A doctor I've work with in the ER for several years listened intently as I shared my observation that we are increasingly driven by pre-set protocols for nearly every major illness. "It seems that the art of medicine is dying. You guys used to spend time with patients and do focused testing targeting a likely diagnosis. It's looking more and more like paint by number. The workups are predictable, and every complaint has an established pathway. There seems to be virtually no decision making in the initial onslaught of testing and treatment in the ER. . . How do you feel about it?"
"Insulted." He answered without hesitation. He stroked his chin, and looked past me into the distance, thinking for several seconds before continuing. "Now, if you fail in one core measure, you only get $8 instead of $10. So, we are forced to cast a wide net to make sure we don't miss anything on the list. We try more to not be wrong about certain things instead of trying to make sure we get it right." Reimbursement as a driver for decision making is not new, but more and more medical decisions are controlled by non-medical people in faraway government buildings. Money rules. Each new mandate tied to funding dictates what doctors must do if they want to be paid by the government. "It's an insult."
As the new paradigm evolves, the number of decisions made by doctors is rapidly declining. Many decisions are predetermined by mandates and protocols. On the opposite side of the coin, nurses are seeing dramatic increases in autonomy, responsibility, and labor intensity. Consider each briefly:
Autonomy
I'm writing from an ER perspective, where nurses have historically had more autonomy than nurses in other hospital units. We've been able to treat fever and asthma without waiting for a doctor's order for more than two decades. In the past few years, our authority to invoke a wide array of protocols has increased exponentially. Abdominal pain, chest pain, and possible stroke all have protocols in place which allow us to start testing and treatment. In our ER, everyone over 30 who complains of CP gets an EKG immediately on arrival, even if the history strongly suggests an injury or a musculoskeletal problem. If the story even hints at a cardiac origin, we can initiate a protocol for an IV, labs (CBC, CMP, Troponin), CXR, heart monitor, and aspirin. Until this year, we had to get a doctor, PA, or NP to remove a patient from a backboard. Under a new protocol, nurses have the option to remove them ourselves. The list of nursing "order sets" is now up to fifteen different areas of illness and injury ranging from a possible hip fracture to a UTI. We can initiate labs, IVs, EKGs, pertinent x-rays, and, in some cases, order medication. Generally, ordering specific medications remains the physician's last stronghold on authority, but under several protocols (community acquired pneumonia for example), the doctor's antibiotic choices are spelled out in advance.
Responsibility
We have a lot more responsibility. With the shift to protocols, more ongoing evaluation and adjustments to treatment fall to nurses. We've had the responsibility of titrating drips like Cardizem, Nitroglycerin, Fentanyl, Diprivan or Nipride for years, based simply on the patient's clinical response. A sliding scale to treat blood sugar has been around for decades. Then we added an electrolyte replacement protocol, a heparin weight-based protocol, and a DKA insulin protocol where nurses are responsible for timed lab draws, evaluating changes, and adjusting the drip rates according to preset formulas. There are protocols for Baker Acts (FL, involuntary psychiatric hold), restraints, alcohol withdrawal, etc. The sepsis protocol is the most recent arrival, boasting a lengthy flow sheet covering several possible pathways of testing and treatment for potentially septic patients.
Predetermined pathways have spawned panels of orders packaged to hit the system with a single keystroke, introducing a new layer of gate-keeping responsibility. Nurses have to be hypervigilant to ensure that the whole panel is appropriate: "Did you really mean to order a septic workup on the hip fracture in 9?" "Do you want to run the full 2,673 ml fluid bolus on the guy in 14 with CHF?" A single click for large, sometimes unedited, order sets creates a myriad of potentially dangerous possibilities.
Labor intensity
This one is huge. We test, treat, and document more than ever. The doctor needs seconds to order a stroke alert. One little click of the mouse, and the nurse is now saddled with a half hour of labor intensive activity pushed by a timer that starts ticking from the second the order hits the screen. An EKG, cardiac monitor, two large bore IVs, labs, banding the patient for a type and screen, a CT brain, the NIH stroke scale, and a swallow evaluation are passed to the nurse in a single click. The new focus on sepsis adds labs, including two sets of blood cultures and a lactic acid level ("deliver immediately on ice"), and a fluid bolus to a lot of patients who used to be considered minor care. Two years ago, a lactic acid level was virtually unheard of. Now, I may draw ten lactic acid levels during a twelve-hour shift. Most often, the results are predictably insignificant. With the focus on not missing a core measure, even simple patients become labor intensive.
Taking the art of medicine away from doctors has a few pitfalls. Fans of government mandates might argue that forcing medical practitioners to cast a wider net is in the patient's best interest. "Better safe than sorry." The truth is that it's hard to quantify the damage caused by unnecessary invasive testing, injecting contrast, exposure to radiation, etc. A wide net misdirects the focus in many cases, like the patient with epigastric pain who is admitted for observation to rule out an MI. He goes home with his epigastric pain. We confirmed he's not having an MI, but we didn't find his real problem. Unfocused testing creates wasteful busywork and staggering cost increases. For example, a patient sent home on a z-pack after a simple exam last year might easily spend $5,000 wandering along the sepsis maze for two hours before going home with the same diagnosis and medication this year. A paraplegic who has a chronic sacral wound, chronic low blood pressure, and a slightly tachy heart rate might end up in the sepsis line even though he's functioning at his baseline.
In some cases, the mandated pathway causes a reduction in the care it is designed to increase. For example, the new "thirty-minute window" to treat pain from a long bone fracture is circumvented by giving Tylenol or Motrin on the doorstep to make sure we don't miss the cutoff for full funding. In some cases, the patient ends up getting less pain control because the mandate has already been covered. Big brother's oversight has been assuaged, so, at least on paper, mission accomplished. Less rushed, more thoughtful treatment might have netted some Percocet.
An old-school doctor who could have retired years ago still works with us because he enjoys seeing patients. He still leans toward a focused assessment and sensible testing. He still discharges patients home from the ER when it's reasonable to do so. I admire his courage. I wish the money directive would go away so younger doctors would be more like him, taking control, being the artist, and making the sensible decisions they were trained to make. I want them to fight back against the insult.
My old-school doc agreed that physicians have abdicated the throne. "I think the reason is that we don't organize well. It started back in the 80s with managed care. Then there were increases in defensive medicine due to litigation . . ." He reminisced briefly about how medicine used to work. Then he shrugged, shook his head, and smiled a mixture of sadness and bewilderment. "Now? I don't know where it's going. It seems that you still need a person there somewhere to make sure we get it right."
He's right of course. We do still need a person there somewhere. We always will. With mandates and protocols usurping the medical throne, more and more, that "person there somewhere" is the nurse.
