Starting With Curious

Here’s a statement that could be a set up for a high school debate team or one of those shows on cable news: “The US has the best healthcare in the world.”  I have debated this with myself many times.  The pro argument emphasizes the role of research and technology, the availability of tests and treatments that may have seemed like science fiction not too long ago.  But I usually land on the con side, thinking of our dismal overall statistics on life expectancy, child mortality and health status, coverage, and costs.

Sometimes, though, anecdotes trump statistics, as I learned the other day when I had the opportunity to spend the morning rounding in our operating suite.  First, I observed the set up in OR 3 for a Norwood procedure, a now standard operation for an otherwise fatal congenital heart condition, hypoplastic left heart syndrome.  They were getting a heart-lung bypass machine ready for a 1 week old infant.  Although it is done in many centers now, our hospital has one of the highest volumes, and literally some of the best outcomes in the world.  For a condition that was once uniformly fatal – standard treatment at most centers when I was a resident was hospice  – today at Children’s Hospital of Wisconsin about 90% of children survive.

Next, I went to OR 6, where an EXIT procedure was being performed.  EXIT stands for ex utero intrapartum treatment, and it’s an acronym that actually has some intrinsic meaning.  It was developed for when a mother is carrying an infant with some kind of anomaly (in this case, a giant cyst in the neck) that would make it impossible for the infant to breathe after birth.  A Caesarean section is done, but only the baby’s head and shoulders are brought out – a partial exit, if you will.  A team of ENT and general surgeons then works to establish the baby’s airway before delivering the rest of the baby.  Technically, the baby is being operated on before it is actually born (the moment of birth is when the cord is cut), and the mom serves as a type of heart-lung bypass machine.  This is a highly complex, technically difficult procedure, requiring enormous coordination (there were at least 20 people involved), and only done at a handful of institutions, including ours.  Even at that, this is only the fourth one we’ve ever done.

But wait, not done yet!  As I was leaving the successful EXIT procedure, I passed OR 8, where a team of neurosurgeons was doing our first ever, apparently oxymoronic  “minimally invasive neurosurgery,”  to treat a young child with a brain tumor that might otherwise have been inoperable.  Using a specialized guidance device in the OR, the neurosurgeon placed a laser-tipped catheter into the child’s brain.  The patient is then moved to MRI, where the tumor can be zapped with the laser.  MRI guidance allows the surgeon to see exactly where the laser is, and to monitor the temperature of the surrounding tissue so that only the tumor is targeted.  And get this: at the end of the procedure, the catheter is removed, the wound in the scalp is closed with a single stitch, and the patient can go home within 1-2 days.  After brain tumor surgery!!  This isn’t exactly Dr. Leonard McCoy with a tricorder, but it’s darn close.

Three children who when I was in training would almost certainly have died – three families left with an unfillable hole – who instead will all go on to soil thousands of diapers, enjoy kindergarten, create adolescent havoc, and perhaps have their own children.  On the one hand, this was thanks to Star Trek-type technology that really highlights our value of innovation.  Yet I was also struck by just how routine, how normal it all seemed.  A casual observer might not have been able to appreciate how groundbreaking some of this was, because the physicians and staff were just so – I guess “controlled” is maybe the best word.

I, on the other hand, was floored.  Three children saved from fate.  Yes, we still have too many children who do suffer or die, many from things that are easily prevented.  And the kinds of things I witnessed are very expensive; having them is wonderful, but if only a small handful of those who need them can get them, that’s not good enough.  Yet the look of hope and joyful anticipation I saw on the face of the mother about to undergo the EXIT procedure forced me to acknowledge that the answer to the question of whether the US has the best healthcare in the world is an ambiguous one.  The debate goes on.

I now know that the five most disquieting words in the English language are “This is not a drill.”

