HIERARCHY IS NOT A BAD WORD

The movement by nurse practitioners(NPs) to gain “independent” practice in multiple states is partially steeped in the propaganda that their autonomy is somehow limited by the presence of a hierarchy in medicine that places them in a subservient position which then prevents them from practicing “at the top of their license”–whatever the f**k that means. It’s bulls**t and they know it, but the brainwashing is effective with the mostly male legislators who view the mostly female NPs as “victims” they need to “rescue” from some imagined oppression. In promoting this nonsense, NPs have managed to persuade many legislators, the public and even physicians that a hierarchy in medicine is outdated and no longer warranted. Hogwash.

Why is a hierarchy important? I like the definition from Nandan Khumar Ja, a supply chain specialist (https://www.linkedin.com/pulse/what-hierarchy-importance-organization-nandan-kumar-jha):

Importance of hierarchy in an organization

1.   Accountability: Without an established structure, all level of employees are unable to perform their roles efficiently. Hierarchy establish the protocol that inform everyone within the organization from top to down on how to address issues that affect the company.

2.   Supervision: Every kind of work require supervision. Appointing supervisor for a team is very important to keep the team functioning smoothly. Supervisor is also accountable for his team’s work, he points out and fixes all kinds of flaws before they can have any damaging effect on the outcome.

3.   Discipline: Having established hierarchy within an organization, employees will be discipline naturally since everyone is answerable to someone, discipline and ethics are essential to get things done, especially in a large organization.

4.   Commitment: Commitment plays a vital role to achieve organizational goal, working in a hierarchical organization you are forced to take deadlines more seriously as you are supervised and accountable.

5.   Training: A hierarchy should be designed in a way so that the team lead or manager is more skilled to train their subordinates, as team member will always look up their managers or team lead for their guidance and experience.

6.   Delegation: A hierarchical organization appoint good managers who know how to delegate work according to the skills of his individual team member, and also knows the amount of workload each one can handle. If not the operations would be all over the place, without following a structured pattern.

7.   Team-work: An organization goal cannot be achieved by a single person. A well designed hierarchy gives birth to teamwork among the employees. Employees are happy if they know the organization hierarchy and their position in that structure, they do not have any personal vendetta among themselves or towards the management.

Social hierarchies have existed for hundreds of years, as societies have become more complex. Imagine a civilization or world in which no structure existed–the chaos that would ensue. Besides healthcare, hierarchies also exist in countries, the military, business, law enforcement, politics and more loosely in arts and entertainment(ie: bands). What organizations like the American Association of Nurse Practitioners(AANP) desire specifically is to not only dismantle the entire medical team, but also to remove physicians as the natural leaders. There is no question that hierarchies, when confused with power, can be toxic. So get rid of the leader and the individuals causing the issues. Don’t demolish the entire f***ing team. How is that beneficial for the patient? 

NP lobbies have convinced dimwitted legislators that master’s degrees prepare them to practice medicine equivalent to physicians, particularly primary care physicians. Any physician who has rotated through Internal Medicine, Family Medicine or Pediatrics knows that s**t ain’t easy. Unfortunately, some medical/surgical specialists somehow develop amnesia about their training and seem to think that s**t is easy and that non-physician practitioners(NPPs) can indeed do the same. IM/FM/Peds are specialists who manage and treat the entire human body and all of its systems, not just one system as specialists do. How many of us actually completed reading the entire, gargantuan Harrison’s Book of Internal Medicine, our bible for med school? I know I didn’t. The foundation of all medical and surgical practice is medicine. It is why Dermatologists know to send neonates with fever to the ED. It is why most cardiothoracic surgeons know the same. And why psychiatrists know that a woman of child-bearing years who is pregnant and has abdominal pain must be evaluated for an ectopic pregnancy. Med school and residency drilled that information into our heads over and over and over again so that we understood the fundamentals, regardless of specialty. By the time all physicians complete their training, they are experts in their respective fields because that is what our training ensures. We are not taking care of furniture, we are taking care of human beings.

This is not the case with NP education today, which has deteriorated to the point of being laughable when described as “education”. No standardization, structure or consistency to speak of. I am baffled by the number of institutions, including the Ivy League hospitals, who don’t appropriately screen or vet NPs that they allow into their midst and then lie to patients about them being “specialists” when they have no such formal training. Working alongside a hematologist/oncologist for 6 months does not a NP “specialist” make. It would be more honest to state that the individual is a NP working in hematology/oncology. It does not matter if they were an oncology RN prior to becoming a NP because RNs are not providers, so curriculums are not equivalent or even cumulative with NP programs. As an example, no formal ACCREDITED curriculum exists for NPs in cardiology. What does exist are specialty courses that NPs take related to that sub-specialty, under a recognized specialty(ie: Family Nurse Practitioner, Adult-Geriatric Nurse Practitioner, Pediatric Nurse Practitioner, etc.). 

