U.S. News & World Report: "Who Needs Doctors?"
January 31, 2005 - February 7, 2005 -- This week's issue of U.S. News & World Report features a massive special health report, including six significant articles and three related items. Its basic theme is that as the medical profession struggles with the pressures of managed care, insurance and generational shifts, other professionals are increasingly providing care that used to be the exclusive province of physicians. The report features an unusually positive--even glowing--look at the work of advanced practice registered nurses (APRNs). It also has a valuable discussion of some of the major challenges facing physicians today, though it appears to overstate medicine's distress. Some of the report gives readers the impression that APRNs are worthy of attention because they're doing things physicians do, whereas other nurses--the vast majority--remain engaged in what the report seems to view as the traditionally subservient and intellectually limited work of...nursing. In this sense, the report may actually reinforce regressive attitudes: nurses matter to the extent they can act like physicians. Thus, despite a little material on non-practitioner nurses and a short sidebar on the nursing shortage, the report does not convey that nursing as a whole is as vital and important to society's overall health as medicine is.
The special report's cover tells readers a lot about what's in store. It has a deliberately provocative headline--"WHO NEEDS DOCTORS?: Your future physician might not be an M.D.--and you may be better off"--which it places over a photograph of young, attractive, professional-looking Pittsburgh oncology nurse Lara Bartley, R.N. This suggests that Ms. Bartley may soon be replacing your tired old physician, and that she may even be better for you.
Obviously, this is the kind of thing that sells magazines, and practically begs for strongly worded responses from the American Medical Association and similar groups. It is a questionable approach. No responsible person would argue that physicians are becoming unnecessary. (If this were The Economist, known for its irreverent cover wit, we might have a different reaction, but U.S. News doesn't strike us as being very zany.) The choice of language is problematic as well. Advanced practice nurses and others do not become "physicians" merely because their practice may include some elements that physicians have traditionally done. We're not suggesting they're not as good as physicians; we're suggesting "physician" is not synonymous with "good." Moreover, it would have at least been more accurate to say "who needs physicians," instead of "who needs doctors," since many nurses, psychologists, and other advanced practitioners have doctoral degrees. Finally, Ms. Bartley does not seem to be an APRN, and though we're happy to see a staff nurse on the cover despite the lack of focus on them inside, it's probably not helpful to suggest that a staff nurse is going to replace physicians. That invites understandably indignant responses from physicians, but more importantly, it ignores the fact that Ms. Bartley's work is equally important because it is nursing, not because it is medicine, or like medicine.
The special report itself, which occupies about 30 pages of the issue, is far too extensive to summarize in any meaningful way here. But we will look at a few of the relevant highlights.
Josh Fischman's short "Who will take care of you?" is basically the overview piece. It argues that nurse practitioners (NPs) and other "new healers" are stepping in to fill the "growing gap" between physicians and patients. The piece traces this "gap," which leads to rushed and unsatisfying patient interactions, to pressures from managed care and insurance concerns. Rightly reporting that communication and psychosocial factors have been shown to affect patient outcomes, the piece closes with quotes from a Massachusetts public relations executive who has been with an NP since 1992. He notes that his NP "really knows me, and I have complete confidence in her and her clinical ability. ... She really is my doctor." This statement is obviously meant as a huge compliment, though some may feel it undervalues nursing education by equating advanced clinical skill with medicine. Please see our FAQ "You could be a doctor!"
Katherine Hobson's lengthy "Doctors Vanish From View" is subtitled "Harried by the bureaucracy of medicine, physicians are pulling back from patient care." It argues that the many rewards of being a physician--including relationships with patients, high status and high pay--are "increasingly outweighed by the reality of a 21st-century U.S. medical practice." Physicians are reportedly opting for specialties with less demanding schedules, restructuring practices to limit patients, or simply burning out. The piece admits that medicine remains extremely lucrative, with $150,000 average salaries for family practitioners and 2-3 times that for lucrative specialties, figures that appear to take into account malpractice insurance costs, though not the significant student loans many new physicians face. (Of course, new Ph.D's (including nurses) would appear to face comparable debts, or more, without the salaries of the U.S.'s most lucrative profession to help pay them off.) Some experts evidently predict a U.S. shortage of up to 200,000 physicians by 2020, though surpluses were predicted until recently, and the piece cites no evidence of a national shortage now. The current data appears to relate to the lack of physicians in certain specialties in certain states, and an overall shortage of physicians in less lucrative urban and rural areas, which is nothing new. Another factor is the generational change in medicine: new physicians, women and men, still like money but also appear to want a life outside medicine, and this affects their choice of specialties. Surgery and family practice are not so hot; dermatology is. Some opt for exclusive "boutique" practices to limit their patient loads. The piece notes that physician Abigail Zuger has argued in the New England Journal of Medicine that physicians are finally feeling social and economic pressures that have long plagued other professions, including teaching, law...and nursing. The piece includes some material suggesting that most physicians remain generally satisfied, and admits that medical school admission remains very competitive (no hints of a faculty shortage there). But the overall impression left is that the profession is deeply troubled.
