We’re obliged to one of our physician colleagues for bringing to our attention a story that appeared on FayObserver.com. It’s about President Obama’s appointment of Maj. Gen. Patricia D. Horoho to be the Surgeon General for the United States Army.

“The nomination, which must be confirmed by the Senate, includes promotion to the rank of three-star general.

 

The Office of the Surgeon General is in Falls Church, Va. As the senior officer of the U.S. Army Medical Department, the surgeon general provides advice and assistance to the Army secretary and chief of staff on health care matters.

 

Horoho also would serve as commanding general of the U.S. Army Medical Command at Fort Sam Houston at San Antonio.”

Our hearty congratulations go to the good general on her promotion and great career move.  There is only one strange thing about this arrangement.  General Horoho’s medical qualifications are those of a nurse, not a physician.

“Horoho is the Army deputy surgeon general and 23rd chief of the Army Nurse Corps. She has been the leader of more than 9,000 Army nurses in the active Army, Army Reserve and Army National Guard.

 

She would replace Lt. Gen. Eric B. Schoomaker as the Army’s top medical officer. Schoomaker completed his internship and residency in internal medicine at Duke University Medical Center from 1976 to 1978, followed by a fellowship in hematology at Duke in 1979.”

Another colleague kindly provided a link to the Introduction to the U.S. Army Medical Department, which had this to say about the position General Horoho has been nominated to fill:

“With the overseas contingency operations continuing, the spotlight justifiably is on the Army’s medics, evacuation units, surgical teams, and field hospitals.

 

Yet the Army Medical Department is also a seamless chain of care stretching back to fixed hospitals in Europe and the United States, where Soldiers and Families receive state-of-the-art care.

 

Field medical units are under the command of the combatant commanders, because their movements and work must be coordinated with those of fighting forces

 

In contrast, all fixed hospitals (in the U.S. and outside the U.S.) are commanded by the MEDCOM.  The challenges for Army Medicine are (1) How to provide medical leadership for field units while respecting combatant Commander’s “ownership” and (2) How to integrate the work of field and fixed units.

 

Dual-hatted surgeon/commander

 

The AMEDD’s answer is to “dual-hat” the top Army physician [emphasis added, ed.] as both the Army surgeon general and the commanding general of MEDCOM.

 

As The Surgeon General (TSG) of the U.S. Army, this lieutenant general is the medical expert on the Army staff, advising the Secretary of the Army, Army Chief of Staff and other Army leaders and providing guidance to field units.  As commander of the MEDCOM, he actually commands fixed hospitals and other AMEDD commands and agencies.  This dual-hatted role unites in one leader’s hands the duty to develop policy and budgets as TSG and the power to execute them as the MEDCOM Commander.”

Now it’s not the purpose of this post to put down General Horoho in any way.  From her biography she seems like a wonderful person and a solid leader.  And it’s not to claim that there is any wrongdoing involved in her appointment as the Army’s Surgeon General.  After all, in his capacity of Commander-in-Chief of the nation’s military Mr. Obama can probably make up any rules he wants to with respect to the qualifications needed to be appointed military Surgeon General.  No, what’s noteworthy here is our the schizophrenic – if not downright hypocritical – attitude displayed by our political and medical leadership when they talk about “quality” and “qualifications” in healthcare.

First let’s consider the relentless pressure to continually improve and burnish the “quality” and “qualifications” physicians – arguably the single most important type of healthcare provider in the country.

Most physicians in the U.S. are “board certified” in some specialty or another, even if that “specialty” consists of being a generalist in family practice.  Becoming “board certified” means that our doctors have undergone rigorous training: first in medical school, then in a medical residency lasting anywhere between 3-7 years.  They have also passed written examinations that are typically filled with clinical minutia, just to make sure that they were paying attention when it came to the boring (or even irrelevant) details hidden in the far reaches of those medical textbooks.  Preparing for all of this is, of course, incredibly time consuming and expensive.  Board certification exams typically cost several thousands of dollars to take.  Preparing for them by taking courses devoted to cramming costs thousands more.  Extensive travel costs are almost always involved, since the super-secret board exams are almost always given in just a few locations.  But, as originally intended, it was all in the cause of making sure that America’s doctors weren’t schlocks.

Until around 20 years ago, our physicians were trained, board certified, and then released into the wild to practice their craft.  They were expected to undertake continuing medical education (CME) in order to keep up with medical progress, but that was it.  The presumption was that well-trained and carefully chosen individuals with a rigorous work ethic and under the constant threat of medical malpractice lawsuits could be trusted to stay within their own particular zones of clinical competence.

