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Join Bruce L. Davidson, a pulmonary and critical care physician. We delve into the transformation of health care work conditions, from 8-hour shifts to 12-hour shifts, and how this impacts both health care professionals and patient care. Bruce sheds light on the challenges health care providers face, the rise of hospitalist corporate models, and the blurred lines between professionalism and corporate interests in medicine.

Bruce L. Davidson is a pulmonary and critical care physician.

He discusses the KevinMD article, “Restoring professionalism in health care: How 8-hour shifts and direct payments could make a difference.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Bruce Davidson. He’s a pulmonary and critical care physician. Today’s KevinMD article is titled “Restoring professionalism in health care: How 8-hour shifts and direct payments could make a difference.” Bruce, welcome to the show.

Bruce L. Davidson: Thanks very much for having me, Dr. Pho.

Kevin Pho: So we’ll get into your article a little bit, but just first briefly share your story and journey to where you are today.

Bruce L. Davidson: I do pulmonary critical care and a lot of thrombosis, and I grew up in the Philadelphia area. I did Haverford College, Temple medical school, and I did my training, which had a big impact on me, at the University of Texas Southwestern in Dallas. At the time all the training was at Parkland Hospital, big county hospital, and the Dallas VA.

And they had terrific faculty, and we did a lot of work, and they were very strong on defining what our job was for medicine. The three highest priorities, which are at the end of my article, are, first, relieve pain and breathlessness, second, prevent disability, third, postpone death. And they also said the simplest way to practice is also the very best: you treat everyone the same, the way you’d want to be treated. And they were pretty strict, and all of us who came through that program, I think we’re affected, well affected, we’re trained.

So when people talk to me about what my passion is in medicine, I don’t have passion in medicine. I have passion for some women and certain other things. What I do in medicine is training.

Kevin Pho: All right, so this leads into your KevinMD article. It is titled “Restoring professionalism in health care: How 8-hour shifts and direct payments could make a difference.” So Bruce, tell us what your article is about.

Bruce L. Davidson: Working in ICUs recently, I have noticed an awful change there in terms of how the nurses work. We have excellent nurses still. And during my training, and for so many years up to the year 2000, nurses worked eight hour shifts. They were fit, they were smart, after all they have to do all this physical labor, lifting patients up, moving them around, now they have to prone them if they’re in respiratory failure. And then they’d come and point things out, ask you about things, they’d have to act on things, they’d say, nobody ordered this test and it’s time to repeat it, and you’d have to do that.

Now they’re 12-hour shifts, and especially in ICU where the nursing work is very physical, people get worn out. There’s no one else in the world routinely doing 12-hour shifts, especially if they involve physical and intellectual labor.

So the effect it’s had on the nurses I’ve seen, who’ve been excellent but worked hard to find some other role in the profession or some other profession entirely, is they’re tired. They get home at the end of the day, they’re not going to cook dinner and help their kids with homework. So you’ve moved that whole group of people in that family raising age out of the profession in many instances.

And it’s been replaced with people who are a different kind of person. Some of us can play sports for a while but we need a break. There’s the rare individual who can run a marathon and just blow off all the aches and pains along the way, and we have far too many of them now in the field. Nobody goes into our field of medicine and taking care of people to behave that way, but that’s what’s happened to a lot of nurses, and so many have told me that’s why they’ve left, because they can’t sustain it. And of course we have shortages all over.

So that’s why the first half of the article is saying change it all back to 8 hour shifts by administration. So Centers for Medicare and Medicaid Services: if you take their money, your hospital has to have eight hour nursing shifts.

Kevin Pho: What are some of the reasons that led to the 8 hour to 12 hour shifts? Was it purely saving money, they have to hire fewer staff, is it purely an economic decision? Talk about some of the reasons why we have shifted from 8 hours to 12.

Bruce L. Davidson: Well, I think the things you just enumerated probably explain it. I don’t know, I haven’t been part of hospital administration that made those decisions. But I think this notion of efficiency über alles rules is detrimental to medicine. I mean, in medicine what we know is attention to detail saves lives, not being super efficient.

And the same thing has happened to physicians. I know more about why it happened to physicians this way. I assume nursing is just what you said: you have three cohorts of people to manage and pay their retirement and so on, or you have two cohorts, and they chose two cohorts, two 12-hour cohorts. Short staffing, that didn’t bother them.

