Hospital Admissions: Who Needs Doctors? by Steve Mussey MD

2015-10-27Doctr

Sometime this summer, a large non-profit community hospital began something new and terrifying: It delegated medical admissions to Nurse Practitioners and Physician Assistants.

Yes, sick patients in the ER who need admitting to the hospital are now being admitted and cared for by non-Physicians.

The hospital is not located in some under-served community. In fact, the region is doing very well economically.

Pause. Let me repeat that again…

Nurse Practitioners and Physician Assistants are now admitting and managing medical admissions.

This includes complex patients admitted from the ER to the Intensive Care Unit.

We’ve been reassured: “A physician is supervising the NP’s and PA’s.”

Hmmm… we know what that means…

So… What’s the problem?

Physicians spend four years of medical school, moving on to intensive internships and several years of residency.

For most reputable hospitals, the final privilege of admitting patients only occurs after successfully completing a residency and Board Certification.

Many of us look back at our ignorance in early Internship and tremble. There is no substitute for years of experience and bookwork.

Years later, hospital care has gotten more difficult. For even seasoned and knowledgeable doctors, the task is challenging.

In fact, every year, the challenge grows.

Now, though, you don’t even have to be a doctor. As the difficulty increases, we reduce the required skills for the job.

Does this make sense?

Teachers in medical school often told us: You only diagnose what you know. If you don’t know much, you will diagnose it wrong.

Fortunately, even a healthcare provider with limited knowledge can blunder ahead for a while and seem okay.

But, then….there are the tough cases.

There are the cases where the initial ER doctor (or ER Physician Assistant) completely blows the assessment.

These are patients with a care team all charging in one direction, the wrong direction, until someone re-examines the case and says: “WAIT!!! We need to change plans!”

It is not an easy thing to do. It takes experience, courage and an excellent knowledge base.

Rarely is that someone the NP or PA.

Sometimes, one physician consultant has to tell another physician consultant: “I think you are wrong. This is why…..”

Again, that person is almost never the NP or PA.

Taking care of medical admissions is one of the toughest jobs in medicine.

Why are we delegating this to those with lesser knowledge and experience?

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  14 comments for “Hospital Admissions: Who Needs Doctors? by Steve Mussey MD

  1. mamadoc
    September 23, 2015 at 10:42 pm

    My hospital shouldered out all the physicians in town. My group was the last hold out, and when we left they hired another hospitalist to replace us who lasted 6 months. Now they’re trying to care for inpatients with 2 overworked hospitalists and an army of midlevels, most of whom are not very good. The same place has been allowing midlevels to admit from the ER for some time. Discharge summaries arrive 2-3 weeks after the patient goes home, dictated by yet another midlevel who was generally not involved with the care of the patient. When family members are there I have to bird dog everything as everything is protocol driven, whether that is the right thing for the patient or not. I have had a family member nearly die as a result of an inappropriate drug being given because it was “in the protocol.” Sorry guys and gals, just NOT impressed. At all.

  2. Mike C.
    September 23, 2015 at 5:50 pm

    Amen! I have NO issues withy PA’s or NP’s – we use them as a part of our teams in the wards AND ICU. But I am frequently told that I am abrasive or rude because I’m quick to say “Hold on! Wrong direction folks!” Or “Um, you were clearly wrong, and here is why…”

    Too much thin skin these days.

  3. Richard Branson, PA
    September 20, 2015 at 1:35 pm

    I’ve been in practice 37 years. I, too, would like you to provide any objective research that supports your position. In point of fact, there are none. Over and over, PAs have been shown to do very good work.
    I did ortho-surgery for 15 years handling the majority of all of the work-ups, pre-surgical and post-surgical management and doing 90% of each surgery. I was trained, one-on-one, by a Harvard educated, Mass General Hosp. trained surgeon.
    I have done years of Emergency Medicine an it was there that I concluded that the majority of patients in the ED shouldn’t have been there . . . had somebody been paying attention.
    I now do multi-system disease management from my own clinic for the past seven years. I’m a preferred provider for some Medicare replacement programs because I do a better job than some physician venues for these complicated patients.
    My job is to provide the best quality care I can. It is not to trash my colleagues.

    • Steve O'
      September 20, 2015 at 7:58 pm

      And?

