Monday, December 29, 2014

Is Less Actually More? Should Your Physician Be A Plumber Or A Violinist?

It seems everywhere you look in health care today, some consultant is telling you that "less" is actually "more".  Less care leads to more quality.  Less expense brings better outcomes.  Nurse practitioners with less training are more cost effective.  Less work hours for residents builds a safer hospital environment.

Never in our entire history have we gotten so much for so little.

A recent article on KevinMD by Arshya Vahabzadeh asks whether shortening medical school is a good idea.  A fairly nuanced piece, a balanced viewpoint is given.  I was particularly interested in the conversation surrounding time-based verse competency-based assessment.  In many ways, I think it is helpful to view the changes overtaking medicine through this lens.  

In the old way of thinking, medicine was an art.  Like learning to play the violin, mastery was a distant mountain with many peaks and valleys.  The climber learned technical skills in the beginning: how to hold the bough, how to read music from the page.  These technical skills, however, were the foundation of knowledge, but not mastery unto itself.

Mastery came when technical skills were married with unfathomable degrees of practice, luck, and passion.  No one in their right mind would tell the musical genius to put down the violin for fear of over practicing.  No one would tell them that less practice is actually more.  And so it is with writing, and singing, and even mathematics.  Technical abilities can only take one so far down the road.  There is something intangible that is only gleaned from exhaustive repetition.  

The new view of medicine is that providers are technicians.  More like plumbers.  Now, I have no problem with plumbers, but once you learn how to change a toilet or unclog a pipe, there are only so many variations.  If a plumber can demonstrate their competency in such fields, there is little need to endure more training.  Hence the training to be a plumber, to date, has been less arduous than that of your typical doctor.  

The educational model for physicians today is becoming more skills based.  We now have teams, checklists, and electronic warnings that allow physicians in training to reach competency quickly.  They become facile at entering data and awaiting a clinical guideline to pop up on their computer screen.  Care plans are less individual and creative, and more standardized.  

If this paradigm becomes reality, who really needs a fourth year of medical school?  Or possibly a third?

But, I bet the average patient will not be so happy as these changes take hold. 

At one's most vulnerable moment expecting a great concerto, a virtuoso, how sad to receive a toilet plunging instead.


Never Again said...

I'm one of those people who expect a doctor to be, well, a doctor, not some pale facsimile of one. I'm sick of uppity "advanced practice" nurses whose self esteem is through the roof. They don't seem to get that somewhere in the alphabet soup behing their name is an "N" for nurse. Not anything like MD, although now they get a doctorate in nursing which makes them...a nurse.

Problem is, no matter how much I protest, demand, wheedle, cajole etc. I am foisted off on an arrogant wannabe nurse. I don't get an downward adjustment to my bill according to the "expert" I get!

I'm not sure how all this came about, but I suspect doctors had a hand in it. Maybe they wanted all the extra money they could get by hiring lesser agents to help with the workload? See more patients in the office without a corresponding workload for themselves? Why is that when I make an appointment to see a DOCTOR I get yet another nurse?

This makes me feel unworthy of the doctor's time no matter how much I pay. I find it faintly disrespectful and sometimes downright devious. Like when I demand a certified a-n-e-s-t-h-e-s-i-o-l-g-i-s-t and get a certifed nurse a-n-e-s-t-h-e-t-i-s-t. I don't like it. What to do?

Anonymous said...

What does the patient do when they are not comfortable with the skill set of the medical staff they are directed. There are times that the PA or RNP do not impress me with their approach or knowledge. Twice in the past 12 months I have dealt with staff that had less knowledge of the reason for the office visit than I had. They demonstrated a very uppity attitude when questioned about their observations.

medicine for real said...

As a doctor AND a violinist I can tell you that it's much harder to be a musician than a doctor, in my opinion, but both fields need sensitive, receptive people, no matter what the training.
BTW, less practice IS more if it is practicing the right way!

Mike, RN said...

Some of the finest docs, PAs, CRNPs, and RNs I've worked with were also capable plumbers, or musicians, or woodworkers, or gardeners, or hunters, or.... By being well rounded individuals, they are better able to relate to their patients as people, and address their problems on an individual basis, as opposed to the cookbook medicine that is so popular today. Medicine is as much art as science, and subject to interpretation in the way it is administered, as well as received.

Anonymous said...

I am replying to "Never Again's" ignorant comment. In order to quire a doctorate degree in nursing you have to have 4 years of undergrad, 2-3 years of graduate (masters level), and then another 2-3 yrs for doctorate. In combined that is almost 10 yrs worth of schooling. So yes that makes them experts in their field. So, who are you to judge an individual who sacrificed so much time and effort in order to achieve a dream? I know many, and I mean many nurses who chose not to go to medical schools for different reasons. Does that make then less educated? Not smart? Horrible providers? No, it makes them people who chose to follow their dreams. "What to do" you ask! Well, stop whining and complaining. Read a little more and you might learn something.

Anonymous said...

Dear Humble Doctor, I read this last night, yet did not see all the comments until today. I am a nurse, have been a nurse for 27 years. I am now studying part time to be a NP. I am a humble person. If I ever get uppity, it is on behalf of what sets foundation for good patient care. I do not know that my cognitive abilities are that to study to have become a doctor. I do know, the fiber of my being is that of a nurse. I do believe different levels of education and the character of a person combined create different nurses and no nurse is a doctor. That said, you you believe, in the less is more avenue, that a NP is less than a doctor? OR is it that a NP is different than a doctor? Do you see there can be need and space for both? Is it that any angst there is is a symptom of angst in the changing world at large? In reading your posts thus far, I feel your love for what you do and for humanity. It would not seem congruent, to me, that you would not value nursing, entry level of with diplomas, ADN's, to BSN's and Advanced Practice Nurses.