Challenging Paradigms: Practicing at the Top of Your License

The industrial revolution has come to healthcare.  Old paradigms – from routine physicals to even the concept of the doctor as the captain of the ship – are being challenged as we try to find more efficient ways to deliver high quality care.  However as fast as we break down the rigidity of past practices in order to foster better systemization we seem to build new paradigms that may have negative unforeseen consequences.  These new “truths” can rapidly be set in concrete while the problems they create are given little attention.  We must always be asking ourselves whether we are truly improving care or if we are merely swinging the perennial pendulum of change too far as we try to reject shibboleths of the past. 

A new paradigm that I see in many realms of medicine is the concept of having each professional practicing at the top of their license and their training.  What that means is that a doctor should not do something that a nurse practitioner can do; a nurse practitioner should not do something that a nurse can do, and a nurse should not do something that a nurse’s aide should do. In practice this concept has manifested in a variety of ways.  During my recent hospital stay which I described in a different blog post, the nurses rarely touched me or even saw me as they stayed at the nurse’s station monitoring my cardiac rhythm, watching my trends on the computer, and only coming in to give me medications twice a day.  The nurses’ aides took my vital signs, helped me get to the bathroom and changed my bedding.  The doctors did not come in at all as they were able to access the record from multiple locations and I only saw the physician at the time of my procedure.  In psychiatry, this same concept has developed to the point at which it is unusual for a psychiatrist to engage a patient in talk therapy and instead is involved mainly in medication management with talk therapy being performed by licensed therapists who are not MDs.  For surgeons, it means that they are often focused totally on their work in the operating room with nurse practitioners assessing the patients and caring for them before and after the surgery.

The fact is that this type of approach has some attractive features.  For the system, it could potentially save money.  For the health professional, it frees them from doing tasks that they may not like to perform and allows them to focus on the tasks they are trained to do. But is this better for the patient?  Is this strict division of labor really conducive to high quality, patient centered care?   

In some ways, this new paradigm is related to the industrial revolution that health care is now undergoing.  The assembly line was a key component of the industrial revolution of the nineteenth century and the movement towards a new industrial revolution in health care can be seen to be following that tried and true formula.  A true division of labor approach in which everyone limits their practices to the top of their license and training has advantages.  Assembly lines allow for specialization of roles and that often leads to less variability which is associated with higher quality products being produced at a significantly lower cost.  The cost of labor goes down as each person involved only performs a small number of tasks.  That allows for training requirements to be narrowly focused as well, with the jobs themselves then more easily filled at a lower salary level.  If more can be done by nurses’ aides who are lower paid than nurses, the theory goes that nurses can focus more on the “important” nursing roles which results in a decrease of total costs and a more effective and efficient system. 

However the disadvantage of the assembly line is that unique craftsmanship is lost.  From the worker’s point of view, the work becomes repetitive and the “big picture” of the ultimate goal, complete with individual pride of reaching that goal is lost.  The individual ownership of the product (and in health care the product is the well-being of the patient) risks being lost in a system that is based on assembly line principles.  There is a reason that the finest products in the world are often not made on an assembly line but are made by master craftsman who take great pride in their work.  We see some of these disadvantages in this new medical paradigm as physicians and nurses are rewarded for how well they do their individual tasks rather than how well they treat the whole person.   

Medicine is filled with the risk of low probability and high consequence events, some of which are due to our treatments and not only to the underlying disease.  Quality medical care demands anticipating and avoiding those events and treating people in such a way as to minimize the risk of any intervention.  That may require more holistic thinking about the patient rather than task based thinking.  A health professional who is very hands-on even if that is “below” their training and license may be the best defense against poor quality care.  A recent article in ProPublica that focuses on surgery risks and patient safety makes this point when they describe two surgeons in a small community hospital in northwest Alabama who are among the best in the country at doing joint replacements.  Dr. Aaron Joiner and Dr. John Young have performed 282 knee and hip replacements over the last five years with zero complications.  The way they accomplish this is the antithesis of practicing at the top of your license.  As described in the article, they often operate together even though that hurts their income.  They believe that having two surgeons in the operating room provides a backup and an immediate quality control.  They describe a typical interaction in the OR as one in which they are open and honest when they see their partner doing something that does not measure up to their own standards.  “I may look at something a little backwards or get turned around,” Joiner said.  “It’s nice for one of your partners to say, ‘What the hell you doing?  You’re not out huntin’ this morning.  You’re doing a knee replacement!”  They also do all the post up care themselves rather than having physician assistants or nurse practitioners do that for them.  As Dr. Joiner puts it, “We don’t cut corners.  We do it the right way every time.” 

I remember when I was training in gastroenterology, serving on the service of Dr. William Silen, a giant in the world of surgery, who was also a dedicated teacher, mentor and patient advocate.  At Harvard Medical School, the William Silen Lifetime Achievement in Mentoring Award honors his leadership and his memory.  We would make our rounds with Dr. Silen to see patients at 5 AM every morning and at 6 PM every evening, personally seeing each patient pre and post operatively twice a day with our operating room duties in between.  The fellow or resident who just wrote an order without actually seeing the patient, talking to the patient, and examining the patient would not last long with Dr. Silen.  The doctor in training who thought that removing a naso-gastric tube or changing an intravenous line was a nurse’s job and not his or her direct responsibility would quickly learn that attitude was not acceptable.  For Doctor Silen every task that involve caring for a patient was in the physicians scope of practice and was, by definition practicing at the top of their training and license because medicine was about ownership of the entire patient – their problems, their hopes and their lives – not about the specific task that needed to be done.