As some of you undoubtedly know from national news coverage, we had a shooting at Children’s Hospital of Wisconsin yesterday.  Police, responding to a report of a visitor who was armed and dangerous, shot the suspect (not fatally) and gained control of the situation.  From around noon until 2 pm, the hospital was in a lockdown situation.  During that time, the other leaders and I were in a command center; much of our time since then has been spent in analyzing what happened and our response, and most important, in supporting all of our patient families and staff that were affected.

Thanks to our planning and procedures, and the outstanding work of our staff and law enforcement, no patients, families, or hospital staff were injured.  In retrospect, things went as well as one could reasonably expect, maybe even better.  I mean let’s face it, education and drills notwithstanding, there is no way to really rehearse for the real thing.  Adrenaline and neurotransmitters are running rampant, time becomes completely elastic, people get hungry.

You might think an actual situation like this would be less choreographed, more chaotic than the drills.  (We actually had an active shooter drill within the last couple of months.  It was kind of boring.)  Although I was never in danger myself, it was certainly nerve-wracking.  And going around to all the care areas after, behind the modest words I could sense that many people had been frankly frightened and concerned for others.  But what I saw everywhere was not chaos, but calm.  Even when communications were spotty, or procedures unclear, there was no panic.  It was almost surreal.  At the time, I was mostly relieved and appreciative (and a bit hungry).  I chalked it up to the supreme professionalism of the people I work with.

But reflecting now after 24 hours, that wasn’t quite it.  Not that there wasn’t extraordinary professionalism, it’s just that that isn’t enough.  What I saw was skilled professionals living out our values of being At Our Best:

1.  Purpose – We act in the service of patients and their families.

The nurses who shepherded families to safe locations in the clinics, and the nurses who stayed with the patients who couldn’t be moved.

The code team that despite the lockdown responded to not one, but four different emergency (“code”) situations, including to assist the man who was shot.

2.  Integrity – We build confidence and trust in all interactions.

Althea, the administrator on call who took charge as the incident commander and calmly directed activities.

The CHW security staff who  worked with four different law enforcement agencies to control access, provide escort to personnel who needed to move about, and provide a sense of confidence that all was under control.

3.  Collaboration – We work together to care for children and families.

The administrative team in the command center who during the incident and in the hours after worked together to return the hospital to normal.

The off duty security officer who happened to be in the hospital with his child for an appointment, who stepped in to help.  And the clinic staff who watched his child in the meantime.

4.  Innovation – We commit to breakthrough solutions with continuous learning.

The many people who made creative suggestions of ways we can make our response even better should we ever need to in the future.

The communications team who use various means to get information out via email, Intranet, Twitter, etc. to try to keep people informed.

5.  Health – We are at our best.

The behavioral health providers who canceled clinics to be available as a resource for staff, along with social workers, human resources, etc.

The environmental staff who within minutes of the “all clear” were out making sure our facility was clean and ready.

Every single person who stopped to ask someone else if they were OK and if they needed anything.

As the swarm of media vans and news helicopters attests, this is the kind of incident that draws a lot of attention.  News is, by definition, what doesn’t happen every day – it’s what’s not normal.  Our values, though, are a constant.  Not terribly newsworthy.  But as the attention fades, as we get back to our routine, I’m reflecting on how grateful I am to be part of an organization that lists and lives those values.  That’s our normal.

When asked what I do, I still reply “I’m a pediatric emergency physician,” but honestly, these days I’m mostly an administrator.  I’m a suit.  I deal with things like contracting and billing, staff productivity measures, even surgical inventory management.  {That’s a thing?}  Which sounds, frankly, less noble {and less “sexy”} than the first answer.  So I want to try on a new answer:  I’m a steward.

Stewardship is “the activity or job of protecting and being responsible for something; the careful and responsible management of something entrusted to one’s care.”  The term is often applied to finance and natural resources, but has also been used to refer to pastoral care.  I like this definition because it emphasizes not only the actions of making careful decisions and avoiding waste.  It also encompasses the special relationship between the steward and the resources being managed, the elements of trust, of accountability.  All healthcare providers are, in essence, stewards – we are entrusted to care for our patients and to manage their health.  But even those who wear scrubs rather than suits to work are stewards in the business sense.

