2005 May 02 Monday
Nurses Could Take Over Many Physician Tasks But Are Slower
Nurses can provide many forms of primary care with adequate quality but they take more time to do it and thereby cancel out much of the cost savings.
“ The findings may be considered controversial by health care professionals and policymakers, as there is a widely held belief that nurses can save physicians’ time and reduce costs,” says lead reviewer Miranda Laurant of Radboud University, Nijmegen in the Netherlands.
The systematic review included 16 studies totaling more than 25,000 patients in the United Kingdom, United States and Canada. The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
In each study, nurses were responsible for one of the following types of care: first contact and ongoing care for general patients; routine management of patients with chronic conditions; or first contact care for patients seeking urgent attention.
In the first two categories, the reviewers found no appreciable differences between doctors and nurses in health outcomes, process of care, resource utilization or cost.
Patients were happier with nurses. Longer consultations seem the likely cause of this effect.
Among urgent-care patients, health outcomes were similar for nurses and doctors. Moreover, nurses tended to provide longer consultations, offer more information, recall patients more frequently and receive higher patient-satisfaction ratings.
But the longer time spent with patients cancelled out the savings from lower salaries of nurses.
Because nurses spent more time with each patient, however, they saw fewer patients per hour. In four of five studies on nurse-led urgent care, lower salary costs were offset by this so-called “lower productivity” and increased use of resources.
Do male nurses spend less time per patient than female nurses? Is there personality type of female nurse that would be just as efficient who would spend less time per patient? Or are the doctors faster because they are smarter on average and can therefore think their way to diagnoses more quickly? For whatever reason(s), those stereotypical rude abrupt doctors are time efficient.
Perhaps in the United States the savings from nurses is greater because (and I'm guessing) the salary gap between doctors and nurses in the US is larger than in Canada or Britain.
“As salary differentials between nurses and doctors may vary from place to place and over time, the net saving to health care services, if any, will be highly context dependent,” note the reviewers.
The single study that investigated the impact of nurses on doctors’ workload confirmed reductions in demand for doctors when nurses responded to patients needing after-hours care. While such substitution may save time for physicians, note the authors, it is also possible that doctors’ workloads may remain unchanged either because there was previously unmet need or because nurses generate demand for care where previously there was none.
If automated devices and advances in testing technologies can serve up more accurate diagnoses more quickly will people continue to demand just as much face-to-face time with physicians?
Caveats, caveats, caveats:
Laurant cautions, however, that many of the studies had methodological limitations, and follow-ups of less than one year left long-term health outcomes unclear. In addition, most studies included only a few nurses, so the findings may reflect personal variations rather than broad trends.
This study is interesting because health care costs continue to grow more rapidly than the economy as a whole. Shifting more responsibility onto nurses might not help. Researchers need to discover why nurses take more time with patients. Is it because they like spending time with patients? Or because they don't want to be rude by cutting off conversations quickly? Or because they are less efficient at deciding questions to ask to examinations to do? Or because they require more time to think through the information that patients provide?
Also, are there types of illnesses for which nurses are nearly as quick as doctors?
Male nurses spend more time with female patients. Particularly the young ones.
But surely this study is talking about nurse practitioners and not mere nurses. Nurse practitioners as well as Physician Assistants are trained specifically to replace physicians in many office and hospital roles. Generally a physician serves as a backup.
The best nurse will never perform as well as the best physician. But some NPs and PAs perform as well as or better than many physicians. Some people are naturals and some people can't get it right no matter how much training and experience they have.
Just some definitions: "Urgent care" means cuts, factures, ENT, bad flu, mumps - the kind of things that don't require hospitalisation but warrant a visit to a doc - maybe a couple of stiches, a tetanus shot and a day or two off work. Contrast that with "emergency medicine" - car accidents, severed limbs, gun shot wounds, blood & gore, crash carts, machines that go beep, flashing lights etc.
If differences were gender based, I'd expect doctors who are female to also spend more time with patients than do male doctors. I'm not saying that's not the case - I'd don't know one way or the other.
I would not assume the difference between nurse and doctor salaries is larger in the US. Many, many nurses leave Canada for the US just as doctors do because the supply and demand curves for nurses in the US keeps nurse salaries high. Whereas, here in Canada, the legislature removes such trifling market influences to protect us from the greed of all those evil nurses.
Assuming the difference in time spent with each patient is an actual trend and not due to the small sample sizes, I can think of any number of hypotheses why doctors would spend less time:
For instance, nurses perform a set of tasks and roles, A, that doctors do. Doctors also perform a disjoint set of tasks and roles, B, that nurses never do.
When prioritizing their time, doctors may give a higher priority to some of the tasks and roles in B and as a result see it as their duty to spend less time performing A.
Or the education of nurse practitioners may stress the importance of A more than the education of doctors does--which may stress the importance of B instead.
Nurses also perform a set of tasks and roles, C, that doctors never do. I assume many of the tasks in C are time-consuming tasks that do not require the special skills of a doctor. As a result, the indoctrination for nurses and doctors would differ. We may indoctrinate nurses to spend more time 'caring' for patients, and we may indoctrinate doctors to diagnose, treat and move on. After all, from the doctor's perspective, they have nurses and orderlies to handle all that messy caring stuff.
In fact, that last hypothesis reminds me of the difference in cooking styles between my mother and my brother-in-law, the chef. While an exaggeration, it sometimes seems my brother-in-law cannot make dry toast without soiling every utensil, pot and pan in the house. On the other side, it seems my mother's ultimate goal in life is to make a four course meal with a single saucepan and spoon.
At work, my brother-in-law has grown accustomed to having bussers and dishwashers so that the dirty utensils, pots and pans magically re-appear a few minutes later clean and ready to go again. As a result, he just naturally grabs the most appropriate tool for a given task, uses it and moves on.
Seems like this is good news. If costs are the same and the patient's are happier, doesn't this argue for more nurses and less doctors?
While the costs are the same and it is certainly not bad news, having nurses perform more tasks traditionally performed by doctors does not solve the problems we face in a few years. I.E. The subsitution has been implemented largely to reduce costs not to increase patient happiness at the same cost.
"Or because they are less efficient at deciding questions to ask to examinations to do?"
If that's the case, technology can be used to assist nurses with diagnosis and patient records, thereby increasing productivity. Businessweek had a good article along these lines a while ago...
And that would be good news, because I'd bet this country can ramp up the supply of nurses a lot faster than the supply of doctors to go along with potential surges in demand.