Every young medical student and resident will quickly learn that they have a lot to learn from nurses. Personally, I think that a resident’s years are made infinitely more smooth and safe with the additional guidance of experienced, patient nurses.
Many outstanding nurses have gently guided my patient care in the correct direction when they felt something was overlooked or could be done better.
“Perhaps 40mg of Lasix would be a good idea, doctor?”
“Do you want me to administer some Lopressor?”
But, as every doctor knows, always expect your nurse to speak his or her mind. This skill seems to go hand-in-hand with nursing. Although I might not agree with everything my nursing colleague believes, I know where he or she stands.
I’ve started to think more and more about this difference between doctors and nurses because of a bill that will be voted on this November. Massachusetts ballot Question 1 creates rules regarding nurse to patient ratios. Over the course of the last several years, the Massachusetts Nurse Association, a local nursing union, has had a goal of creating mandated nurse to patient ratio staffing minimums. Nurse volunteers were mobilized, they gathered signatures, and got a bill on the upcoming ballot. I’ve heard about this issue from television ads, social media, and I know which nurses support the measure. (They wear a button saying so.)
When was the last time we saw physicians mobilize for a wide-sweeping change to our work environment? How often do you notice your physician colleagues speaking publicly about changing our work environment beyond airing complaints on social media?
You may argue that we have organizations who fight for the interests of physicians. This is true. The American College of Emergency Physicians, for instance, has been very active in advocating for fair insurance reimbursement for emergency medical care, despite health insurer efforts to the contrary. Grassroots efforts by physicians to change how we maintain board-certification has gained some of the most traction toward change. How do we translate what has made this effort effective to other areas of physician advocacy?
The physician culture, in general, is very slow to change. Many fully-qualified physicians graduate medical school, pass their USMLE exams and are eligible for residency training each year. But many fail to secure a position because of the lack of positions stemming from a 1997 freeze on federal funds to create more positions. Yet, we have not effectively advocated for the provision of an adequate number of residency positions despite the reported physician shortage. Most of the physicians I’ve spoken to about this are not only not aware of this problem, but many still harbor an attitude that the physician didn’t get a spot because there was something wrong with him, making it harder for him to get a spot later and leaving him hanging in limbo in the meantime.
Some efforts have been made to provide these physicians a pathway to practice as assistant physicians or associate physicians in a handful of states, so that the public can benefit from these highly trained professionals while the physician can continue to learn and hopefully secure a traditional residency pathway to independent practice. These are great changes, but where is the collective voice of support from our physician community?
In the meantime, the organized, unified, and funded voice of nurses has rung loud and clear. Millions of dollars have been donated to help the American Association of Nurse Practitioners advocate for the mass training and independent practice of advanced nurse practitioners (APRN, also known as nurse practitioners). APRN education has changed dramatically as a result. What previously required a minimum number of years of bedside nursing experience, for example, now no longer requires any prior bedside nursing experience. In the past, APRNs attended brick and mortar schools with standardized, intensive bedside training. Now, APRNs can graduate after 18 months of online classroom education followed by as few as 500 hours of clinical experience that the student is required to secure.
This experience, as a result, is not standardized nor does it require APRN’s to provide any direct patient care themselves. The APRN graduate is then expected to begin to provide patient care, without the assistance of a physician (independent practice) in 26 states. This is unfair to the nurses who have sacrificed their time, money and effort to pursue advanced education. It’s unfair to patients who expect that the degree of APRN means the same thing now as it did 10 years ago.
We Need to Care About More Than What Happens in our Own Practice
So what does all of this mean? I may have a great work environment, but if others in my physician community are being asked to work in unsafe conditions without the ability to speak a dissenting opinion without fear of retribution, I need to care about that. It is only a matter of time until that horrible work environment becomes the new normal for everyone.
Nurses have long known this. Advocating for their patients and their work conditions go hand-in-hand with the nursing culture. I saw many nurses taking their own time to get signatures for the Question 1 ballot. Nurses are much more likely to pursue administrative positions. In fact, many advanced nursing degrees include formal education in leveraging social media, how to participate in legislative advocacy, and the business of healthcare. When was the last time we educated our medical students in these areas?