The idea that all health professionals practice at the top of their training and license when used in the context of a true team all sharing full accountability for a patient can help both quality of care and the human caring that patients need.  However it is very easy for that pendulum to slip past the midpoint into the realm of assembly line care that focuses on the immediate task rather than the entire patient and their family.  In an age of ever expanding health systems, employed physicians, corporate medicine, government medicine, and large mega-health benefits companies, it is far too easy to focus on an assembly line mentality rather than a team mentality that can truly improve care.  Let’s not allow the new paradigm that demands division of labor to ever divert us from the idea that all care for a fellow human being in need is by definition at the top of one’s training and license.  

My Recent Hospital Stay: Getting the Joke

I was home following my hospital stay, trying to modify my lifestyle and attempting to adjust to new medication to help me deal with my angina (chest pain due to heart disease) when the 5 page letter, using words that only a lawyer could love, came from the health plan. 

“We have reviewed information received about your care and specific circumstances using the MCG criteria for Inpatient and Surgical Care. Based on this review, coverage for the requested admission is denied.” 

Happily I did not take the denial letter seriously.  If I had I would have been at risk for readmission to the hospital with more chest pain and shortness of breath.  My first reaction was to think this was extremely funny.  I know how these issues work, and also know that my diagnosis of unstable angina (increasing chest pain related to heart disease while on medication) with an abnormal stress treadmill test fit criteria for coronary angiography, an invasive procedure to see my coronary arteries.  I had, indeed already received health plan “approval” for the cardiac procedure.  I also knew that the best practice algorithm from the American College of Cardiology, for unstable angina called for “admission to the hospital for bed rest with continuous telemetry monitoring.”  All that had happened correctly.   I assumed that somewhere along the line, despite more attention being given to documentation than to actually doing anything (see my last blog post), something had been lost in translation.  My cardiologist, a very exacting person when it came to do a cardiac procedure was perhaps less exacting when it came to filling out the paperwork.  The hospital department that submitted the documentation may have missed the boat in communicating what was really happening in my life when I was forced to enter the hospital – a step I loathed taking. 

But then I stepped back.  What if I had received that letter and did not have the knowledge I had?  Would I believe that my doctor did something wrong or did not treat me correctly?  Would I curse my health plan and accuse them of being uncaring and incompetent?  Would the anxiety of potentially getting a huge bill I could not afford create more stress when I was trying to deal with the stress of having ongoing heart disease?  And would I believe that MCG criteria were some magical code that determined whether I would live or die? 

My knowledge of the facts made me see the humor in this and not be stressed by the game of telephone that occurs when physicians and hospitals try to communicate medical needs to the health plans.   I knew that MCG stood for the Milliman Care Guidelines first developed by an old friend, Richard (Dick) Doyle who was a brilliant physician and consultant when he worked for Milliman, a respected actuarial consulting firm.  I used to joke that the first generation of the Milliman guidelines were made up by Dick Doyle with his feet up as he looked over the Pacific Ocean in his house in San Diego rather than by any scientific method.  It felt like the use of only the initials, in the denial letter, made these guidelines have so much more weight than they really were meant to have – making their use in the denial letter almost comical.    Milliman Care Guidelines are used by many health plans and even by government plans to judge efficiency because of their operational ease, not because of their scientific rigor.  They are not meant to be nuanced and rather are guides to what can be achieved in the perfect world that those who practice clinical medicine rarely see.  My cardiologist, who admitted me and did the coronary angiogram, was well trained, smart and caring and did everything right clinically.  The people in the health plan were all caring professionals trying to uphold the plan requirements in a fair way.  All these people are good people doing the right thing and yet the letter that was sent to me seemed to say that my care had been wrong and would not be paid by the health plan.  It was communicated to me, the patient, in a heavy-handed way that said that what I had done was “not medically necessary” according to those magical guidelines. 

Upon further investigation, I discovered that the contract that the health plan has with this hospital calls for these admissions for unstable angina to be billed as observation unit days, rather than admissions.  I was lying in a bed in a room as an inpatient and this contracting fiction that drives payment was meaningless both to me and to the hospital staff who cared for me (or who cared for the computer as I speak about in my previous blog).  I, as the patient, will be held harmless and not have to pay for this purported mistaken admission driven by my acquiescence to supposed “sub-standard” care since the mistake did not occur and the denial was just due to the financial relationship between the health plan and the hospital. Now that my investigation is done, which I took on as a form of entertainment, I will go back to focusing on my own health issues. 

The good news is that my cardiac procedure did not show any critical lesions but instead showed disease that is readily managed by lifestyle modification and proper medication.  I am also fortunate to appreciate the irony of the whole episode.  I get the inside joke that others may not.  My goal is for everyone to have someone at their side who also gets the joke and who is able to understand health care and health benefits.   That person – in my world the Accolade Health Assistant – knows how to navigate the system and help people through the decisions, the documentation, and even the denials when they come.  I don’t want anyone with heart disease or any other medical issue to be at risk for new medical problems due to “payment fear” related to accessing health care just because they don’t have my knowledge.  Everyone needs a health assistant and with the experience gained from this medical interlude, I will continue my efforts to make that happen.