Why Not Nurse Practitioners and Physician Assistants?

Evidence-based medicine has the potential to enlarge the army of health-care givers. The author believes physicians, patients and others should have an open dialogue about the future of medical practice.

A deaf medical student some time ago suggested that she could become a cardiologist, since that profession has come to prefer visual diagnostics like echocardiography and cardiac catheterization over the stethoscope. Her ambition foretells the time when paralyzed surgeons can carry out operations by blinking their eyes to guide robots to the cutting and sewing. Sixty years ago, when I was a medical student, that would have seemed the stuff of science-fiction. But not today!

We physicians and patients need to plan ahead for greater miracles that will change medical practice even more. The coming of “evidence-based medicine,” which is the sifting of research and clinical reports to come up with published guides for clinical practice, has the potential to enlarge even further the army of what is optimistically labeled “health-care” givers, the physician associates and assistants, and nurse practitioners. Will there be a need for so many extensively trained physicians, when technology helps those less skilled get the same results? How will the public accept non-physicians as independent care-takers?

Given “rule-based” guidance and technological advances, should we think about changes in how medical students are selected and educated in the 21st century? M.I.T. Professor William Holstein in the New York Times of December 31, 2006, cautioned, “We haven’t moved the health care profession into a world where nurses can provide diagnosis and care.” His intent is to reduce costs, but he could be hinting politely that most physicians even now are over-qualified for what they do.

It is the old question about whether medical practice is a science or an art. It is both, of course, but the proportions vary. For the past three decades, science has ruled the old roost: included in the minimal requirement for admission to medical school are courses in biology, general chemistry, organic chemistry, and physics , while mathematics and statistics are also encouraged. Yet this emphasis on scientific knowledge has eliminated many college students, even at Yale, who would have made excellent clinicians. How many practitioners use their college organic chemistry in treating their patients?

Such selection was necessary in the past to bring about the remarkably improved medical care we all enjoy, in community hospitals as in academic centers. My point is that guidelines and technology will maintain that improvement . Current medical education takes a long time, residency training even longer, and it all costs a lot of money. It is hardly surprising that medical school teachers now worry about their students choosing lucrative specialties to pay off their debts; academics, saddled with medical care to earn their keep have told me they are too busy to carry out the clinical research that transfers scientific advances to the bedside, and even to teach as much as they want.

There is more to come. Physicians will shortly be required -- and may even be paid extra -- to follow rules of an evidence-based menu. All the more reason to wonder whether the long-standing emphasis on basic science serves any practical purpose in a guild guided by rules. Physician-extenders can surely care for most patients with easily recognizable complaints; not every health-care worker needs to be trained as extensively as in the past. Moreover, not every complaint has a basis in what computers can display, and more intensively specialized physicians freed from their less demanding tasks will be able to return to their long honored role of diagnostician and advisor -- and hospitalist
caring for the very sick where the rules may not apply.

Obviously, medical scientists will still need to continue the advances of the past half-century, but do all physicians need the same training? To suggest that physicians need less science and the greater understanding of human nature that experience in social sciences and the humanities brings is not to “dumb down” the profession. Rather, now that computers are extending physician knowledge and experience, the rules intended to guide medical practice make it plausible to open the profession to far more varieties of experience and human skills than current requirements permit- like that deaf student.

A bright note has been sounded in some medical schools. For some years now, Mt. Sinai Medical School in New York City has been accepting a small number of college students without a background in science, and they are doing very well, so much so that next year, I understand, 40 such students will be accepted. That may be a harbinger of more to come, and elsewhere.

But doctors and patients alike -- and maybe even economists -- need to have a say about all this in free and open discussion.