But in the early 1990s questions began to arise in the minds of the various medical specialty boards.  (These boards are not really controlled by practicing physicians but are instead independent non-profit commercial enterprises who sell medical education “studying” materials and specialty certification testing services to clinicians.)  “Could it be,” they asked, “that even more training and testing could be required?”  There was little or no evidence that clinicians were actually practicing incompetently, but neither had all of those specialty boards yet managed to actually maximize their potential revenues.  Even though continuing medical education was already a requirement, why not make board certification expire after 6-10 years, and then require doctors to pay thousands more dollars in training and testing fees?

So that’s exactly what happened.  Specialty boards began to grant certifications that would expire, and therefore and require more and costlier testing in order for physicians to maintain “certified” status.  But beginning in 2006, physicians were dismayed to learn that even this was not enough, as medical specialty boards began to introduce the concept of a continuous, endless “maintenance of certification”.  As described in a 2010 article in Managed Care Magazine:

“At this stage, MOC is more an experiment than a tried and true measure. From 2001 to 2005, all the major medical specialty boards phased in programs that require physicians to update their certification every 6 to 10 years through MOC. Public accountability is a key reason that certifying bodies such as the ABMS have adopted MOC. “We’re seeing a much higher degree of expectations from the public for physician accountability and transparency,” Weiss says.

 

There is more to MOC than physicians merely taking a retest every 5 or 10 years, however. As Weiss explains it, physicians under his organization’s 24 member boards have to jump through a series of hoops in a 10-year cycle to prove them worthy of board certification. They include:

• A fixed number of hours of continuing medical education each year (for example, the American Board of Surgery requires 50 hours yearly)
• Practice performance assessment, called a practice-improvement module, or PIM, which is essentially an audit of patient charts to compare outcomes with peers
• A secure examination late in the cycle

 

Of the 759,000 physicians who hold certificates from ABMS boards, 200,000 are engaged in MOC, according to ABMS. In all, 147 physician specialties have adopted MOC.”

All of this certification stuff matters because it is increasingly the level of qualification that health insurers and our political and medical leaders expect to see in order for physicians to qualify for payment, hospital staff privileges and other basic practice needs.  Of course none of this extra qualification is free to physicians, in either time or monetary terms.  It’s just one more burden society expects them to pay in exchange for the right to evaluate and treat patients, and to make decisions about the allocation and use of medical resources.  Since they’re supposed to be the experts, “the system” has come to insist that physicians know everything about everything in order to maintain their leadership position in healthcare.

Which brings us back to General Horoho.

For some time now, it has been increasingly clear that non-physicians are in the ascendency in the American healthcare system, politically, psychologically and financially.  Indeed, there has been a great deal of pressure – much of it originating from influential sources such as the Obama administration and The New York Times – to place traditional “physician extenders” in the position of operating as completely independent practitioners.  For example, in 2010, The New York Times published an editorial entitled “Who Should Provide Anesthesia Care?”, in which it discussed two studies that found:

“…no significant difference in the quality of care when the anesthetic is delivered by a certified registered nurse anesthetist [CRNA] or by an anesthesiologist.  The studies were paid for by the professional association for the nurses, a potential conflict of interest, but were conducted by researchers at respected organizations.

 

Analysts at the Research Triangle Institute found that there was no evidence of increased deaths or complications in 14 states that had opted out of requiring that a physician (usually an anesthesiologist or the operating surgeon) supervise the nurse anesthetists. The analysts recommended that nurse anesthetists be allowed to work without supervision in all states. Researchers at the Lewin Group judged nurse anesthetists acting without supervision as the most cost-effective way to deliver anesthesia care.”

After noting that California was the latest state of 16 states to legislate freedom from supervision for CRNAs, the editorial continued:

“There is not much difference between the two professions in the amount of training they get in administering and monitoring anesthetics. Where the anesthesiologists have a big advantage is in their much longer and broader medical training that, many doctors say, may better equip them to handle complex cases and the rare emergencies that can develop from anesthesia.

 

From a patient’s point of view, it would seem preferable to have a broadly trained anesthesiologist perform or supervise anesthesia services, but, in truth, the risk is minuscule either way…

 

In the long run, there also could be savings to the health care system if nurses delivered more of the care. It costs more than six times as much to train an anesthesiologist as a nurse anesthetist, and anesthesiologists earn twice as much a year, on average, as the nurses do ($150,000 for nurse anesthetists and $337,000 for anesthesiologists, according to a Rand Corporation analysis). Those costs are absorbed by various institutions and public programs within the health care system. As health reformers seek ways to curb medical spending, they need to consider whether this is a safe place to do it.”

In fact, it appears that CRNAs may now be doing even better financially than the Times allows.  According to CNN Money, many CRNAs are now making more than the average primary care physicians, despite being held to what is presumably a more relaxed standard of care:

“Despite the growing shortage of family doctors in the United States, medical centers last year offered higher salaries and incentives to specialist nurses than to primary care doctors, according to an annual survey of physicians’ salaries.

