What is “Good Enough” to be a Doctor or a Nurse?
Most parts of our country are experiencing major shortages in the number of doctors and nurses required to serve the medical needs of the community. This problem has been exacerbated by the Covid-19 epidemic fueled retirements, as well as the diminished number of foreign doctors and nurses able to enter the country due to immigration policy changes. Even if a substantial number of new schools were to be built in the near future, they lack qualified and interested people to teach newly enrolled students to produce the graduates capable of meeting current needs. There are a number of reasons for the shortage of teachers. One is that not everyone who has the requisite knowledge is capable of transmitting that knowledge to a new student. The petty politics of academic centers, the lower salaries offered, and the difficulty of meeting publication demands combined with the progressive paucity of funding for research, are all elements in the lack of teachers in our institutions.
One offered solution has been the rapid rise of ancillary health care providers, including physician assistants and nurse practitioners, who have a much abridged training time, and often work semi-autonomously from doctors. The general public has accepted them, though their long term impact on the overall quality of health care is still far from settled. Most health care issues in primary care offices are relatively straightforward, and can be dealt with adequately by these new providers. However, the unanswered question is the ability of someone with less training to recognize that a presenting problem is in fact much more complex, and requires greater expertise, than the ancillary provider possesses. The number of people who will experience delay or failure of treatment by someone not capable of this level of problem recognition will ultimately determine if this experiment works. Unfortunately, patient satisfaction scores do not always reflect practitioner competence. All that patients can judge is how well they relate to the person seeing them, how long they had to wait, how professional the person looks, and how clean and modern appearing is the facility in which they are being seen. The public is sadly at the mercy of the profession in determining who is sufficiently competent, along with the people who set the standards for licensing those who practice medicine. Due to a number of external and internal factors, which I will try to now explain, this monitoring system has grown more deficient with time.
Until recently, most schools training doctors and nurses have been non-profit. However, in the past twenty or more years, there has been an explosion of for profit degree granting institutions. The tuition they charge is equal or greater than the corresponding non-profit schools, yet the education they offer is often inferior to their counterparts. In large part, this is due to the almost uniform lack among for profit institutions of having their own clinical staff and hospitals in which to train students. They rather rely on volunteer practitioners from the community to accept students for training in their own offices and community hospitals. I can state from personal experience with two of these institutions that beyond holding a valid license to practice, there is no selection process or monitoring by the for-profits as to the degree or quality of teaching their students receive. This results in a great variability in the amount and quality of instruction given to students. While some try to do their best to offer what is needed, teaching is not their primary mission or responsibility. Others simply use students as a source of cheap labor, assigning them menial tasks without much if any supervision or learning associated. I’ve had students from these programs who were sufficiently motivated to study on their own, and seek out what they needed. They went on to become good to excellent doctors. Others, however, were willing to do the least amount possible, showed little or no initiative, and in the case of one particular individual, were so clearly ignorant of basics, and showing no desire to learn, that I wrote a letter to the dean stating that this student was so deficient that they should be held back and repeat their year of study, or kicked out of the program. They constitute clear and present danger to any future patient, and not be allowed to practice. The school chose instead to graduate this individual, which is when I resigned from teaching any future students from the school. I was also faculty at one of our better medical schools, and periodically had students who I wouldn’t want to see my family members, but their deficiencies were no way close to the one I wanted to flunk.
This brings up the question: how do these less competent students get a license? The answer lies in the pressure that has been placed on the various accrediting bodies to lower the bar for passing in order to have greater numbers graduate. You know what they call the person who graduates at the bottom of the class? Doctor or nurse! The patients are never privy to the results of test scores. (Truth be told, those with the best scores don’t always turn out to be the best doctors.)The best they can do is research where the person gained their education, and if they are certified by their accrediting specialties. Even that has changed over time. When I took my internal medicine boards, only half the examinees ever passed, as being accredited demonstrated a higher standard of competence that just having finished school. Now, the pass rate on those same boards, following lawsuits by those who failed them, is up to 95 %. We have all become above average.
Doctors are rightfully accused of failing to police their own ranks, weeding out those who should not be allowed to practice. Here again, the legal profession has stepped in, and made any kind of restriction on the practice of those felt to be less than competent just about impossible. If you have been given a license to practice, in today’s world, it’s just about impossible to keep you off the staff of any given hospital, unless you have been convicted of a crime, abusing drugs, or sexual impropriety. You have to establish a record of killing or injuring any number of patients (greater than the expected number of treatment failures for a given disease) before your privileges can be revoked. For the rare few for whom this occurs, they can often be found somewhere in an area so desperate to get medical assistance that their prior records never get revealed.
If it comes to us, or our families, we want the best, most competent person taking care of us. If you came to my hospital, and asked me who those people are, I could tell you. So could the nurses in the ER or the OR. However, if I were in a medical community I didn’t know, I would be in the same boat you are. I would likely call the closest academic center or large hospital, ask to speak to the charge nurse in ER or OR, and ask them who they want taking care of their family. Despite all the technological advances, medicine is still as much an art as it is a science. Subjectivity cannot be completely eliminated. But the debate over which is better; having smaller number of truly competent individuals versus larger numbers of less than competent ones so more people can be treated, should be long, thoughtful, open, with all stakeholders, including patients, involved. My personal feeling is that medical practitioners, just like pilots, should not be graded on the curve. You either know it or you don’t. The difficulty lies in agreement as to where to draw the line.