Duke University has the #1 Family Nurse Practitioner(FNP) and Adult-Geriatric NP program in the U.S. Below is an example of their NP sub-specialties. At the most, three courses are required to become a “sub-specialist”. Remember, this is the number one NP school in the nation. Completion of these courses results in a post-graduate or professional certificate. THEY ARE NOT BOARD CERTIFICATIONS. This would explain why a “cardiology NP” consult in the ED cannot interpret an EKG.

Employers(including physicians) not doing their due diligence will present these individuals as “specialists” to reassure patients who rightly want a physician. Implying that a healthcare professional is a “specialist” in the same vein as a physician, WITHOUT accurately and transparently clarifying their education to patients and instead allowing them to presume wrongly, is a violation of the False Claims Act–that is, lying by omission or implication. It is for this and many other reasons that the foremost expert in a medical specialty, including the primary care specialties, must remain at the head of the medical team.

The AANP and other nursing organizations like to propagate the lie that a hierarchy is a bad thing and is antithetical to the team model. It isn’t. But the unsupervised practice of medicine, formerly known as FPA, is.

Kapu says physicians must accept change. “The key is for all of us to recognize that health care is changing, and old-style hierarchical models are being replaced to put patients, not a single health care profession, at the center of the health care team. We have a shared obligation to modernize these outdated structures and we invite our physician colleagues to join us in achieving this goal for the benefit of our patients.”

F**k change. If Ms. Kapu understood the definition of a medical hierarchy, she would understand the medical expert is always at the head of the medical team–it only makes sense. Nursing has its own hierarchy and nowhere does she mention dismantling that chain of command. Patients have been and always will be at the CENTER of the team. She does what many NPs pushing for the unsupervised practice of medicine do: feign victimhood, claiming that hierarchies in medicine are outdated and oppressive. However, there is never an answer that when the s**t hits the fan, to whom will heads turn? With whom does the buck stop? It is exactly this kind of disorganization, lack of unity and clarity that will get patients killed.

Read between the lines people. What is not said is probably more important than what is said. Remember that the most important goal of a hierarchy is to ensure accountability. The AANP does not want NPs to be accountable for s**t, so they leave that part out of the conversation. They talk about “shared” responsibility, failing to identify how the responsibility is shared, how much and by whom? That phrase alone should be a red flag to physicians and the public that NPs seeking the UPM are trying to finagle out of ownership and responsibility for the patient. Vagueness and opacity is their modus operandi. Because when the dust settles, it will always be the physician holding the bag and the patient paying the price while the NPs skip off into the sunset. If they wanted true “independence” and accountability, they would have no problem doing what CRNAs did in Arizona, ensure the FPA bills include statements that indemnify physicians from being liable for the NPs mistakes. There is a reason that the majority of the UPM(aka FPA) states mandate NPs have a “collaborating” physician. Most legislators who passed these laws did not make this a requirement. The Boards of Registered Nursing(BRNs) and/or the nursing liability companies, like the Nurses Service Organization(NSO), mandated it. Why? Perhaps because they acknowledge that the NPs are, in fact, registered nurses with master’s degrees practicing medicine without a license and that errors and mistakes are not only predictable, they are damn near guaranteed. In what world can anyone with a master’s degree not only practice medicine, but practice it without any supervision by someone actually trained in medicine? That was the impetus of the creation of the DNP/DNAP online degrees. The concept was so preposterous they had to develop a sham s**t “doctorate” degree to lend some kind of credibility to this imbecilic concept. Nursing and medicine are not one and the same(nor were they meant to be); nevertheless,  the AANP still convinced nimrod legislators that they are “basically” the same and even more remarkably, that NPs practice the same as primary care physicians. If I didn’t witness this s**t I would never believe it because it is asinine. Legislators should be ashamed of themselves for endorsing this idiocy.

Here’s the bottom line: Healthy, functional and respectful hierarchies in medicine keep patients safe because it ensures accountability, that identities and roles are clearly delineated, training and supervision of subordinates is expected(again, accountability), structure and organization establish cohesiveness and most importantly, the patient’s safety and care remains front and center. Intentionally disrupting the team for unseemly agendas is diabolical and no one should be sanctioning that s**t.

Hierarchy works well in a stable environment.–Mary Douglas

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