As America begins to grapple with realization that it doesn’t have enough family physicians, a common suggestion is that the shortage can be solved by growing the mid-level workforce, i.e. nurse practitioners and physician assistants. I’ll talk more about mid-levels’ role in primary care next week. Today, let’s step back and think more broadly. The physician assistants might disagree, but let’s lump them in with nurse practitioners as doing the same job and having similar skills.
Nurses’ work lives in general are driven by algorithms. Check your patient’s vital sign every four hours. If the temperature is greater than X give Tylenol. If the temperature is greater than Y or less than Z call the doctor. Assess the patient’s mental status by asking these questions. If they are answered correctly, move to the next set of assessments. If one is answered incorrectly document the finding in the nurse’s notes and review the patient’s answer in the previous assessment. If similar, continue to monitor. If there is a change, call the doctor. You get the idea.
Nursing self-identity is also founded on the belief that they are experts in patient education. They believe they add value to patient care by spending the time with patients to explain the illness and treatment plan that doctors can’t or won’t take the time to do. And they’re right. How many times have you heard a person who just was discharged from a hospital rave about how attentive the nurses were compared to how great the doctor was? It must be at least 10 to 1 in favor of nurses.
One of the major rationales for putting nurse practitioners in the role of primary care providers is that their income expectations are less than physicians. I say, why stop there? Wouldn’t there be even greater bang for the buck if the healthcare system used them in areas where there is even more room for savings?
Heart catheterizations (where a thin catheter is used to squirt x-ray dye into the heart arteries to look for blockage) are almost always performed by cardiologists. When the concern is whether or not a patient has cholesterol blockage causing chest pain or similar symptom, the procedure is performed the same way most every time with little variation. For low to moderate risk patients, it would be easy to teach nurse practitioners how to do the procedure and respond to common findings. Calculate coronary artery blockage by comparing this measurement to that measurement. If greater than 50% blockage, remove diagnostic catheter and insert balloon catheter. Position balloon to the mid-point of the blockage and initially inflate to 3 atmospheres for one minute. And so on.
Cardiologists would still perform heart caths on the sickest patients at highest risk of sudden death: e.g. patients having an acute heart attack. But especially in regions of the country where the standard practice has become catheterizing every patient who reports a twitch in his chest, imagine this:
Apply a model similar to one where an anesthesiologist supervises a group of nurse anesthetists. Three cath labs are going at once with nurse practitioners doing the procedures. One cardiologist is on back up duty to help with complicated lesions or rare findings. The nurse practitioners spend the day catheterizing patients who had occasional bouts of chest pain and recent abnormal non-invasive heart tests such as stress tests.
In this scenario, several aspects of patient care could improve. The nurses may be more inclined to adhere to pre- and post-procedural checklists, thus improving patient safety. There is a good chance they would spend more time explaining the procedure beforehand and reviewing discharge instructions after.
And what if a patient gets into trouble during the procedure and “codes”? Every nurse in a hospital is already trained in cardiac resuscitation. Running a cardiac resuscitation code is like following a recipe. If the patient has one kind of EKG finding give drug A. If the patient has a different EKG finding shock her. Running a code is merely an exercise in . . . . . . . . . . FOLLOWING AN ALGORITHM!
This approach could be expanded to other body parts. Nurse practitioners could be trained to spend their days dilating eyes and lasering abnormal retinal spots. They could do screening colonoscopies or flex sigs. They could replace knees in skinny patients that aren’t technically challenging. Leave the obese patients to the orthopedists.
Think about it. The savings to the healthcare system could be enormous.