Yes, America’s health insurance mess requires repair. Meanwhile, there’s an even more crushing burden on America’s patients and health professionals—the replacement of professionalism by greed, the replacement of genuine professional leaders with pliable greedy ones.
For a long time before the 1980s, nearly all hospital nurses worked 8-hour shifts, getting sign-off before and giving it after, the same for hospital respiratory therapists, custodians, and pharmacists. Then, in the name of “efficiency,” this morphed into 12-hour shifts, not just here and there, but everywhere. When the next shift nurse can’t show up due to a sick child, a 4-hour emergency extension, 12-hour shift becames a 16-hour shift. In a job where you have to think and do physical labor, move patients around, carefully prone them, prop them to listen to chests and bellies, then think about what you need to do about what you just found—how do you do that with equal diligence for each patient for 12 hours, day after day? Is that how the readers of this article spend every working day? How about when you’re working from home? Is the 8-hour workday for everyone else, including outpatient clinic staff, just one giant mistake?
In medicine, a fundamental tenet is that attention to detail saves lives. It’s not just a jingle. Another tenet: The very best medical care delivered is also the simplest—treat all patients the same, the way you’d want to be treated. None of us can do that in these jobs for 12 hours, day after day, even if it’s a 3-day work week some weeks. Twelve hours of this hard work means you can hardly make dinner or help with homework when you get home, and you’re toast. You’re a professional, but you don’t want to read after work about your patient’s complex disease the way 8-hour-per-shift nurses used to do. After a while, you want to find a way out—to be replaced by a special species of marathon runners, able to overlook the aches and pains during the race and focus on its end. But people don’t go into these professions choosing to be that way.
Physicians are no exception. Hospital overnight physician coverage by someone(s) from 5 p.m. to 7 a.m. has always been a given, but the internal medicine hospitalist corporate racket now dominates 24 hours, everywhere, from big cities to small towns. Hospitalists, internists who never, ever want to see an outpatient in a clinic—unlike surgeons, for example—never learned how capably these patients can cope long-term outside despite multiple problems, so when they’re admitted with a worsening, too many hospitalists push for palliative comfort care—death, instead of repair. Too many hospitalists’ goal is their manager’s goal—push patients out early, and their personal goal, the end of the 12-hour, $180 per hour, $2,100 per shift. Hospitalists outside the university centers could be flying in from anywhere without continuity or commitment to that community’s patients. Internal medicine leadership has embraced and sold out to this “efficiency” (greed). The once-great American College of Physicians now counsels hospitalists in its “Endless War on Readmissions” article (readmissions are American patients needing hospital readmission) that “social issues” may be largely to blame and for sicker patients, “offer them … advanced care planning,” code words for “nursing home” or “do not resuscitate.”
With genuine professionals pushed out of leadership at local and national levels, don’t rely on professionalism emerging from the greedy who pushed it aside. But there are two things we can insist on now as administrative changes and executive orders from the Centers for Medicare & Medicaid Services. First, decree that every hospital taking Medicare and Medicaid transition to 8-hour shifts for nurses and other salaried health professionals within nine months. Allow rare emergency and flexibility exceptions. Hospital corporations will scream about manpower, but with the restored 8-hour conditions, proper rotations between shifts, and proper pay, nurses, and others will come flocking back to these reasonable health professions people-helping positions. Next, the decree that professional services payments for every hospital accepting Medicare and Medicaid must be sent to the person who provided the service. If the physician is employed and wants to turn over the check as part of his employment agreement, fine. But some doctors will recognize this empowers setting their own rules, reestablishing professionalism, and giving each patient the care they require, extending when necessary. Outpatient doctors can set their own schedules again and choose to follow their inpatients if desirable.
Neither of these transitions is a silver bullet, but both will help take power from the greedy middlemen and give it to those professionals providing medicine’s priority-ordered duties to patients: Relieve pain, prevent disability, and postpone death.
Bruce L. Davidson is a pulmonary and critical care physician.
