Every Team Needs a Leader

Let me start with the following:

We’ve all heard that the team-based model of health care is the best model of health care. In fact, physicians are frequently chastised for suggesting that anyone on the health care team should be deemed in any way less or more competent than anyone else on the team. Why is this nonsensical?

If you played or watched a team sport, who calls the plays? Does the team pause, take a moment to chat about what’s going on in the game, take a vote on what play they should make next then restart the game? No. The coach and quarterback in football make the calls. The baseball coach decides who’s starting and who’s pitching.  Every effective team has a clear leader, someone who makes the final decision.

Health care teams are the same. They should have a team leader, and that the team leader should be the professional with the most comprehensive medical education, someone with the most experience and training to lead the team to a performance worthy of a championship trophy.

Physicians spend 2 years of post-graduate focused study on biochemistry, physiology, biochemistry followed by 2 years of directed study of clinical medicine, seeing patients, during which they apply what they learned while being directly supervised by a physician.  The number of hours spent at the bedside in this stage of education is around 5,000 hours, conservatively speaking.  

A board-certified physician spends a minimum of another 3 years of directed study in their area of expertise (residency), after which she is deemed competent after consideration of her work by her training director, keeping a log of the patients she sees as well as procedures she does, and by passing 1-2 rigorous exams, which need to be repeated at regular intervals during her career.

By the time a board-certified physician has passed her 3 national medical board examinations and board examination in her speciality, she has the equivalent of at least 15,000 hours of supervised, standardized residency education in medicine and is ready to provide medical care in an unsupervised fashion. 

Nurse practitioner (NP) education, by contrast, is not consistently or rigorously structured. There are several routes to various degrees in nursing, which may or may not include a bachelor’s degree, master’s degree or doctorate (DNP). Nurse practitioners receive their degree after their initial certification in nursing and then may apply for entry directly into a Master’s or Doctorate level educational program without any bedside nursing experience.

In fact, some NP programs require only a minimum of 500 clinical hours during which there is no required structure or oversight. In fact, NPs can simply follow a physician or another NP around for 500 hours and that is sufficient to fulfill their clinical requirement for graduation. This is dramatically fewer clinical experience hours than a new medical school graduate has experienced.  500 shadowing hours are painfully shy of the  15,000 (minimum) hours of directly supervised, standardized training that a fully trained physician experiences.  That trained physician has also achieved competency in a standardized list of procedures and knowledge. NPs have not and do not. NPs are also being graduated and told they are ready for independent, unsupervised practice, which they are certainly not. Many NPs know that they are not ready.

The two fields were created to complement each other and to function as a physician-led team for the betterment of the patient. Nursing experience is not the same as medical school education, yet this is an argument commonly made to advance NP scope of practice.  Bedside experience as a nurse does not equate to medical experience or directly correlate to any ability to practice medicine.  

Physician assistant (PA) education is more standardized, but is an abbreviated version of a medical education.  A PA finishes graduate school in about 27 months, at which point the PA takes a certifying exam and qualifies to start work.  A new board-certified PA has finished fewer hours of clinical education than a medical school graduate, and that medical school graduate still has to move on to a residency training program. PA education is directed at working on a physician-led team. They are expected to attain most of their clinical training on the job, under the supervision of a physician.

Some argue that it would be adequate to require a certain number of years of supervised practice for NPs or PAs to “catch up” to the training level of physicians.  This is a problem for the following reasons:

• Supervised nursing practice does not fill the medical knowledge gap left by an absence of medical education. Nursing practice and medical practice are not interchangeable.  The short track to medical practice afforded by PA education is not equivalent to that of a physician.
• Supervision can mean many different things. Residency training for physicians is rigorously controlled, and goals of education are clearly defined. Supervision as an NP may simply be an NP watching what a physician is doing (you can agree that watching a pilot fly a plane is not enough to make you competent to fly one).  PA programs provide a clinical educational experience similar to that of a medical student, but over fewer hours. A PA graduate does not have the same education as that of a medical student and certainly not that of a board-certified physician.

I know it’s tempting to say that some medical care is better than none, but I believe all people deserve the highest level of care. Just “good enough” shouldn’t be good enough for anyone. This is why everyone should want a physician or a physician-led healthcare team taking care of them.

-Submitted by a physician colleague-