From Letters to Numbers…
Today I am pissed off. I’m pissed off at the hierarchy. I’m pissed off that people fight via social media about the security of professions before they fight over health care availability for the underserved.
Today I read a tweet that a Cardiac Nurse Practitioner (NP) in the UK performed a TAVI procedure in England. (Sorry scrabble masters, TAVI is not a word rather an abbreviation for Transcatheter Aortic Valve Implantation, and it is also known as a TAVR) The tweeters celebrated with clapping hands and thumbs-up emojis how great John’s success was with this procedure. Yay, I thought. Great clinicians doing great work for patients… that’s something to celebrate.
And then I noticed that the tweet was taken down. Why? Well, it was replaced with an apology about how the tweet had upset the cardiac community and about how they are looking into clinical governance… basically to see if somebody already had a rule against such brilliance among non-physicians. How could an NP be qualified to be so capable?!? And, what do the comments by cardiologists saying this “isn’t a game” imply? That NPs are playing games when they scrub into to do surgery? Maybe so, since one clinician tweeted back that there are “so many other issues they wouldn’t know how to deal with.” And what did that mean to the rest of the medical world in general if doctors aren’t the only ones to perform such activities? Marilynn Larkin wrote an article for Medscape Medical News, published on June 29, 2023, on the topic. It was even noted that “some say doctors are being exploited.” It’s a lot to unpack.
One person replied to a related tweet by saying that “the ‘old boy(s) club’ culture in medicine needs to end–perhaps breaking up the rigid hierarchies might help? Patient safety is being put at risk by a culture that often seems to be run more for clinical careers than for addressing patient needs.” Then, like other tweets and re-tweets, it broke down into a political stone-throwing affair. Sounds pretty on-brand for social media and the apparent free exchange of ideas… But I digress.
We all want the same things. We want quality care for ourselves and the ones we love, and we want those who work hard and add value to be rewarded and appreciated for their work. But we have a messy healthcare reimbursement system, and something doesn’t jibe.
From where I sit, I see lists of Americans coast to coast waiting to see a cardiologist. According to the American Academy of Family Physicians, the average wait for a cardiology appointment is 26.5 days. This average wait time was based on the AMN/Merritt Hawkins’ 2022 Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates, which only surveys the top 15 major metropolitan areas in the US. In many, many communities outside of these major metropolitan areas, the situation is much more dire. Patients who need to see cardiology in these areas can wait months for an appointment, never get an appointment, or never move on a referral in the first place because there aren’t enough cardiologists to meet the demand. Not enough.
As we learned in Economics 101, these two forces are at play and must be balanced. If the supply is very limited and the demand is high, then cost can become a factor in mitigating that demand. Here we are. If you are a cardiologist with staff salaries (that keep going up due to inflation and staff leaving), insurance premiums to pay, and increasing rent on your space, you may be forced to limit the number of patients who cannot pay. That makes sense from an economics perspective for sure, although the ethics here are challenging. As a cardiologist, you paid for your education, you worked hard for it, and now you need to recover from that spend. Definitely all true. But who takes care of the cardiology needs of the underserved?
So, maybe we need to raise up more physicians. We do, in fact, need to do that. And we also need to pay attention to unnecessary limitations in scope and how they impact public health. Nurse Practitioners have skills that can be used. Not every NP can do a TAVI; not every physician can do a TAVI. The point is that the people who can, should. And we need to switch our gaze from letters to numbers. The letters after the name should matter less than the quantifiable outcomes produced. Individual patient outcomes and public health outcomes are at stake. After all, Glenfield Cardiology’s tweet pointed out that John’s procedure was successful. Plus, adding an NP to the list of providers patients can get care from increases the number of patients who can receive care. Numbers matter more than letters. Results matter more than titles.
Just because someone has a title doesn’t mean they do better. That has been proven repeatedly from Vatican City to your own front door. Here’s the problem with the tweet and the taking down of the tweet. The tweet highlighted the success of one, and yet it cast the fear of upheaval into the professional lives of others. Its takedown reinforces the unwritten protections and untouchable titles that exist in healthcare and slow its progress. Its takedown stirs fear in the greater healthcare community for treading on that territory. We are supposed to tolerate sometimes harmful wait times and respect the hierarchy. After all, it’s for our own good, according to one tweet respondent. All the while, patients suffer, put off care, or give up on the system. Because we stayed quiet precisely when we should have spoken up and helped move the needle.
I have a huge amount of esteem for the many, many physicians I call friends, family, colleagues, and clients. Huge. You play an indispensable role in our lives. And, yet, like any system, we are all better with transparency toward outcomes and without defending the status quo. Sometimes it’s hard to fight human nature. The next generations will surely challenge the status quo, as they have with almost everything else. Let’s embrace it and help find ways for the most qualified to provide care to all so that both the most and least affluent, connected, and well-insured get timely access to care.