 

Primary care doctors were offered an average base salary of $173,000 in 2009 compared to an average base salary of $189,000 offered to certified nurse anesthetists, or CRNAs, according to the latest numbers from Merritt Hawkins & Associates, a physician recruiting and consulting firm.

 

And the firm’s projections for 2010 indicate that the average base salary for family physicians will be about $178,000 compared to $186,000 for CRNAs.

 

CRNAs are advanced practice nurses who administer anesthesia to patients. An important distinction between CRNAs and anesthesiologists is that when anesthesia is administered by a nurse anesthetist, it is still recognized as the practice of nursing rather than a practice of medicine.”

With the prospect of a bankrupt healthcare system and potentially massive shortage of physicians looming, it is becoming increasingly fashionable to propose unsupervised and independent practice for nurse practitioners (NPs) and physician assistants PAs) as well.  Roughly 23 states now allow nurse practitioners to practice “independently”, although it is often unclear as to what this really means.  As of April 2011, the Texas legislature had no less than three “independence” bills under consideration, and similar legislation has been proposed in many other states, including Mississippi, Kansas and New Hampshire.  Fans of “practice independence” for NPs California have gone to the trouble of creating a YouTube video that visually equates physician supervision of NPs with the religious practices of the ancient Aztecs, (presumably including ritual human sacrifice.)  A similar path toward physician independence is being sought by at least some physician assistants, many of whom are anxious to change their title to “physician associates” in an effort to command more respect.

The effort to place non-physicians in the forefront of healthcare is being supported by no less illustrious a person than our Commander-in-Chief.  President Obama has publicly stated that: “I have a longstanding bias toward nurses.”, that presumably has  something to do with the fact that, in implied contrast to doctors, “Nurses aren’t in healthcare to get rich, last I checked.”  Less than a year ago he formally thanked the American Nurses Association for its support of the Affordable Care Act (“ObamaCare”) legislation by proclaiming that “nurses are the ‘beating heart’ of the health care system”. Viewed in this light, the promotion of General Horoho is simply a logical step toward moving control of American healthcare from greedy, expensive and unscrupulous physicians toward enlightened, benign and less expensive non-physician providers.

We’re not going to comment in this particular post about who is as good as who medically, or whether handing the medical reins of the country over to non-physician clinicians is a good idea or not.  But the entire notion does raise serious questions about what the devil our medical and political leaders and the American public really want in terms of “quality” and “qualifications”.  The uncomfortable fact is that there seem to be two contradictory alternatives.

If, on one hand, nurses, if NPs and PAs are just as good as physicians when it comes to taking care of patients – or even running the entire Army medical corps – then why is our healthcare system so intent on forcing doctors into ever-higher levels of training, accreditation and certification?  That would mean that the public insists that non-physicians are “good enough”, while requiring still higher standards for doctors.  Doing so is expensive, time-consuming and frankly infuriates a large percentage of physicians who, frankly, resent the time and cost that it represents.  There is no question that intensive certification and re-certification reduces the number of physicians who are available to care for patients.  Given the choice between spending thousands of dollars and months of study time and simply shifting their careers away from clinical care, there is absolutely no question that substantial numbers of physicians are opting for the latter.  This process will accelerate dramatically if and when state medical boards conspire to increase the amount of “certification” time and money required to maintain medical licensure; something that they are currently discussing.

On the other hand, if nurses and PAs really aren’t really as qualified as physicians for many of the duties that they are being asked to take on, we’re looking at a public that is willing to demand one standard of “quality” for physicians, but a lower standard from non-physicians.  If so, this is a textbook example of the power of marketing and public relations, with the demand for nurses and PAs as case managers and clinical care administrators generated by leaders like President Obama.  The relatively lower cost of non-physicians generated the necessary financial incentives, while personal stories contrasting the “selfish” nature of physicians with the skills and selfless nature of nurses and PAs will have allayed whatever medical concerns the public might express.  The lower relative quality of non-physicians isn’t a factor because, well, the public has been led to believe that it’s not.

The downside of this scenario is, of course, that any satisfaction that patients and families might feel is unlikely to survive the first few unsatisfactory encounters.  And with so much medical board profit on the line, there is every chance that the certification “inflation” killing doctors will simply be re-directed toward non-physicians.  As nurses and PAs shell out increasing amounts for MOC expenses over time, their own costs will gradually rise to match those of physicians.  Different medical boards will be selling the need for higher and higher qualifications all over again.  Excessive administrative overhead in healthcare is an ill wind that blows no good.

Of course neither scenario is really good for patients, providers or those of us who have to pay for this system.  Ironically, that’s what makes the bad parts of both of them so likely.