Why nursing homes need more doctors on site

The recent New England Journal of Medicine article, highlighting burdensome healthcare transitions in a subset of nursing home patients, is certainly of documentary value. However, for many of us with real-world experience in the nursing home medical care venue, the article certainly falls short of newsworthy.  Not even mildly surprising really.

Too many of our nation’s nursing home staffs suffer from a lack of onsite MDs for evaluating acute medical conditions of their residents. Additionally, many of our nursing homes also are frequently operating with the minimal number of licensed nursing staff permissible, under state and federal regulations. Making matters worse is that a very large number of these licensed nursing staffs are minimally experienced and minimally skilled, at performing acute clinical evaluations of patients. Equally problematic is that the bulk of the time, of the licensed nursing staff, is taken up by supervisory matters—particularly in regard to care plans, chart documentation and other paper trail maintenance—important to regulatory agencies—and, consequently, of top priority to the facilities’ administrations. In short, our nursing homes’ licensed nursing staffs have become increasingly more proficient and comfortable with their administrative tasks, than they are with clinical tasks.

Thus, the day-in-day-out clinical decision making within our nation’s nursing homes is being significantly influenced by a nursing staff that is struggling with a 4-F syndrome: fear of adverse publicity for the facility, fear of clinical decision making, fear of regulatory surveyors and fear of job loss or subsequent legal repercussions.

As I point out in The Medical Profession Is Dead and the Doctor Is “Critically ill!” nursing home patients will experience more new complaints and more frequent declines from their baseline health status, on any given day, than any other patient population. Paradoxically, the facilities we then place them in, for addressing these daily high-maintenance health care needs, are the very facilities having the least physician-presence of all other health care venues within the medical system. Consequently, most patient medical assessments and medical interventions are carried out by nursing staff.

My personal real-world experience suggests that nursing home residents’ medical interventions begin with phone tag with the attending MD, progress to phone consultation with the attending MD, proceed to trialed phone orders from the MD and, inevitably, end up with the order: “Ship by ambulance to the ER.” It differs from physician to physician, as to how many calls from the nursing home nurse will be required, before the “Ship by ambulance to the ER order comes, but come it will.

What almost never comes, however, is the doctor to the nursing home—for evaluating the patient, documenting his evaluation and treatment plan within the chart—and, by so doing, sharing with the nursing home nurse the responsibility for the outcome of the patient. And so, within our nursing homes, almost any acute or subacute change in a patient’s medical condition—especially if occurring on the eleven to seven shift—generates “the perfect storm” for blowing the patient out of their familiar and secure environment, into the frenzied milieu of the nearest hospital ER.

Of course, the arrival in an already hectic ER simply cries out for expediency, with the result being even more defensive medicine posturing than usual. This generally translates into the patient being admitted to the pricey acute care hospital or the patient undergoing a battery of terribly high-tech (also terribly expensive) tests and imaging, which, all ER doctors know, will be looked upon as surrogate markers for quality care, by any regulatory inspecting agencies—should the chart ever be pulled for their reviewing pleasure. With copies of the results of these pointless tests now safely ensconced within the patient’s permanent medical record, the ambulance can then be called for transporting the hapless patient back to the nursing home—for awaiting his/her next “sinking spell” and their next burdensome ER trip.

In any given twenty-four hours, it is likely that thousands of unwarranted medical interventions, costing hundreds of thousands of dollars, are being ordered within our nursing homes’ populations for the sake of convenience and a host of other self-serving agendas having nothing whatsoever to do with the patients’ needs or best interests.

Alan Cato is the author of The Medical Profession Is Dead and the Doctor Is “Critically Ill!”

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  • http://www.facebook.com/profile.php?id=655523194 Jeanine Satriano-Pisciotta

    True in the 26 years of geriatric nursing, the patients have changed to younger and more complex conditions, then the “typical” NH patients of years ago. They now come a few hours after major surgery, IV’s, central lines, etc. More like med surg, but without all the neccesary equipment or skills. We had an MD almost daily until a year ago and it was great. We intervened with IV fluids, meds right away to prevent ER trips. It’s hard when your calling report to the MD, for him to see thru the phone and eval the patient and we still have families that demand a trip to the ER for a stomach flu. It’s changing for sure and will in the future. We get patients in their 20′s who are very sick and multple medical needs and a boatload of meds. Then I have 101 years olds on 2 meds and ambulating with walkers. They are the ones that help read and do activities with the sicker, younger ones! Gone are the days of the typical old folks home! :)

    • Anonymous

      What happened to the MD that was there?

