Do Doctors Matter?
As we previously reported, the promises of the health reform act far exceed the available resources — implying a large doctor shortage. But do we really need doctors? Or American-trained doctors? Two new studies appearing in Health Affairs find that:
- Allowing nurse anesthetists to work without supervision from a doctor does not put patients at risk.
- Foreign-trained doctors provide the same quality of care as doctors educated in the United States.
See a pattern? Tell me what you think.
John, I see a pattern. And it doesn’t look good.
If I’m reading the study correctly, the foreign born and educated physicians “had significantly lower mortality rates”. That sounds to me like the provide better care then us doctors.
I think I’m going to be sick!
Pretty soon my janitor is going to be starting IV’s… and the dietician is going to be diagnosing and treating diabetes…..
I think it’s critical that we retain a neutral stance on this until the data have truly been analyzed. It is intuitive that greater training leads to greater capability, but it’s not necessarily the case that this greater capability is applicable in the majority of circumstances. And here’s where the statistics start to become interesting.
Let’s say that we have 100 patients, each with hypertension and headache. 99 of them have uncomplicated hypertension. One has pheochromocytoma. All are evaluated by a physician.
100 matched patients are evaluated by a nurse-practitioner.
The hypertension is accurately found to be present in all 100 patients by each clinician. The doctor discovers the pheo. The nurse misses it. Already, this is somewhat of an unlikely scenario since the doctor is likely to miss the pheo, but bear with me anyway…
Now we compare the statistics and find that 99% of the time, the nurse’s skills are equivalent to those of the physician. The conclusion of the study would be that nursing roles should be expanded since from a diagnostic standpoint, they are just as good as physicians (within an acceptable margin of error).
That’s essentially the study that was done with nurse anesthetists.
There could be another study, in which we would take 200 patients with pheo, divide them among MD and RN, and see which group makes the correct diagnosis more frequently. Here, we’d hope that the MD’s do (but note that we don’t know that to be the case). The problem, of course, is that the vast majority of the population has horses and not zebras and that findings involving a sampling of the population at large are likely to indicate that a well trained 8th grader could diagnose hypertension as well as a physician.
One could argue that zebras but not horses require attention by a physician, but this is useless if the zebras aren’t found by the nurse first. Studies of the general population won’t have sufficient power to distinguish whether nurses do as good a job in those with zebras. What I want to know about nurse anesthetists is NOT whether they do as well as MDs in ALL cases, but whether they do as well as MDs when everything goes to hell in the middle of a surgery. Since most patients don’t have complications, it would be unlikely that we could demonstrate that significantly greater or fewer patients have complications with any one clinician type. But if we took all patients with complications as our study population, we might then be able to demonstrate a difference in outcome based on the clinician variable.
All that said, I think we need to plan for the possibility that there might be no outcome difference. If, as Marcy points out, the janitor is starting IVs, and if he does a wonderful caring job that results in perfect IVs every time, then we should consider whether we’re doing the best job teaching our students how to put in IVs.
Soon we will have:
Certified Registered Nurse…
CRNI (internist)
CRNN (neurosurgeon)
CRNO (orthopedist)
CRNG (gastroenterologist)
CRNR (radiologist)
CRNTS (thoracic surgeon)
CRNPS (plastic surgeon)
CRNU (urologist)
You get the drift …
The following is from a New York Times article on foreign-born doctors: http://nyti.ms/9HLkSo
“Graduates of foreign medical schools now make up a quarter of all the practicing doctors in the United States. In order to qualify here, they have to pass a series of rigorous exams and complete residency training. About one-fifth of the foreign-trained doctors in the United States are Americans who studied abroad, often at medical schools in the Caribbean. Most foreign-born doctors in the United States come from India or Pakistan and initially studied medicine in those countries.”
Also from the New York Times “But the results are not as good when the doctor is an American who went to medical school overseas and then returns to practice, the researchers determined. In that situation, patients with heart disease have longer hospital stays and slightly higher death rates.”
So, Best Care: Foreign born and foreign educated; Second Best Care: American Born and American Educated; Worst Care: American Born and foreign educated. Well, one thing about american medicine, you can buy better, but you can’t spend more (actually, you can’t spend nearly as much).
I too found it interesting that Americans who studied abroad did not do as well as foreign-born, foreign-trained physicians.
What is not addressed by such studies is the fact that medical school is only a modest first step in the training of a physician. The quality of residency training is almost certainly a far greater factor. Quality of residency training is highly variable around the world such that IMGs with U.S. residency training may be far different than those with foreign postgraduate training. In addition, though domestic medical schools are highly similar in their output, international medical schools vary widely in the quality of the education and the resources avaiable. The differences between foreign-IMGs and US-IMGs may partly be explained by the quality of the schools attended.
I have worked with many IMGs who did their residency in the US and there is no major difference from US grads.