We Need to Educate Ourselves Beyond Continuing Medical Education (CME) Credits
As I alluded to above, there is woefully little education provided to our medical students about the practical side of medicine. I don’t mean getting proper sleep or learning mindfulness. I mean understanding the business of healthcare. If we don’t understand the driving forces in healthcare, we cannot effectively advocate for ourselves or our patients.
We need to seek out our own education on this. Read online sources of information about the healthcare industry and healthcare related business news. Subscribe to social media groups to keep up to date about legislation and issues impacting physicians. Connect with other professionals in healthcare via LinkedIn or Doximity. We need to stay connected to professional peers outside of our immediate place of employment to keep a finger on the pulse of the state of our profession.
Learn about coding and billing by speaking with your billing company or finding online resources. Participate in your local organized medical society, which can be a great resource for information about legislative changes that impact your ability to do your job. Join committees at your local hospital and get to know your peers. Go to legislative conferences hosted by our medical societies.
I know we’re all short on time, but if we don’t get our heads out of the sand, look around, and adjust our practice to the new healthcare world, we’re going to find ourselves obsolete.
We Need to Advocate for Ourselves as Individuals
I am guilty of dealing with changes in my workflow by simply saying, “Just tell me what to do and I’ll do that.” But, as the demands become more frequent and onerous without improvement in the quality of care that I provide my patient, I am starting to say, “Wait, you want me to do what now? Why?”
We need to consider every new request made of us. Does it make patient care better? Does it improve our ability to do our work? If not, why is the change happening? Question the change. Ask your colleagues what they think of the request. Consider opening a dialogue as a group with the administration. If we simply blindly follow everything we’re told to do without a clear benefit to the patient or our work life, then no one will think we prioritize these things.
And We Need to Advocate for Ourselves as a Collective Voice
This is probably where physicians are the weakest. Physicians by nature are independent, critical thinkers. We don’t organize well surrounding issues of advocating for ourselves.
I joke that getting doctors to move in the same direction is like herding cats. That’s because before we’ll sign on to anything, we need the evidence. What are the facts? Where’s the proof? Is the direction being recommended in the right direction? It’s uncommon to see a doctor who will jump onto a bandwagon without considering these factors first. And if the bandwagon is an out-of-the-box idea, it’s an even steeper uphill climb. (Strangely this does not seem to apply to mandates from insurers. Maybe we’re fatalists in this area?)
But, the volume of a collective voice is much louder than the voices of many small groups. How can we create a collective voice when it comes to advocating for ourselves?
One avenue is to utilize the existing infrastructure of organized medicine. Groups as small as your physician accountable care organization to state-level groups like the Massachusetts Medical Society to national groups like the American Medical Association (AMA) are potential outlets of change.
I have heard more and more physicians express dissatisfaction with the goals of larger organizations, like the AMA, because their goals do not align with the needs of the individual physician. The growth of social media has allowed several grassroots groups to gain traction to tackle specific causes. This may be an outlet if you find organized medicine groups to be less effective for your needs.
One of the more progressive concepts to help physicians to develop a collective voice is the use of blockchain technology. HPEC is a start-up created by Emergency Medicine physician Leah Houston, MD to harness the power of blockchain to decentralize ownership of information (in this case, your professional information as a physician) and create a virtual physician community. No more updating your credentials with a third-party every year (think CAHQ) so that that information can then be sold to future employers or hospitals looking to credential you.
Blockchain can also create a community of physicians where we can build online consensus surrounding issues relating to the physician workplace. De-identified information about salary, benefits, quality of work environments can now be freely shared with other physicians. This would give back individual physicians the power of information: which employers to avoid, how much a fair wage is for their speciality in their geographic area, what the gender pay gap is in their area. The blockchain community can also create physician consensus regarding what a fair contract should include, what the minimum standard is for supervising advanced practice practitioners, and how many hours of on-call services are safe, to name a few examples.
Physicians may be behind the times in self-advocacy, but it’s better to be late to the party than to not show up at all. We need to empower the next generation of physicians by giving them the tools and guidance on how to speak up for themselves and their patients in order to contribute to the healthcare system.
I still have a lot to learn, but I’m willing to make the effort. Are you?
Dr. Irene Tien is a board-certified Emergency Medicine and Pediatric Emergency Medicine physician who still loves to help patients in the emergency department. She creating a space to connect with patients via her telemedicine service and blog My Doctor Friend.
Dr. Tien is a 2018–2019 Doximity Author.