I realize that referring to medicine as a business gives many healthcare providers hives.  But the fact is, while I believe medicine is more than a business, it is still a business.  If you are wondering if what we do is a business, ask yourself, “Do we charge money for what we do?”  The answer, of course, is “Hell, yeah.”  Albert Schweitzer may not have been in the business of medicine, but the rest of us are.

Stewardship is critical on two levels.  The first is the organizational one.  Many of us are in the non-profit sector of healthcare.  The gap between the revenue we get for the services we provide and the expense of providing those services {salaries, supplies, mortgage, utilities, etc.}, is our margin, which we hope is a positive number.  {These days, accountants don’t use red ink for bad numbers, they use parentheses – parentheses are bad.  That’s why I’m using brackets instead.)  The margin doesn’t go to executive bonuses, or to pay off shareholders.  That extra revenue is what we have available for two things.  It supports those parts of our mission that we don’t get paid for {charity care, injury and illness prevention, community engagement, research and education}.  It’s also what we rely on to invest in new and replacement equipment, facilities, and programs.  It is a cliché to say “No margin, no mission,” but that doesn’t make it any less true.

Our hospital and health system is a tremendous asset to our community, one that has been entrusted to us.  Our vision is that the children in Wisconsin will be the healthiest in the nation, and I truly believe that our community would be less healthy if we were not here.  We are challenged by many changes in the healthcare environment.  Spending on healthcare has reached unsustainable levels, and while it is leveling off, we will continue to get paid less for what we do.   Which is why all of us need to be good stewards.  By focusing on making what we do cost less, we will ensure that the margin that supports our mission can be sustained.

We also must be good financial stewards for the sake of our individual patients and families.  One of the most striking effects so far of the Affordable Care Act is the acceleration of employer sponsored consumer-directed plans, also known as high deductible health plans, in response to the ACA’s tax on so-called “Cadillac” health plans starting in 2018.  While only 4% of employer health plans were HDHPs in 2006, they were over 20% in 2012.  For 2014, over 40% of employees in our system selected an HDHP {including me}.  Ironically, this is a solution that has long been promoted by free-market health economists.  The idea is that by having patients have more “skin in the game,”  in the form of high deductibles and hefty cost-sharing, they will shop more carefully for health care services.  While the several thousand dollars of out of pocket expenses are going to make me think twice about what services I seek and where, for many of us they are an inconvenience.  But for many of our patients and families, it’s more than that.  A parent may be deciding whether to have their child’s tonsils out or save for college.  It may be a choice of filling a prescription or having a meal.  We may find the idea distasteful, but it’s reality.  If we don’t control our costs, families will either be forced to go elsewhere, or go without.

Our hospital, our patients – these are things that have been entrusted to our care.  We say “kids deserve the best.”  Let’s be good stewards, so they can have it.

…is another one’s treasure, as the saying goes.  This is an important principle to bear in mind as the US tries to get a handle on healthcare spending.  As health economist Uwe Reinhardt notes in a recent New York Times blog, value is often in the eye of the beholder.

The 2012 Institute of Medicine report, “Best Care At Lower Cost,” examined the estimated $765 BILLION in “waste” (of the total $2.5 Trillion in annual spending on health care), and broke it into six categories:

1. Unnecessary services – $210 Billion
2. Excess administrative costs – $190 Billion
3. Inefficiently delivered care – $130 Billion
4. Excessively high prices – $105 Billion
5. Fraud – $75 Billion
6. Missed prevention opportunities – $55 Billion

This table leads to some finger pointing.  Physicians can blame pharma, insurers can blame docs, and everyone can blame those who commit fraud.  It’s tempting to think we can make significant progress without having to do much ourselves.  Take administrative costs.  (Please.)  We’re all familiar with the statistics – a recent estimate, for instance, that the typical US physician spends nearly $83,000 in her or his time dealing with administrative issues, four times as much as their Canadian counterpart).  And we have our own frustrating experiences: when I started as a faculty member at AI DuPont Hospital in Wilmington, DE – with a catchment area that included parts of four states – I had to complete a 7 inch thick stack of insurance enrollment forms for the over 60 different payers we had contracts with.  Our own clinical practice services at MCW – the folks who do the billing and collections for our professional fees – employ around 500 people, or nearly 1 for every 3 providers!  Why focus on “unnecessary services” when we could shave nearly as much by eliminating the non-value added “administration.”