Now for physicians, I witnessed what happened. Internal medicine is based on, we don’t operate, we do some procedures in pulmonary, we do bronchoscopy, we insert chest tubes and so on, but it’s primarily thinking, analyzing, fixing, right, and understanding what’s going on with our patient over time.

So in internal medicine, the leadership replaced the previous leadership and fostered hospitalists. And so this famous Dr. Robert Wachter, I forget where he is, maybe San Francisco, and now the head at Michigan, and so on, one after another they came up through the ranks as hospitalists, because those departments make a lot of money.

And think about it, these are internal medicine doctors who never ever ever want to take care of an outpatient. And anyone will tell you who’s taking care of outpatients that over time you learn a lot of medicine through them, and you see how a lot of people with chronic illnesses can cope over long terms. COPD, bad asthma, pulmonary fibrosis that you’ve been able to arrest, or sarcoid that injured their lung, that’s in my specialty. But in every specialty, hell, surgeons see outpatients, they follow them over time, they see them to decide if they’re going to operate on them. But we have this group of internists now who will never see outpatients.

And as a consequence, the American College of Physicians, which has been an internist group, prestigious for a long time, well, it’s now dominated by hospitalists, and the pay of the leadership is all pro-hospitalist. And one of their recent newsletters was entitled The endless war against readmissions. In other words, patients who need to be readmitted because they’re not repaired properly, or because we haven’t optimized how to take care of them, or figured out how to tell them where the end of the line is, it’s a war against them. And that’s the American College of Physicians saying that. And within that article it was recommended that, to stop these sick people, our patients, coming back to the emergency department, you should get them to sign a form that says they’re finished, they won’t come back.

So I mean, that is what’s happened. And I think in both instances, changing shifts in medicine, in hospitals, you’ll need some people covering from 5:00 p.m. to 7 in the morning, and we’ve always had that, and so you hire people to do that. But during the day, having hospitalists, and cutting the numbers of hospitalists who have to round on the floors and take hits from the ER, it’s just become nuts, and it’s fostered by these chairs of internal medicine who we need to replace.

Kevin Pho: So talk about the effect on patients. And you mentioned that health care professionals save lives with attention to detail. So tell us how these changes, whether it’s the 12-hour nursing shifts or the focus on inpatient hospitalists, how in your opinion has that impacted patient care?

Bruce L. Davidson: If the physician who’s been caring for a patient as an outpatient is their inpatient doctor already, that physician, he or she, knows a lot about the patient, the patient understands that they’re concerned about them and that the goal is to fix them and get them out.

Instead we have hospitalists. And unless you’re in a city or in a university system where you have the same doctors over and over, these are so often people from outside who are hired. You don’t know their training. And I’ve encountered several who have only family medicine training and board certification from community hospital settings. Now family medicine is an outpatient specialty primarily, not inpatient, so certainly not internal medicine. And they know how to do things like pediatrics and look after obstetric cases, which we in internal medicine don’t know because we focused on a different area.

So patients encounter doctors like those, who are not from the community, who don’t know them, and at the end of a 12-hour shift they just want to reduce their census and get out of there, because they’ve got to come back the next morning. And they do this seven days in a row. For example, a hospital shift may be from a Monday to Monday or Tuesday to Tuesday. It’s a marathon race. It’s not focused on fixing individual patients.

In terms of nursing, if you can’t look after yourself, or you’re on a mission at the moment to complete three or four 12-hour shifts and get them out of the way so you can get time off, so you can be with your family or get away on some vacation, you’re not focused on getting through the day to day. Now if all you’re doing all day is changing oil and oil filters, that’s all right, but that’s not what we need from nurses.

And that’s not the way nurses used to be. Most physicians, including me, will tell you that during house staff training they learned a heck of a lot that you still remember today from nurses who guided them through stuff that was going wrong with patients that we didn’t recognize, or how to get an IV started and so on.

So today’s nurses, if they’re doing these 12-hour shifts like that and just trying to get to the other side, they are not looking after patients with the detail. And because it is such grueling work that, remember, nobody on the outside does, everybody outside has eight hour shifts, bus drivers, office workers, even people in clinics. So they’re just trying to get to the other side, and the patients see that, and the patients get kicked out prematurely from the hospital, they have to fight to stay. I help plenty of friends or family of friends, interacting for them, and I see it a lot. The nurses I’ve dealt with see it a lot.

