The doctor shortage is real and most acute in certain specialties, like family medicine, internal medicine, and pediatrics. There are various reasons for this. Economics of course-these specialties pay less that others. But over the course of the past 7 years under the ACA the bureaucratic and regulatory burden that has been placed on office-based primary care doctors has become so onerous that many are retiring early and fewer students are willing to enter those areas of medicine.
To counter this graduate schools are cranking out ever-increasing numbers of ‘mid-level providers’—physicians’ assistants and nurse practitioners. As I’ve mentioned previously, these providers can do an excellent job in certain situations, but they don’t have the breadth and scope of knowledge a physician has. Another trend of Obama era medicine was the development of ‘best practices’, ‘core measures’, and various diagnostic and therapeutic algorithms. The alleged purpose was to identify the most appropriate approach to various illnesses and presenting complaints and to create a checkbox system of treatment. Financial penalties were instituted against providers and hospitals for non-compliance.
My own suspicion was that CMS wanted to create a centralized system for delivering health care that did not rely upon physicians to administer it. A mid-level could use the guidelines and get it right for something like 85% of the people 85% of the time. Population medicine was the focus of the physicians and politicians working for the Obama CMS—and much of the paperwork being required of office-based doctors is providing data on treatments and outcomes to generate more algorithms. Not all of this is bad. Some useful information will be gleaned and some more effective or efficient or affordable treatments will be developed. It is not, though, the type of practice doctors of my generation were taught. We were taught to study the evidence and then use our clinical skills to tailor our therapies and diagnostic evaluations for the benefit of individual patients.
An example of check box medicine run amok is the core measure for the treatment of sepsis. Briefly, sepsis is a condition of systemic infection with abnormal vital signs and evidence of failure in one or more organ systems. It has a high mortality rate, especially if not diagnosed early and treated aggressively. As part of the core measure for sepsis, patients have to have lactic acid levels drawn and repeated. This value is used to determine whether or not sepsis is present, and if so, to what degree. Unfortunately many other conditions besides sepsis can cause an elevated lactic acid level.
For ‘severe sepsis’, defined by the CMS as a lactic acid level greater than 4, the patient is supposed to be given a 30 cc per kg bolus of saline IV. Regardless of whether or not the patient has another underlying condition, like renal failure or congestive heart failure, that would make this fluid bolus dangerous and possibly fatal. If the fluid isn’t given the case falls out of compliance, the doctor and hospital don’t get paid, and this ‘poor performance’ is published on line by the CMS for all to see and few to understand. Even if the physician documents clearly why the fluid is being withheld or the amount modified the case is still considered a fall-out. This absurdity was recently reviewed by the CMS and kept in the protocol.
This sort of governmental interference leads to cynicism among physicians, nurses, and hospital administrators. It would be more honest for the CMS to simply say they don’t want to pay for certain care than to create a bogus protocol that needs to be gamed in order to be compensated. A study was done and published in the New England Journal of Medicine a year or so ago in which the authors compared the outcomes of patients with sepsis treated either according to protocol or according to clinic judgment. The study found no significant improvement in outcomes among those patients subjected to the protocol. The Obama ‘science administration’ did much to pervert science across its broad spectrum, from the environment to healthcare. Maybe some of this gets fixed over the next few years.