But every one of these categories, seen as waste from the system perspective, benefits someone.  Even fraud.  So any effort to decrease these will face some resistance, on top of any other barriers.  Decreasing administrative costs by, say, having a universal credentialing process and single claims platform, would costs tens if not hundreds of thousands of jobs.  And decreasing “unnecessary” utilization means less revenue to providers, meaning less resources to take care of the needy and advance knowledge.

It  does seem like a zero sum game.  But there’s one perspective we haven’t yet considered – the patient’s.  If we streamline the insurer bureaucracy, it might mean some of those people paid to deny claims may not be needed, but the hospital gets paid faster.  But more important, patients are more likely to get the care they need. If a $100 brand-name albuterol inhaler can be replaced with a $15 generic, it hurts the manufacturer, but it helps the patient who can perhaps afford to buy both that AND a controller med to keep from getting ill in the first place.  And yes, if I order fewer CT scans in children at sufficiently low risk after head injury that it’s almost certain to be negative, my bottom line suffers.  But the child is less likely to have a radiation-induced malignancy later in life.

One person’s trash is another person’s treasure.  But to the person who should be at the center of all of this – the patient – it’s all trash.

I am rarely mistaken for George Clooney, and my job seldom resembles the TV show “ER.”  The vast majority of what we do is, at least after a number of years, pretty routine.  But every once in a while, life resembles art.  A couple of months ago, on an otherwise steady but undramatic day, the nurse walked a 2 week old baby back from triage and asked for immediate help.  The baby was blue, not breathing, and had no pulse.  A team of folks – nurses, other doctors – swiftly descended on the room and began working.  I directed one person to do CPR, others to try to get an IV and to give medications.  After a minute or so we were able to get a pulse, but the initial signs weren’t great.  The parents, who were in the room with us, asked if they should baptize the little girl, and they did.  After almost an hour, we had stabilized her and sent her to the neonatal ICU.  I went up and checked on her and her parents after my shift.  While things were improved, it was all still quite tenuous.

This past weekend, the triage nurse came back and told me and one of the nurses that there was a family in the waiting room that wanted to talk with us.  We went out to find the family of that little girl.  They wanted to thank us for what we had done, bringing a delicious lunch for the whole staff.  It was a touching gesture, as were the drawings from the girls siblings that said “Thank you for saving our sister’s life.”  But the best thing was seeing the baby herself.  She had spent a month in the ICU, but did well and went home.  The last time we had seen her she was literally on death’s door; now she was a pink, chubby-cheeked, smiling 3 month old.  As we exchanged thanks and hugs, all of us were a bit teary.

I happened to have a college senior interested in medical school shadowing me that day.  As we were sitting down to enjoy the pizza and ravioli, I told him that this sort of thing doesn’t happen every day, or even every year.  But, I said “This is what it’s all about.  Don’t forget that.”  It’s all about purpose – acting in the service of children and their families.

I also thought of our emphasis on “being here now.”  When the team swung into action that day a few months earlier, each of us was there, fully present, doing what we needed to do.  We were also there for the family, explaining what we were doing and what it meant even as we feverishly worked to save their baby.  And when that family returned, intact, to bring us a meal, it reminded me that it could have been very different.  Life is short, unpredictable, and very precious.