And the night shift, Dr. Pho, in ICUs, these are people who are worn out, they’re coming in to work to earn some money, they’re hoping nothing happens, they’re sitting at the computer, they’re not going in checking the patients, because it’s no longer 11 to 7 with a goal, it’s seven to seven, it’s a marathon at which they’re hoping nothing happens.

And for the physicians in small hospitals, they’ll have one physician hospitalist covering the whole inpatient system, so he or she will take hits from the ER, and they’ll have to manage decompensations on the floor, and they’ll have to look after all the stuff that the daytime hospitalists missed because they were too bummed out or burned out.

Kevin Pho: So let’s talk about some of your solutions to each of these issues. Regarding the nursing issue that you brought up, we’re already short staffed, right? And if we go to three cohorts, how are we going to find enough nurses to fill that? And regarding the hospitalists, I’m a primary care internal medicine physician, so I’m acutely aware of the issues that you bring up, and we’re under a lot of pressure from an outpatient standpoint. And I guess my question is, how feasible is it to go back to what it once was, and have outpatient physicians take care of patients in the hospital, when they themselves have increasing bureaucratic burdens to deal with that may not have been present decades ago?

Bruce L. Davidson: Well, let me take the second one first. I certainly do not intend that outpatient physicians have to add to their burden by heading into the hospital to see these people. On the contrary, my solution was to pay the money to the physicians.

So if the physicians themselves start receiving the revenue, perhaps you do, but if you’re part of a system then you won’t, it goes into the people who run it, who pressure you to put that volume on you all day long. And if instead you start receiving the revenue and seeing what it looks like, then you may say, you know what, I don’t need to see people every 20 minutes or every 40 minutes, and I’m going to set aside these hours to look at my outpatients in the hospital. For the current hospitalist, when they see this kind of money they may say, look, if this is what I’m earning versus what I’m getting, number one, I don’t have to work to this extent.

Well, what about shortages? How much of the shortage that we currently have for physicians and nurses is an artifact, is caused by the system? For example, I personally have found it impossible to find outpatient pulmonary medicine slots. I instead have a patient waiting for months to see an outpatient pulmonary physician. But the people who own the hospitals, in some cases UnitedHealthcare owns Optum now, they’ve bought clinics, so they ratchet back the number of appointments, they stop putting physicians in those slots to see them. Instead they hire nurse practitioners, who get paid 85 percent by the insurers but the owners pay them a lot less, and they are willing to see people every 20 minutes, new people every 20 minutes, every 15 minutes, just ratchet the patients through. Because they don’t have the same ethic of attention to detail the way we were trained, and they weren’t trained in pulmonary to look at all the old relevant chest radiographs to figure out what’s going on today.

So there would be adjustment required, certainly. For nurses, I said over nine months I think you would see nurses flood back into the system who could work eight hour shifts, who want to work part-time. And not only the nursing shortage but the quality of nursing would improve, and more people coming out of nursing schools would be looking to work in hospitals instead of for insurance companies going through charts.

Kevin Pho: We’re talking to Bruce Davidson. He’s a pulmonary and critical care physician. Today’s KevinMD article is titled “Restoring professionalism in health care: How 8-hour shifts and direct payments could make a difference.” Bruce, let’s end with some of your take-home messages that you would like to leave with the KevinMD audience.

Bruce L. Davidson: Well, I think we have a dearth of quality leadership in health care right now. The AMA is an enormous disappointment. I’ve held high hopes for them in the past, there’s some good individuals in there, but who passed through as president. The AMA has over $900 million in stocks and bonds according to their tax return. They could launch lawsuits against UnitedHealthcare and other major players for pre-authorization scandals that are going on, but they don’t.

Same problem with the American College of Physicians. I’ve already mentioned how they’ve endorsed hospitalists and systems and their high payment.

And our leadership used to come from the surgeon general of the country. But our surgeon general instead, as the Washington Post reported when he got renominated in 2021, made $2 million working for insurance companies and private companies doing consultations. And he has identified our biggest medical problem in this country as loneliness.

So my message to listeners is, professionalism is not going to come anew from the people who destroyed it and don’t care about it and are chasing money instead. We can do well by doing good, but it’s going to come from people like you, Dr. Pho, who I assume, on your own, without being subsidized by any of these folks, have these programs. And we need to find leaders who will similarly do this.

And my suggestion is, start by making the hospital a better place for patients with eight-hour nursing shifts, and by changing the hospitalist paradigm, and by paying physicians themselves, requiring that they get the money, so they can take charge of their futures and their patients.

Kevin Pho: Bruce, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.