The Institute of Medicine in 2010 famously recommended that nurses should be encouraged to practice “to the full extent of their education and training.” Often, you’ll hear people advocate that every health care worker should “practice at the top of their license.” What this concept is supposed to mean, I think, is that anyone with clinical skills should use them effectively and not spend time on tasks that can be done by someone with fewer skills, presumably at lower cost.
So I would like to know, please, when I’ll get to practice at the top of my license?
As a physician who specializes in anesthesiology at a big-city medical center, I take care of critically ill patients all the time. Yet I spend a lot of time performing tasks that could be done by someone with far less training.
Though I’m no industrial engineer, I did an informal “workflow analysis” on my activities the other morning before my first patient entered the operating room to have surgery.
I arrived in the operating room at 6:45 a.m., which is not what most people would consider a civilized hour, but I had a lot to do before we could begin surgery at 7:15.
First, I looked around for a suction canister, attached it to the anesthesia machine, and hooked up suction tubing. This is a very important piece of equipment, as it may be necessary to suction secretions from a patient’s airway. It should take only moments to set up a functioning suction canister, but if one isn’t available in the operating room, you have to leave the room and scrounge for it elsewhere in a storage cabinet or case cart. This isn’t an activity that requires an MD degree. An eight-year-old child could do it competently after being shown once.
(Just for fun, I sent an email one day to the head of environmental services at my hospital, asking if the cleaning crew could attach a new suction canister to the anesthesia machine after they remove the dirty one from the previous case. The answer was no. His reasoning was that this would delay the workflow of the cleaning crew.)
Then I checked the circuit on the anesthesia machine, assembled syringes and needles, and drew up medications for the case. To each syringe, I attached a stick-on label with the name of the medication, and wrote by hand on each label the date, the time, and my initials. These tasks, as you might guess, don’t require an MD degree either. A pharmacy can issue pre-filled syringes, and clever machines can generate labels with automatic date and time stamps.
It was now 7 a.m., and I moved on to the preoperative area to meet my first patient. I introduced myself, and started to interview her. Then I noticed that no one had started her IV yet. I asked the patient’s nurse if he would set up the IV fluid, which had already been ordered via the electronic medical record. “If I have time,” he replied.
The nurse, in fairness, was busy with his own tasks — few of which required a nursing degree. He was doing clerical data entry in the computer, recording answers to a host of questions such as whether or not the patient had stairs in her home. In between, he was answering the phone, as there is no desk clerk to pick up the phone or check for incoming faxes.
So I got hold of a liter bag of IV fluid, attached sterile tubing to it, and flushed the air out of the tubing. Then I did my first clinical care of the day, inserting an IV catheter into a vein in the patient’s hand. For the record, IV starts are well within the scope of nursing practice and don’t require a physician.
Finally, at 7:07, I began my clinical assessment of the patient’s readiness for anesthesia, which was the first activity that approached working at the top of my license. Multiply the 22 minutes I had already spent doing lower-level tasks by hundreds of cases per year per physician, and you’ll start to see what a colossal waste of resources is occurring every day.
Not just at my hospital but also at hospitals nationwide, administrators have pared back support staff in an effort to cut costs. Their reasoning appears to be that lower-level support staff can’t do more advanced tasks, but their work can be “rolled into” what physicians and nurses do. A nurse, so this thinking goes, can easily answer a telephone during idle moments, though most nurses I know would laugh bitterly at the idea that idle moments occur very often. A physician can type on a computer keyboard and enter data while doing a patient’s physical exam, regardless of how much extra time this takes compared to dictating the same information. Don’t think about how much the need to focus on the computer screen detracts from the doctor’s personal interaction and eye contact with the patient.
Bureaucrats and administrators advocate “practicing at the top of the license” as a not-too-subtle way of enabling health care workers with lower-cost skills to replace physicians. An alarming example of this is the Veterans Health Administration’s recent attempt to change VA rules so that advanced practice nurses could work without any physician supervision at all. Vigorous opposition from veterans’ advocates has stymied this initiative so far, but it could rise again.
These same bureaucrats and administrators eliminate lower-paid personnel — desk clerks, transport orderlies, and dictation typists, for instance — to trim their budgets, with no regard for how much they prevent physicians and nurses from truly practicing at the top of their licenses. Someone still has to do the tasks that were previously done by those employees, and that someone, too often, is a physician or nurse.
The next time you wonder where your health care dollars are going, remember this: Your physicians and nurses would like to spend more time taking care of you. But they may be too busy doing other things.
Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA. She blogs at A Penned Point.