We find Dr. Zuger's analysis the most persuasive, and it seems to us that rumors of medicine's death are greatly exaggerated. It may well be that in a managed care era driven by declining willingness to reimburse for care, changing social values and an explosion in public access to information, even the relatively charmed lives of physicians cannot remain wholly unaffected. These factors, combined with the stresses to which very challenging profession has always subjected its members, may account for many of the current discontents. It would indeed be curious if a profession that had long been the beneficiary of so many positive stereotypes and distortions--one that society generally viewed as the provider of all significant health care, with practitioners who despite flaws were the epitome of human intellectual, emotional and moral achievement--would still be going down the tubes. (Indeed, it would make us question our own mission; if even physicians' godlike media status was not enough to save them, we might conclude that media image really did not matter much.)
This is not to say that medicine has no problems. In fact, it may to some extent be the victim of its own unrealistically heroic image. Imagine if the media and many physicians themselves spent less time reinforcing the idea that today's physicians had the skills and the time to do the most glamorous and impressive parts of their own and everyone else's job, and more time letting the public know that there are worlds of important health expertise that physicians do not have, and that many physicians' practices include poor interactions with patients and other care givers, defensive practice, mounds of deadening paperwork, and chronic exhaustion that actually hurts patients. Then society might be more ready to address the profession's real concerns. But it's hard to have things both ways. If you're happy to be regarded (and compensated) as gods, and to take credit for everyone else's work and expertise, then you may be expected to handle some adversity on your own. No one feels sorry for God.
"Medicine's Turf Wars," by Christopher J. Gearon, tells the story of the practitioners who are not physicians but who are increasingly assuming care responsibilities that were traditionally done only by physicians. These include not only APRNs such as NPs and nurse anesthetists (CRNAs), but also psychologists, pharmacists, oral surgeons, optometrists and others. One example cited is the "MinuteClinics" that have appeared in some Target stores (see our write-up), small offices in which NPs provide a range of health services on a timely and affordable basis; the article discusses and includes a photo of Minneapolis NP May Hang. But much of the piece is about the "turf wars": battles between physicians and the "new healers" over scope of care, especially requirements of physician "supervision," prescribing rights and the rights to perform certain surgical procedures, including the provision of anesthesia by CRNAs, which it calls the "mother of all turf battles." In essence, physicians have claimed that the expanding practices of the newcomers threaten patient safety, while the newcomers suggest the physicians' views have more to do with the threat of competition. Commendably, the piece notes that "[w]hat research has established most notably is that an assortment of nurses with advanced training, including nurse practitioners and certified nurse midwives and other registered nurses with master's- or Ph.D-level education, are safe." The piece notes that more than 100 studies have examined NP care, and quotes Penn's health care outcome research leader and nursing professor Linda Aiken as saying that she does not know of a single study showing a negative health impact due to NP practice. Rather, as the Center often has cause to remind media entities, many studies "show the care APRNs deliver is equal to or better than that delivered by physicians." The piece examines the disputes over physician "oversight" of nurse anesthetists in key states such as Florida, and notes that 65% of all anesthesia care in the U.S. is provided by CRNAs--which may surprise most readers. Despite all the battles, the piece notes briefly that most non-physicians do work collaboratively with physicians, and that all agree "a team approach to care is best for patients." However, the piece closes, somewhat ominously, by noting that calls for collaboration are fine, but "many observers" (i.e. many physicians) think "stronger intervention" in scope of practice regulation is needed, and by quoting a physician stating that the system is "pushing nonphysicians to the limit of their capability."