  4. Dave Mittman, PA,
    September 20, 2015 at 11:21 am

    Not going to get in a pissing contest with you but PAs and I presume NPs have been doing this for years across America. Admitting from the ER at many of the best teaching hospitals in NYC.
    There are some really good PAs with years of experience. I doubt you have met them. This attack is unwarranted unless you have some studies to back up your negativity.
    Dave

    • Steve O'
      September 20, 2015 at 8:00 pm

      If here’s where it starts, where does it end? There are some extremely bright and talented EMT’s who could provide medical care to patients. Why are we preventing them from having prescribing rights?

      • Fred powell
        September 20, 2015 at 10:09 pm

        I agree, there is no study that supports not giving them prescribing rights. Turn ’em loose. After all, some of them have been EMTs for 37 years, and that makes them far better at delivering care than a physician.

  5. Vardoc
    September 20, 2015 at 10:41 am

    This happens because we have allowed it to, tiny increments at a time. The time to reclaim the hill is now.

  6. fred powell
    September 20, 2015 at 10:21 am

    It’s time for physicians to go to law school so we can review these cases, and help deliver justice to those who are damaged by a system that no longer strives to provide the best care, just the least expensive. Everybody and their brother practices medicine now. People who never took a class at a medical school are allowed a “Dr” title and practice medicine.

  7. Steve O'
    September 20, 2015 at 8:30 am

    10-4, Steve, and that’s a big J18 comin’ atya.
    It’s even scarier than having a NP/PA attending on the wards. What’s been brewing for years is the “guideline” approach to hospital care. Someone comes in with a cough and fever, and you run down the computer checklist on the EMR, and up pops J18 on the screen.
    In ten days or so, that means “Pneumonia, unspecified organism” and the machine orders the tests – can’t have a pneumonia without a chest x-ray, canya? – and up comes the checklist for the orders and two-day admission. Or one day. Zing! goes the pharmacy app, and out comes the order for the discount cephalosporin-du-jour. Diabetes? Sliding scale. Hypoxia? Nasal cannula.
    Anybody can attend on the wards, now – I’m waiting for the NP/PA’s to start howling when the RN’s admit to the wards. Or the EMT’s.
    Now that medicine is a bureaucratic machine, you start to treat the patient, and if they fall off the conveyor belt – who was to suspect? ARDS? COP? Who remembers those obscure things? They aren’t on the checklist. Besides, 90% of infectious-bacterial-pneumonia-looking-things ARE infectious bacterial pneumonia. The other cases – who could have known? It’s just nature’s way.
    We are in the wayback machine, and the answers to coding are – J18, or some other damn thing.
    Skilled diagnosis is a REVENUE LOSER for the hospital, and the insurance company. We’re rewinding to the days of “nature is taking its course.” Reduced training and experience at the bedside allows for the big shrug, the “more-of-the-same,” switch the antibiotic, up the oxygen, and still the patient gets worse. Oh, well. “It’s nature’s way….”
    The damnedest thing is, the Third-World countries are struggling to get good medicine – doctors not pharmacists, hospitals not clinics, obstetricians not doulas. In African countries, 40% of babies are born in hospitals – not real good hospitals, but hospitals nevertheless. Because the moms are simply illiterate perhaps, but not stupid.
    We are skipping down Fantasy Highway, where the Magic Electronic Wizard will tell you what to do. And it’s easy doing anything for which you don’t catch the blame for failure.
    Ask your doctor…..wait, what’s a DOCTOR?

  8. Ed
    September 20, 2015 at 8:08 am

    Wow. Where to begin?
    Disclaimer: I have been a PA for 35 years. 15 yrs surgery house staff, 10 years private IM practice with 2 MDs, 10 yrs university hospital based Interventional radiology practice.

    It would be helpful if you could identify the system referenced above. I, as a “Senior PA” cannot believe there is no physician oversight… as this is a PA practice requirement, by law, in all 50 states.

    In my community, PAs and NPs provide the bulk of inpatient medical care, as part of a team, overseen by a Physician Hospitalist. The Hospitalists Are usually physicians who trained here and worked with the PA/NP staff throughout their residency.