      • http://www.facebook.com/profile.php?id=655523194 Jeanine Satriano-Pisciotta

        He retired. He was early 60′s and had 2 NH and that was it. He had an office practice years before. He had been the director for years and knew all the patients inside and out. He was also a wealth of knowledge and enjoyed explaining/ teaching the staff and patients. We did alot more as far as IV’s, Lasix pushes for CHF, etc. Our new MD is a fine MD but in addition to the NH, he also has an office and works the ER. So he can’t be in a million places at once. When your not familiar with the patients, some MD’s prefer to send them out. We (nurses) would rather treat in house for treatable conditions. We don’t like to send them out, only to return in two hours with an antibotic order either. Equipment such as a urinalysis machine to R/O UTI’s, coag machine to do PT/INR’s would be helpful. Not to mention AED’s ( that have been ordered…….). We have been asking for that for years, with all the older people, AF and arrythmias and of course full code patients- that would be helpful. So it’s not always about training staff, it also involves equipment to work with.

        • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

          Dear Jeanine, Thanks so much for commenting to my post.  Your reply to buzzkiller, in my estimation, immediately identifies you as an invaluable nurse of integrity.  I wish that all the licensed nurses, in all our nursing homes and skilled care nursing homes, were able to share in your attitude.  I have been retired now , since 2008. I note in your reply to buzzkiller that your prior NH director also retired in his sixties.  I can only speculate as to why, but disappoiment with the system and inability to make any headway toward change for the better (even with our staff and within our facility) led me to retire in my early sixties–even against financial advice.  I was primary attending physician and also acting medical director of a 140 bed skilled care duo-diagnosis facility, and was on-site Mon-Fri from 8A to 4:30P (or whenever).  I also was the medical officer responsible for all acute and chronic non-psychiatric medical problems of the patient population within the 222-bed state psychiatric hospital on the same campus.  I was more fortunate than you, in your situation.  Being a skilled care facility, we had both lab and x-ray department available during the same hours that I worked.  Despite this advantage, I would come in every morning to find one or more patients had been sent needlessly to the ER, after the nurse had consulted my on-call night coverage.  Most often it was apparent to me that proper communication and proper listening could could have prevented the needless transfer and, frankly, I think most often the bulk of the fault was the on-call physician’s i.e. convenience & defensive medicine.  The major point of my original post (besides the need of on-site MD evaluations, when needed, in our nursing homes) was that the nursing staff in our facility was exstremelyl hampered by the points I make in the post—especially the lack of physician reassurance and their resultant 4-F syndrome.  At any rate, thanks for your input and thanks for your attitude and good work for your patients.  Respectfully, A. Cato MD

           

          • http://www.facebook.com/profile.php?id=655523194 Jeanine Satriano-Pisciotta

            Thank you for the kind words. I do agree regarding an on site MD, it not only reassures patients and families, but the nursing staff as well. Yes, our good doctor had left us for retirement and travel as he said, but I suspect you may have more insight into this. He actually did not renew his medical license, which we all thought was crazy. He loved to lecture and was a frequent area speaker on geriatric topics and aging in local hospitals.
             We live in a small town, so I know the handful of hospitalists and MD’s in the area. The small town atomosphere is very conducive to ” what does the doctor say?” Families and patients know some of the MD’s since they were kids! That being said, we have a little hospital- 3 beds in the ER ( maybe 1 patient in there) and the med surg floor has about 10-15 pts. at most. Seriously. The other local hospital is larger, but all trauma gets flown out to Erlanger in Chattanooga. We draw labs and take them over to the hospital. We use a mobile xray service. I think being in a small town, allows you to hone your skills. Being from NY and FL, I worked in much larger areas with more help. I was a “paperwork” nurse at one time and missed the patient care. I enjoy teaching and now work the unit, train, teach and mentor new nurses. Our retention on new nurses is a lot higher then most, and the first year is scary! I give meds, do treatments, blood work, iv’s, pass all kinds of tubes from all different directions, etc. I also expect all nurses on the floor to be proficient in these skills and if not they come with me and we do it together. I also teach patient assessment and what is going on with this patient. What interventions can be done and what the MD needs to know when you call.
             I have 3 special talents- first, just by putting my hand on a forehead, I can tell the temp. within 0.2 degrees. Second, I can guess within 35 cc by palpating a bladder how much urine is in there. Third, just by smell I can correctly guess 8/10 times what organism has infected a wound. Yes, my special skills, not sure if I should be proud of these things!  I’m am also the one that sings down the halls and my patients laugh. 
            Frankly, there are very few nurses to mentor others, esp. when they have their 29 of their own patients and a ton of paperwork, but most of my co-workers make time. We know the value of a good nurse, who’s hard working and willing to learn. They are our future, otherwise I may not get to retire until I’m 90!!

      • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

        Thanks for commenting to the post.  I spent fifteen plus years as the on-site attending  MD and acting medical director of a 140 bed skilled care dual diagnosis facility.  I was onsite Mon-Fri 8A to4:30P and, like yourself, I was discouraged nearly daily at coming in to find that a patient I had evaluated at 4pm and left clear orders for what to do If– on the chart–had been ordered to the ER, by ambulance, after my on calll coverage for the night had been contacted by the nurse for some minor sign or symptom change, when what the nurse was really wanting was some time spent listening to what she was saying, along with some reassurance.  By the way, the twenty years before the last fifteen, I was in private practice and saw an average of 55 patients in the office daily, averaged five patients per day in the hospital, ran out to the ER two to three times per night and, yes, went to the nursing home when called,  instead of telling them to send the patient to the ER.  By the way,I wasn’t anything special, the other four doctors in the community were behaving the same.  I suppose that I am lamenting that the doctors no longer are able to follow their patients in the nursing home and while they are in the hospitals.  I am also lamenting that the nurses in past times seemed clinically more secure and more confident in their judgement. A. Cato MD

  • Anonymous

    More doctors, more cost, people complain of higher costs…need I go on?

  • http://bit.ly/gwalter gwalter

    Because of the economic meltdown a couple of years ago, I had to re license as a paramedic in order to find employment. I had been out of the ambulance transport business for over 20 years.

    I’m saddened and disappointed at the frequency we go to assisted living and SNFs to take people to the ED for relatively minor issues.

    UTIs, skin ulcers, flu, fever, and general malaise. They are not being served by riding in a bumpy, cold ambulance for something that could readily treated in their facility. A PA, or RNP could easily deal with these issues.

    Not only the inconvenience and dehumanization, but a $1000 ambulance bill (x2) and a $2000 ED bill is not very cost effective.

    We need to get it together.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      But they won’t spend fifty bucks on the medical visit.

  • http://www.facebook.com/people/Janet-Gysi/1302002770 Janet Gysi

    I am a Nurse Practitioner working in 2 nursing homes.  I know these patients very well and I am on call 24/7.  I try to keep residents in the facility and intervene before crises occur.  Patients sent to the ER are typically diagnosed with one of 3 things: CHF, UTI, dehydration.  All of these are problems that we should be able to manage before they become critical, possibly with the exception of CHF as we have all seen fulminating pulmonary edema at some point in our careers.  Nursing homes have limited ability to handle patients in crisis.  My facilities can do IV therapy and, of course, lab/xray/US/EKG with an outside contractor but nursing homes are not “mini hospitals”.  In addition, each of the nurses (mostly LPNs and very dedicated) has a patient load of at least 30.  There are just logistical limits. Add to this the declining funding for nursing home care on the order of 11% this year alone.  Again, there are just limits to what can be done in the facility. 

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      And they speak English?

      I’m jealous.

  • Anonymous

    For all you board-certified geriatricians who can’t wait to start running to the nursing home in the middle of the night for Medicaid rates, the line forms to the right.

  • Anonymous

    In the mid-90s I worked at Kaiser in the Bay Area.  Admin had the idea that we could provide better care and, more importantly to admin,  save money by having one of the docs spend half his time riding the nursing home tiger.  The guy quit after a few months and so we were back to the previous dysfunctional system of nursing home telephone tag plus the ambulance ride back and forth to and from the ER shuffle. A dirty little not-so-secret is that doctors don’t like nursing home patients and perceive taking care of them as a waste of professional time and talent. Oh, and did I mention it doesn’t pay? A potential solution will be apparent to the perceptive reader.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    I’ve known doctors with Geriatrics subspecialty boards, who stopped advertising the credential, preferring to call themselves general internists.