The last major piece is "Nurses Step to the Front: In Hamlets and High-Tech Hospitals, Nurses Are Taking on Bigger Roles," by Samantha Levine and Angie C. Marek. This piece discusses the wide scope of current APRNs' practice and the benefits of their "whole-patient" approach, which makes them especially good at preventative care and managing long term illness. In this sense, though the piece does not specifically say so, APRN practitioner care might be viewed in some ways as a kind of hybrid of what nurses and physicians have traditionally done. Several APRNs are given short but positive profiles, notably rural West Virginia NP Teresa Ritchie and Pittsburgh senior oncology nurse Ann Welsh. In a summary near the beginning, the piece observes that many nurses are
taking on jobs that were once the purview of physicians, like administering chemotherapy and running their own primary-care practices. They are carving new niches in fields such as genetics and computerized patient records, where nurses were once hard to find, and bringing philosophies oriented toward health promotion and problem prevention to geriatric care and case management.
A few later paragraphs give detail as to some of these non-practitioner roles, including nursing innovation in computer-based patient data management, and research by nursing Ph.D's in areas like how genetics affect heart conditions. Commendably, the piece also refers briefly to two critical problems that continue to hamper the profession's progress in these key areas: "lack of respect," as epitomized by the 0.5% of the National Institutes of Health (NIH) (pdf) budget devoted to nursing research, and "abuse by doctors," which the piece notes can "adversely affect care." The piece does not discuss how the lack of respect came about, or what might be done to address it, except to suggest that continued nursing research might have an effect.
However, in tracing the development of APRN clinical practice over the last few decades, the piece at a number of points gives the impression that nurses who are not practitioners--mainly RNs--have been and remain unthinking physician handmaidens, and by implication, that traditional "nursing" is of little importance. Ritchie is quoted as saying that when she started out--which based on her clinic's web site appears to have been roughly 1980--"nurses were not told we could think for ourselves," and "[w]e just did what a doctor planned out for us." We're confident those statements would come as a surprise to many nurses, because since long before 1980, nursing has been a distinct and autonomous science with its own sphere of practice based on constant assessment and intervention to help patients. Though nursing has of course long operated in medicine's shadow, and most nurses did enjoy relatively little authority until recent decades, nurses do have a long history of innovative, independent thinking and patient advocacy, from Florence Nightingale to Lillian Wald and Mary Breckinridge right through to...the nurses of the 1980's. Had the writers consulted a nursing scholar, he or she could have provided more perspective.
The piece then describes the rise of NPs since the 1960's as "the seeds of nurses' liberation from doctors' white coattails," another inaccurate description of traditional nursing practice, though it does seem likely that the proliferation of APRNs has enhanced nursing's overall power to some extent. A few sentences later, we read that "[t]hrough the 1980's, the idea of nurses doing more than just assisting doctors gained acceptance" as patients began seeking out nurses as their primary care providers. This effectively equates what physicians have traditionally done with all significant health care, and it reflects a lack of understanding for what registered nurses do and have traditionally done.
Nurses do not "just assist" physicians. Traditional, non-practitioner RN's are highly skilled, autonomous professionals who help patients heal, teach them to manage or overcome their conditions, monitor them with high-tech equipment and sophisticated assessment skills, and often literally save their lives. In discussing the advanced training of APRNs, the piece does at least note that "[n]urses already have rigorous training," but its focus is overwhelmingly on how education prepares APRNs to do work traditionally done by physicians. In fact, given advances in care technology and health knowledge, the work of the average staff nurse now requires far greater education and skill than it did decades ago, and RN education must continue to keep pace.
