Thursday, February 19, 2009

Performing procedures: Who is capable and how should we pay?

A recent article in the British Medical Journal reported on a comparison between physicians and nurses performing endoscopy in the UK.[1] They specifically looked at “upper endoscopy” (esophago-gastro-duodenoscopy) and flexible sigmoidoscopy, not full colonoscopy which has largely replaced flexible sigmoidoscopy as a screening tool. Their conclusions show that there were no differences in outcomes at 1 day, 1 month, or 1 year in the two populations, and that the patients of the nurses indicated greater satisfaction, particularly with the teaching and explanation that they received. This study is consistent with the findings of one published in 1994 in the New England Journal of Medicine by William Maule.[2] Nursing journals and other advocates have pointed to the latest study as indicating that nurses are, or can be, as “good as” doctors[3]; certainly within the limits of the study it does provide such evidence. The editorial accompanying the BMJ article discusses many of the limitations of the study, which I will not go into here, except to say that none of them particularly indicate that nurses trained to do endoscopy do not perform as well as physicians.[4]

I don’t doubt that this is encouraging to nurses, and to nurse educators, who have frequently been disparaged by implications that their education and training did not provide them with the background to perform as well as physicians. However, the important point here is not a nurse/doctor one, but rather the fact that endoscopy, like many medical procedures, is essentially a psychomotor skill, which should be able to be successfully taught to anyone who is moderately intelligent and moderately dexterous. In Britain, they have taught this skill to a large number of nurses, who apparently do it very well, as did the nurses in the US reported upon by Maule 15 years ago. But why should such training be limited to nurses? It is obvious that many procedures, including endoscopy, require significantly less psychomotor skill (and probably knowledge) than complex automobile mechanics, such as, say, rebuilding a transmission. Yet our automobile mechanics, even transmission specialists, while well trained, are not required to even attend college, not to mention receiving education and training as rigorous as nursing or medical school. Not to mention the 4 years of college, 4 years of medical school, 3 years of internal medicine residency, and 2 years of gastroenterology fellowship that are required in the US for a physician to become a GI specialist, the primary group doing endoscopy. For those who wish to note that working on a car is less serious than working on a person, I suggest that there is likely much greater risk to the health of the people riding in a car with a poorly rebuilt transmission or other major mechanical work than from a poorly done colonoscopy.

It seems obvious that adequate – even excellent – training could be received by those attending a two-year community college course, comparable to those training our radiology and laboratory technicians. A well-trained technician doing 10 or 20 endoscopic procedures a day would be very good indeed, and would free the well-trained gastroenterologist to make the complex medical decisions that do require a great deal of medical knowledge, skill and experience rather than spend their time performing relatively simple procedures. So why don’t we do it that way? Why do superbly educated gastroenterologic physicians choose to spend their time doing these procedures?

The answer, of course, is money, and the perverted, inappropriate and nonsensical way that we reimburse for health care in this country, in which the value assigned to procedures of any kind far exceeds that assigned to thinking and caring and talking and decision making (so-called “evaluation and management”, or E&M, care). In the US system of assigning value to different numeric codes, representing the work done for a patient, E&M “codes” are routinely, and absurdly, assigned a lower number of “relative value units” (RVUs) and thus reimbursed at much lower rate than procedural “codes”. For example, for approximately 30 minutes spent by a physician doing a visit with an established patient Medicare (2007) would pay $94.20, while the payment for a colonoscopy would be $203 and for a cataract removal, $670! This does not just apply to major surgical procedures, or even relatively large non-surgical procedures such as endoscopy. A physician can collect more money for cleaning the wax from a person’s ears (a procedure!) than for the entire well-person visit! Spending 5 minutes wrapping a gel-infused elastic bandage (“Unna’s boot”) around a foot with an ulcer on a person with diabetes will pay several times more than the entire visit listening to, examining, educating, and prescribing treatment for the patient. What utter nonsense!

The most important point made about the article in BMJ is a relatively minor sentence in the editorial: “Nurse led services in the United Kingdom have been encouraged by government policy, a shortage of doctors, a willingness of nurses to adopt expanded roles, and a salaried NHS workforce where professionals re not in competition for income from patients” (my emphasis). This is the heart of the matter. Where absurd reimbursement systems are not driving inappropriate use of resources, incenting highly trained physicians to do what could be done by nurses or, as I suggest, by well-trained technicians, we could actually decide what kind of care should be done by whom, and how much time should be spent on it, by what was in the best interest of people’s health.

[1] Williams J, Russell I, Durai D, et. al., “Effectiveness of nurse delivered endoscopy: findings from randomized mult-institution nurse endoscopy trial (MINuET), BMJ 2009;338:b231
[2] Maule WF, Screening for Colorectal Cancer by Nurse Endoscopists, NEJM Jan201994;330(3):183-87.
[3] Lomas C, “Endoscopy nurses 'equal' doctors”,, Feb 16, 2009
[4] Norton C, Grieve A, Vance M, Editorial: Nurse-delivered colonoscopy, BMJ 2009;338:a3049

1 comment:

Lady.Dr. said...

Usually, I won't pass up a chance to berate docs for being greedy, but I feel obligated to point out a few items. When I did my residency we learned to do both upper and lower Endoscopy. This taught me a healthy level of respect for people who do a lot and who do them well. First of all, some people have a real (seemingly innate) knack for these procedures. It is correct that even if it's not immediately easy for a practitioner, these are skills that can be learned. You should take into account though, that it's just as important to know what you're seeing and the significance it does or doesn't have. Early lesions and subtle changes are easily missed by the less-experienced eye. The decisions to biopsy or not; to snare or not; to excise or not; to refer to a surgeon or not; as well as plans for future care or surveillance--these are important and made better by smart people with more experience. The GI people to whom I refer my friends and family as well as patients are people who spent two or three years doing LOTS of these procedures, learning at the feet of dozens of experts. Where in the training of any other practitioner would this happen?

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