“Practicing At The Top Of Your License” And The “Great” American Healthcare Labor Arbitrage

Follow on the high of your license.

It’s an expression you hear lots as of late as healthcare organizations search to enhance the work expertise of their staff and lift the standard of affected person care, all whereas decreasing prices.

What does it imply to “observe on the high of your license?”

It normally means somebody with much less coaching is enlisted to do work that was beforehand accomplished by somebody with extra coaching.

On the face of it, this notion is irrefutable.

It brings to thoughts a memorable vignette in my undergraduate economics textbook, N. Gregory Mankiw’s Rules of Microeconomics. To introduce the idea of “comparative benefit,” Mankiw requested the introductory economics pupil a provocative query—if NBA star Michael Jordan in his Chicago Bulls prime had been the perfect on the planet at mowing lawns—is there ever a circumstance by which he ought to ever mow his personal garden?

After all not.

Jordan ought to at all times rent a landscaper—as a result of his time was extra useful spent on the basketball courtroom.

In the identical means, extremely skilled healthcare professionals educated to diagnose and handle advanced sickness shouldn’t be burdened with routine duties and documentation necessities whose achievement don’t require their abilities and intellects.

This work might be accomplished by others. Utilizing this logic, many healthcare organizations have added positions to care groups, enabling individuals with superior scientific coaching to deal with work that makes use of that coaching.

Initially, medical practices supplemented physicians with nurse practitioners (NPs) and doctor assistants (PAs).

Earlier than lengthy, this observe led the enterprise individuals who usually drive the construction and group of care started to ask a collection of provocative questions:

If a few of a doctor’s work might be safely handed off to NPs and PAs, can a few of the NPs and PAs work be handed off to registered nurses (RNs)?

If a few of a NP or PA’s work might be safely handed off to RNs, can a few of the RN’s work be handed off to licensed vocational nurses or medical assistants?

And if a few of the RNs job can safely be handed off to licensed vocational nurses (LVN) or medical assistants (MA)—can a few of their work be handed off to neighborhood well being staff or, even, lay individuals with no medical coaching?

The enterprise of American healthcare is consumed with asking these elementary and (sometimes self-serving) questions on who ought to carry out what duties.

With a better proportion of healthcare being delivered by giant consolidated techniques, publicly traded corporations, retail chains, and startups (all targeted on enhancing their backside traces), there may be actual vitality being utilized to lowering labor prices and addressing labor shortages by introducing new roles as a substitute for elevating wages—and healthcare prices.

Therefore all of the gleeful chatter about enabling clinicians to “observe on the high of their license.”

This can be a development inside scientific medication—but in addition inside different allied well being professions, together with dentistry (with the introduction of dental therapists), bodily remedy (with the introduction of bodily remedy techs), and others.

Questionable Underlying Assumptions

All of this deal with labor arbitrage is constructed on the belief that duties might be simply sorted by licensure or coaching with out sacrificing high quality.

This results in an insidious equivalence being developed by which healthcare professionals are seen as potential substitutes for each other.

Vital variations in coaching size and depth are casually being washed away.

However is there a pure restrict to how a lot task-shifting can happen?

At a high-level, these in control of well being techniques and allocating sources will say that advanced sufferers ought to see clinicians with extra coaching.

Appears easy sufficient—however it’s exactly the undefinable nature of a affected person’s situation that usually makes it onerous to know which affected person is greatest suited to what sort of affected person care.

Put one other means, what defines what’s advanced or easy? How a lot do we all know upfront whether or not a affected person would require deep experience?

A affected person with a historical past of a mind tumor who presents with a headache is likely to be triaged and cared for in a different way than a affected person who presents with a headache within the setting of a traumatic harm.

Finally, it’s usually left to an unsupervised clinician to determine themselves whether or not one thing is advanced or easy.

Devoted and motivated clinicians of all sorts get it improper, not out of willful incompetence, however usually out of ignorance, inexperience or simply error.

Complexity usually lies in subtleties invisible to the untrained eye—and never all well being professionals throughout and inside skilled teams are educated equally properly to see these subtleties (in itself a controversial assertion in some organizations).

Which is what’s so vexing about healthcare’s nice labor arbitrage.

Affected person care is being moved round to people with totally different ranges {of professional} coaching with none clearly outlined structure delineating the place and the way sufferers are greatest served (apart from value).

Programs that rely closely on activity shifting (together with ones that I’ve led) usually make investments insufficiently in defining the boundaries of roles and fail to put money into different coaching and sources that allow clinicians to ask for assist after they want it.

Within the absence of such definition and coaching, many organizations are pushing on the higher bounds of what falls on the “high of 1’s license” with none clear or definable restrict.

Consequently, it’s sufferers—whose care is usually imprecisely or clumsily delivered or, worse, unsafe—who’re struggling alongside clinicians who typically really feel underpowered or unsupported in delivering the care {that a} affected person wants.

Obligatory Circumstances

Does this imply that we must always give up making an attempt to make healthcare extra environment friendly and rely solely on sub-specialist physicians to ship care?

After all not.

However it does imply that organizations and advocates who push for brand new roles in affected person care ought to be hyper-vigilant to make sure that—within the rush to decrease the price of care and permit individuals to observe on the “high of their license”—we aren’t irreparably degrading the standard of care by means of a cascade of false equivalences throughout skilled traces.

To the extent attainable, there ought to be clear boundaries delineating what stage and sort of care is acceptable for a person to offer relying on their stage of coaching.

As a result of these boundaries are so tough to outline, there ought to be clear systematic supervision protocols by means of which sufferers are seen by and introduced to extra skilled, extra highly-trained clinicians at each step of the scientific course of (not simply by chart assessment) to make sure that scientific conditions are appropriately sized up on the outset.

Some organizations excel at this type of sorting—however others have but to tackle the onerous work for financial causes and, additionally, as a result of it’s more and more a subject of sensitivity.

{Many professional} teams have more and more targeted on their capability to observe and ship care “independently”—which is to say, with out supervision or oversight from one other clinician.

Whereas I’m supportive of such actions which can be grounded in reaching financial freedom for oneself, I usually imagine none of us ought to be practising actually independently; independence for its personal sake will not be a advantage.

Nice affected person care is the best purpose, not any skilled’s independence.

It’s irrefutable that we ship higher care after we work in groups that harness a broader base of experience and functionality.

And the experience that resides in each class of the well being career is distinct and infrequently non-overlapping.

Our focus ought to be on designing techniques that enable totally different professionals with totally different ranges of coaching to collaborate with others and leverage their distinct experience to contribute meaningfully to affected person care—not solely on driving prices down by pushing work round which will or might not belong within the arms of one other.