Later, in rightly stressing nurses' holistic approach, the piece quotes oncology nurse Welsh as saying that when she started in the 1970's, she was the '"liaison" between physicians and patients. But the piece notes that now Welsh operates with more autonomy in administering chemotherapy and answering patient questions. This implies that the staff nurse "liaison" role had little substance, and that Welsh has now left all that "liaison" stuff behind. The piece is wrong to imply that this role is of little importance, especially given the sometimes poor communications between physicians and patients. Of course, nurses are often the ones who explain to patients what is going on and how to cope with it, and this patient education role can be critical to patient outcomes. Moreover, one of the most important nursing roles is to advocate for patients by lobbying physicians and others for better medical care plans. RNs take a holistic approach to patient recovery and wellbeing. They check patients' medications, and often advocate for more appropriate drugs or doses, for reasons such as toxicity or expense. Nurses also advocate for more or fewer health interventions, better home care, and other care that may be essential for patients' overall health. Without the vital patient advocacy and education roles of nursing, patients might have no professional check on care plans, and might not even understand those plans in the first place. In fact, one of the most dangerous aspects of nurse short-staffing in the managed care era is that there are fewer RNs to advocate for patients. When RNs are replaced by unlicensed technicians who aren't trained to advocate for patients and lack the professional stature to do so effectively, patient outcomes suffer.
There is also a short sidebar entitled "More Nurses Needed," apparently written by Ms. Marek. Commendably, it recites some of the familiar and frightening data as to the RN and nursing faculty shortages, and suggests that even recent increases in the number of nurses may be only temporary, as nurses who came out of retirement during the current poor economy leave again. Calling it "the shortage that won't quit," the item notes the U.S. Health & Human Services Department's estimate that the U.S. will be short about 800,000 nurses by 2020, when baby boomer retirement will be well underway. There isn't much room to discuss long term solutions, but we suggest that one promising one would be accurate media descriptions of traditional nursing.
Moreover, the sidebar never explains what may appear to some readers as a real disconnect with the overall report--if the profiled APRNs are doing so well that they're about to replace physicians, how can there be a nursing crisis? Of course, the answer is that since the advent of the managed care era in the 1990's, the majority of nurses have faced assaults on their autonomy, resources and staffing levels, resulting in widespread nurse burnout, an exacerbation of the shortage, and untold damage to patient care.
The final item in the special report is an essay called "Teaming Up," by physician Bernadine Healy, the former head of the NIH and the American Red Cross. The essay offers a kind of historical perspective on the changes in medicine. It is full of broad, romanticized statements about the physician healers of yesteryear. Though Healy barely refers to the non-physician practitioners discussed in the preceding eight pieces, she does appear to conclude that a kind of "integrated team model" offers the most hope for the future of care, a model that will presumably include all of the different types of practititioners working together, including RNs, though the Mayo Clinic example she cites appeared to involve only "top-notch physicians from all disciplines."
Without further explanation, Dr. Healy states that "the general field of nursing spawned nurse practitioners, allied health therapists, and physician assistants to complement medical expertise in the vastly more complex care of both the healthy and the sick." We thank Dr. Healy for what is clearly intended to be a compliment, but though the physician's assistant (PA) concept appeared at roughly the same time as the NP concept, the development of PAs had virtually nothing to do with nursing; PAs were created by physicians, for physicians, and PAs are not (as a class) nurses. We're also not sure which "allied health therapists" Dr. Healy believes nursing has created. (We can't help but be reminded of the apparent belief among some physicians that any health worker who's not a physician must be a nurse.) Dr. Healy closes with a "timeless" quote from a Cleveland Clinic surgeon, apparently written in 1955, which addresses physicians' faith in colleagues and patients. It centers on an image of a physician who returns to a hospital in the middle of the night, "sleepless and worried about a patient," and who sees at the end of a silent corridor that "in the glow of the desk lamp, the nurse watches over those who sleep or lie lonely and wait behind closed doors," and feels proud that he, the physician, "is part of his patient's faith." We understand what Dr. Healy's getting at, and it's nice that the writer at least noticed the vigilant nurse on duty, but this romantic vision of a nurse sitting at a desk while the physician wrestles with higher spiritual issues strikes us as something less than "timeless" in the managed care era.
On the whole, the special report is a timely and valuable look at the current state of health care practice areas that have traditionally been the work of physicians, and particularly of APRNs' vital and growing contributions in those areas. Its biggest flaw, in our view, is the underlying implication in much of it that the work of those practitioners pretty much covers all that matters in modern health care, and the statements in the Levine and Marek piece that explicitly suggest that nurses have traditionally been unthinking physician subordinates. We think the vast majority of the nation's nurses would beg to differ.
Post your comments on this item on our discussion board or send them to US News and World Report health editor Josh Fischman at JFischman at usnews.com.