  • Joseph Ward

    surprise surprise, doctors want to increase the demand for their services!

  • http://www.facebook.com/people/Natalie-A-Sera/743004321 Natalie A. Sera

    Well, I was discharged from an acute care hospital after a diabetic coma into a rehab hospital, AKA nursing home, and because it was a Friday night, and the hospitalist was off for the weekend, and the Type 1 protocol insulin orders somehow did not follow me, I was left on minimal insulin coverage (corrections only, which did not bring my BGs down, but did keep me alive) and relapsed right back into blackouts and hallucinations. It was only on Monday, when the hospitalist came back on duty, and I CORNERED him (he was too busy to actually see me), that I was able to convince him to put me on a minimally adequate insulin regimen. So I coped by eating almost nothing, and it took me 3 weeks to get out of there, when it really wasn’t necessary. What’s wrong with this picture?

    • http://CANDIDMDEXPSLAINSHIGHCOSTDECLININGQUALITYUSHEALTHCARE.COM Alan D. Cato MD

      Sorry about your experience Natalie.  Unfortunately, there is truth in what they say about trying to avoid  admission to the hospital on a weekend, having any kind of procedure performed on a weekend—or being discharged on a Friday.  All are bad situations compared to regular-week work days,which, are usually fully staffed, and with the most experienced individuals.  On-site is always better, and I would have hoped that your rehab unit had been able to provide an on call MD for coming on site to evaluate you.  Even the better hotels provide for some method of physician evaluation for their guests.  Alternatively, an experienced, knowledgeable and proactive nurse, for contacting and demanding adequate consultation with an MD, could have been helpful—although it has been my experience that many , if not most, diabetics of long standing duration, are frequently capable of advising the nurse and the doctor on their insulin requirements.  If, as I suspect , you are one of those well informed patients, I would have hoped that it would have been even easier for you to have at least gotten phone consultation and orders for the insulin regimen you required, under the circumstances you described.  All’s well that ends wel,l and I’m glad it eventually ended well for you.  Thanks for responding to the post. Respectfully, A. Cato MD   

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I follow my patients at the SNF’s and in most of the facilities the work is so difficult that there is over 75% turnover of the staff per year. Regulations require the staff to call the doctor for everything so if an individual scrapes their arm and requires soap and water, peroxide and a bandage, it requires a phone call to the physician to give the order. If it is a more serious issue the rule is ” call 911 and copy the chart for transfer.”  It is a lucrative wheel. The hospital ERs get a patient with insurance, the paramedic system gets another trip to use when they go before the local elected officials at budget time and the facility gets a new patient at a higher pay rate than the long time patient who just went to the ER.
    For years I have proposed a national health service requiring all graduate physicians and nurses to put in a year at a SNF or community facility before they can enter specialty training or go out into practice in the community. They should receive some form of loan forgiveness for the service. This would place young still idealistic doctors and nurses in facilities. It would teach them something about geriatric care for the future.

  • Anonymous

    In order to address the doctors on site in the environment of nursing homes, we need to examine whether nursing homes reflect the break down of the extended family.  We need to question how the physical presence of a doctor in a nursing home does not have financial interests and needs, and therefore, uses the location of a nursing home as another source of income.  Nurses and nurse practitioners have raised a voice of concern with respect to accredidation that would be reflected in their pay for services, since they are the ones in a nursing home setting that practice bedside manners with the residents of the nursing home.  If the physician considers his presence on a daily bases to be important for the quality of care for elder, he has to practice medicine under the guidance of a specialist in geriatrics or psychiatry.  The elder deserves respect and not abuse as Mickey Rooney testified in front of Congress describing the abuse of the elders.  If the physician judges that his presence in a nursing home is required, he has to be willing to work with nurses, the family doctor of the patient the attorney of the a patient who can inform him about MAD or DNR documents that reflect the wish of his patient.  That is the only way that he can be a physician to the elder without depriving him of his dignity.