    While we do not admit patients to our “personal service” (meaning they aren’t admitted listing us as the “attending”), we are often the first “line of defense”…. We see and evaluate the patient, do the work up, admit them to the Hospitalist service, write the orders, formulate a plan, then discuss all the above with the Physician Hospitalist, making changes as necessary. At this point a decision is made to keep the patient on the PA/NP service or, if an “interesting case”, assign the patient to a resident covered service. All admitting H&Ps require co-signature by an attending physician as a matter of hospital policy.

    All medicine service patients are rounded on twice per day by the PA/NP, and once or twice by the physician, usually accompanied by the covering staff. On-going care, discharge planning, consults, testing, etc are reviewed and implemented daily.

    The ICU, SICU, Peds services run a bit differently, but the basics are similar.

    The ED is a whole ‘nother story

    This system has worked in our community (upstate NY) since the early 1970’s.

    And I agree, taking care of medical admissions is one of the toughest, most challenging jobs in medicine. I often reflect on the fact that patients who were admitted for a week years ago, now go home in 24-48 hours. Really sick patients who, years ago, required ICU admission, are now cared for on the floor. And our current ICU patients never would have survived Long enough to get there….

    Onward…..

    Your statement “We were assured a Physician is supervising…. Hmmm… We know what that means.”….

    I don’t, please explain……

    I, for one, cannot believe the hospital system itself, or at least their lawyers, would accept the perceived liability risk.

    Regarding your statement on consultants telling another physician “You are wrong, here’s why….”

    I work on a consulting service (IR)…. I take several calls a day from referrers to “discuss cases”…. Other PAs, NPs, and, yes, physicians. I’m generally easy to get ahold of, I actually return calls and pages, and the referrers know if I can’t answer their question, I will either discuss it with the IR physician and get back to them, or hand the phone to the IR Doctor to speak directly with the referrer.

    This system works for us. Most of the PAs I know work under similar circumstances, with minor variation.

    As a reminder, PAs are comfortable with collaborative, supervised practice. We are the original “team player”. Most of us recognize and know the limits of our knowledge. It is comforting to know I can turn to “my physician” for information and advice as needed. It is gratifying to know “my physician” and our patients entrust me with their health care.

    This is team practice.

    As an aside, the label “Assistant” does not accurately reflect our working relationship with physicians. If you’ve been In practice long enough (mid-1960’s), recall our original title was “Physician Associate”… A much more accurate descriptor.

    So, do I now have to dust off my flack vest and helmet?

    • Steve O'
      September 20, 2015 at 8:42 am

      That’s a big ‘negatory’ for the flak vest and helmet. “Divide and rule,” said Uncle Joe Stalin. The whole fandango is set up to make it look like physicians VERSUS PA’s, nurse practitioners VERSUS -XYZ. I betcha they do get privileges for EMT’s, just to broaden the fight.
      A lawyer is someone who gets two folks to strip down and fight – and then just steals their clothes.
      It’s NOT-NOT-NOT about the title after the name. It’s about running the job. And the guys running the job are two time-zones away, with their feet on their desk, running performance reports.
      THAT’S the center of the badness. Don’t get tricked.

    • Steve O'
      September 20, 2015 at 8:54 am

      PS:

      I have been a PA for 35 years. 15 yrs surgery house staff, 10 years private IM practice with 2 MDs, 10 yrs university hospital based Interventional radiology practice.

      You would be the go-to I’d call to ask – hey, can you come look at this lady and tell me what it takes to do renal vein sampling? Because you are part of the IR team and I’d expect you to know your stuff. You’re from the Old World of Medicine, that’s going away….
      The problem is, the CPA’s read your line of experience, and say – hey, how much do we PAY this guy? Can’t we get a newbie out of PA school to do the same thing? Ha.
      A friend of mine worked on the carrier Ranger, and saw a new-mint Ensign out of the Naval Academy decide to “help” the Chief Warrant Officer in charge of propulsion. After all, he outranked the old fellow, and had new and fresh ideas.
      The warrant officer interrupted his “instruction” for a minute, picked up the phone, and called…

      “Warrant Officer Jones for Admiral Smith please…..Fred! Hi! Yeah, Mildred’s fine…you got a few minutes to stop by the engine room? Okay, see you…”
      They scraped the ensign off the floor and sat him down to wait for Admiral Smith to “help him instruct the CWO.” Turned out, the Admiral hardly spoke to the Warrant Officer, but did “help” the ensign quite a bit. Now THAT’S teamwork.

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