians.

By a different route of logic, the Institute of Medicine seems to have come to the same opinion. As reported in the October 11 issue of Modern Healthcare, the Institute’s recent report (The Future of Nursing: Leading Change, Advancing Health) “….argues [that] giving nurses more leadership roles and caregiving authority could save time and money on the path to healthcare reform.”

This point of view also matches my own experience. As mentioned in a previous posting, I have recently had a couple of Emergency Room experiences in which I was diagnosed and treated satisfactorily by Nurse Practitioners and Physicians’ Assistants and discharged without seeing a doctor.

The Modern Healthcare article reported opposition to the Institute’s recommendations by spokespersons for the medical profession. Such opposition is understandable, but I think the die is cast.

Friday, October 22, 2010

An Issue That Won’t Go Away

At the beginning of my hospital administration career some fifty-odd years ago, a cardinal principle of health care was that life was to be extended at all cost. If there were “hopeless cases” in which doctors did somewhat less than they might have (which there no doubt were), nobody talked about it.

Things are no longer that simple. I am reminded by an article appearing in the October 20 issue of The Boston Globe about the risk associated with the use of combined hormone therapy (estrogen plus progestin, sold as Prempro) for post-menopausal patients. The article reported a study that found that a group of 10,000 women taking that medication would experience two or three more deaths from breast cancer each year than a group of equal size that does not take it.

Other studies in the past have also found risks of heart disease associated with the drug. As a result, wife Marilyn was taken off it a few years ago and put on other medications that were supposed to achieve the same result. Well, they didn’t. Her hot flashes returned and her energy level was greatly reduced. Instead of being her upbeat, energetic self, she was struggling every day to make herself get on with doing the things that her life called for.

She finally decided that whatever longevity she might be earning wasn’t worth it and went back on Prempro. Within weeks, she was back to something more like normal.

In a historical sense, circumstances that raise the issue of whether life is worth extending are fairly new and as a society we have yet to become comfortable with them and the decisions they make necessary. The “death panel” brouhaha that arose during the recent health care reform debate is an example.

But it will not go away.

Saturday, October 09, 2010

Not-for-Profit vs. Commercial Hospitals

The long-running debate over whether hospitals should be operated as not-for-profit or as commercial organizations is brought to mind by the desire of the Boston Archdiocese of the Catholic Church to sell its hospitals – years ago consolidated into a not-for-profitn organization named Caritas - to a commercial company.

Hospitals were created initially to care for the poor. Not-for-profit status made it possible for them to accept donations from both public and private sources and to engage in charitable work.

With the development of health insurance and the expansion of government financing, patient care became less and less a matter of charity. To an ever-increasing extent, hospitals were able to charge and collect for services rendered.

As their sources of income grew, hospitals became attractive as businesses and began to attract commercial interest. A number of commercial hospital companies came into being and continue to operate.

A common point of concern has been whether the commercial hospital’s loyalty to its owners would outweigh its responsibility for the welfare of patients. Offsetting that concern was the professionally and economically independent medical staff. Doctors had the primary role in clinical matters and in that sense stood between the patients and the hospital.

But that is changing. To an ever-growing extent, hospitals are taking an active role in clinical matters. Protocols, guidelines, checklists and other measures intended to improve clinical quality and safety, as well as to control costs, are hospital-based and rely on the corporate authority of the hospital for their implementation. Furthermore, more and more physicians are becoming financially dependent on the hospital, as salaried employees or by means of other forms of affiliation.

All of this raises again the question of whether the priority of the commercial hospital will be to serve its patients or its investors. While the ability of the medical profession to offset such concerns is diminished, perhaps the new emphasis on safety and outcomes will suffice to assure that the interests of patients are protected.

Speaking for myself, I’m not so sure. If I am ever in the position of having to choose between a not-for-profit hospital and a commercial one, I think I will go with the former.

Wednesday, October 06, 2010

Like to Malpractice Prevention article

My most recent posting regarding malpractice prevention referred to an Entry Point piece in the September issue of Health Affairs.

For those interested in following up further, the piece can be seen at


Tuesday, October 05, 2010

An Ounce of Prevention

I have long said that the problem with malpractice is that there is too much of it. Measures to limit the size of settlements and to simplify the process of litigation may or may not be good ideas, but surely the best solution would be for the malpractice not to happen in the first place.

Apparently, others are beginning to share that view. A lead-in article in the September, 2010 issue of Health Affairs by Stephen Langel, Senior Editor, reports that the Obama administration last June awarded seven Medical Liability Reform and Patient Safety Demonstration Grants involving a total of $25 million. The article also quoted Nancy Ann DeParle, head of the White House Office of Health Reform, as saying in the context of tort reform that “The President’s preferred approach – preventive medicine to ward off lawsuits – had been part of his thinking for some time.”

Another article in the same issue of that journal estimates the annual cost of our medical liability system as $55.6 billion in 2008 dollars.

There is an old saying that an ounce of prevention is worth a pound of cure. In relation to the size of the medical liability problem, $25 million scarcely qualifies as an ounce.

But it’s a start.

This page is powered by Blogger. Isn't yours?

FREE counter and Web statistics from sitetracker.com