Discover more from Acute Condition
A collection of medical staffing tidbits
It's all kind of related
Almost all of my newsletters start the same way: COVID changed everything. And of all the previously unassailable things that COVID totally changed, the status quo of the medical workforce is perhaps the biggest.
The financial relationship between hospitals and medical schools is getting even more complicated
Hospitals financially support medical schools for a few reasons. Medical schools are prestigious, hospitals get to benefit from having access to a pool of underpaid trainee doctors, and the combined entities can work together on strategic priorities.
Medical schools benefit from the relationship as well. In addition to the prestige and strategic factors, medical schools need contributions to keep the lights on. As a recent STAT News report found, medical school tuition counts for a very low percentage of medical schools’ operating budgets, only 3%. (In comparison, tuition comprises nearly 50% of the budgets of public colleges and universities in the U.S.)
This financial relationship worked fine enough until COVID. To limit transmission and free up overwhelmed staff, many hospitals were forced to cancel elective procedures, a significant source of revenue. With lower margins—and many hospitals tipping over into the red, health systems began reconsidering their contributions to medical schools.
What does this mean? Short term, probably nothing. I would be surprised if hospitals outright stopped funding medical schools, smaller margins notwithstanding. Longer term, I see (some) room for optimism. Medical education in the U.S. has remained much the same for more than 100 years. Maybe it’s time for some updates.
There are revived debates about advanced practice providers
For as long as there have been nurse practitioners and physician assistants, there has been debate over how much these professionals should be permitted to do, with and without the supervision of a physician. But these debates have become louder this month, as New York State expanded the practice capabilities of NPs, and as a Twitter fight started about the difference between MD education and NP/PA education.
Joining 24 other states, New York now allows nurse practitioners to practice without the supervision of a physician. But while NPs and PAs are increasingly able to practice top-of-license, a recent Twitter debate highlighted the challenges in flexing these providers across credential boundaries.
(Unmatched doctors are those who graduated with an MD, but who didn’t get into a residency program and are therefore blocked from taking their next steps toward practicing as fully fledged physicians.)
To spare you from reading all 245 comments (as well as more than 100 quote tweets and just as many subtweets): The arguments were mostly the same. The bulk of comments, mostly from advanced practitioners themselves, argued that nursing education is different enough from MD/PA education that unmatched MDs should not be able to flex into NP programs. Many commenters were okay with the idea of unmatched MDs becoming PAs, however.
At the same time, it’s worth noting, the American Medical Association tightly controls residency spots, creating a bottleneck for new doctors (even as we experience shortages, particularly in some specialist categories and in certain geographies).
(As an outside observer…I believe that NPs and PAs approach things differently, but I would be surprised if the workflow of medical offices and hospitals allows for major differences in practice or thought processes, just as people with DO and MD degrees are trained with different emphases but are functionally interchangeable in the healthcare system. I’m not trying to diminish any of these approaches—my complaint is more with 8 minute appointments than with the various curricula.)
A nurse was indicted for accidentally killing a patient, and another was caught tampering with opioids
Two recent cases, heavily covered in the media, highlighted the dangers of chaos in hospital workflows and the cracks in a credentialing system that is often state-based.
In the first case, a nurse named RaDonda Vaught accidentally pulled a vial of vecuronium, a paralytic, from a cabinet instead of Versed, a sedative. Distracted and busy, Vaught didn’t notice that the drug was a powder instead of the prescribed liquid sedative, and she injected an elderly patient with the paralytic. The patient died before the mistake was caught, and Vaught was criminally tried and found guilty.
The case was unusual in that it was criminally prosecuted, which shook the nursing world. As the AMA put it in a statement:
Health care delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action.
Personally, I blame a dispensing system that puts similarly named, potentially deadly drugs next to commonly used drugs more than I blame Vaught.
A second recent case highlights how state-based nursing boards are often incapable of stopping genuinely unethical nurses from moving state-to-state and avoiding punishment. Jacqueline Brewster, a travel nurse, was recently arrested for allegedly stealing opioids from stored vials and gluing the tops back on. Because the vials were breached by needles of unknown cleanliness, and because Brewster replaced the missing drug with a clear liquid of unknown provenance, patients in several states had to be notified of potential contamination risks.
What keeps this case from being a less quirky Nurse Jackie is that Brewster was licensed in multiple states, allowing her to act as a travel nurse for short-staffed hospitals—and avoid state nursing boards, which don’t communicate well across state lines. The upheaval of COVID certainly exacerbated the potential for unethical nurses to take advantage of the chaos of the system. As one of the co-founders of Verisys, which verifies employment information, told Kaiser Health News, “The system was broken before COVID. It just got more broken during COVID.”
This information shouldn’t be taken as investment advice (obviously), and the opinions expressed are entirely my own, not representative of my employer or anyone else.