In our efforts to promote value, the need to reduce unnecessary variation and follow best practices in the form of clinical guidelines is clear.  As we think about moving toward more evidence-based practice, it may be worth considering some of the alternatives:

1.  Eminence-based practice.  This is where we do what we are told by people who, rightly or wrongly, are well-known in their field.  Although in many cases this may be reasonable and congruent with available evidence, assuming something is correct based solely on the celebrity of a source can be problematic. (See, for example, Tom Cruise and Scientology.)

2.   Precedence-based practice.  This falls under the category of “we’ve always done it that way.”  It is particularly prevalent at certain ivy-clad East Coast institutions, and is the reason we continued to use theophylline for acute asthma well into my fellowship years.  (The cutting edge doesn’t work when it is stuck in cement.)

3.  Elegance-based practice.  This is perpetuated by pharmaceutical and other manufacturers, who promote questionable products with eloquent testimonials and attractive advertising.  The poster child for this is Xopenex.

4.  Arrogance-based practice.  When one is willing to substitute one’s own thin anecdotal experience for the accumulated wisdom of the published literature.  Often expressed in the form of “my patients are different.”

5.  “Are you dense?”-based practice.  Also known as “execrance-based practice,”  this is an extreme form of variant #4 above, whereby not only does one assume one’s own practice is superior to the published evidence, but that all other practices are idiotic.

One of my favorite questions to ask fellowship applicants is what skills they think are important to be a good pediatric emergency physician.  Almost all of them respond with something along the lines of being able to multitask, building and leading a team, and maybe procedural skills.  When I point out the importance of those skills for almost any specialty, and ask for those skills somewhat unique to our field, many draw a blank.  To my mind, one of the unique skills of an emergency physician – indeed, one of the defining features of the specialty – is the ability to make decisions with incomplete information.

Of course, no one ever has truly complete information, but the limitations due to time and resource constraints in the setting of the ED are much greater.  Physicians have to determine and commit to a plan of action despite the fact that the patient’s history may be limited by the absence of a caregiver, or a prior relationship with the patient and family; some tests may not be available in off hours, and results of tests that are performed may not be available until after the decision has to be made; and competing demands more significantly limit the amount of time we can spend with a patient than in a scheduled setting.

Comfort with making decisions in the face of incomplete information, and being able to do so with an appropriate level of confidence, is a critical skill for the emergency provider, but is useful in a variety of contexts.  For example, business leaders must often make strategic decisions vis a vis their competitors without good intelligence on what the competitors’ plans are.  In a rapidly evolving healthcare environment, hospital and other leaders face a number of key decisions that will have impacts for years, when we don’t have a good deal of information about what the environment will look like even months from now.

This skill requires some humility: the less information you have when you make a decision, the more likely it is to turn out to be a bad one.  It also requires a thick skin, as the next-morning quarterbacks are all too happy to wonder aloud about what those people in the ED were thinking.  I have long contended that, although some people may never be comfortable with making decisions in the face of incomplete information, most of us are capable of doing so, and that it is a skill that can be developed through practice.  Recently, I read a fascinating book about decision making by the Nobel Prize-winning economist Daniel Kahneman that provides some support to this.  Thinking, Fast and Slow – about which I will comment more on in future posts – describes the two systems in our mind that are involved in decision making.  System 1 (in Kahneman’s terminology) is the one that allows us to form immediate impressions, take automated actions.  It is responsible for snap judgments.  As such it performs an important function (our forebears would have had a hard time if they had to do a thorough risk analysis every time they were chased by a large carnivore) and usually does pretty well, though it is subject to a variety of biases.  System 2 involved the slower, more conscious and overtly analytical processes that provide a check and oversight over System 1.  One could surmise that making decisions without complete information might involve suppressing System 2, allowing us to go with our gut impressions.  But in fact, it turns out that, again in Kahneman’s words, system 2 is “lazy”.  The challenge is not to suppress it, but to invoke it.  I suspect most of us realize that our gut impressions are subject to bias.  It’s why we have sayings like “don’t judge a book by its cover,” and why we abhor racial profiling.  As a result, I believe that we are suspicious of our System 1 judgments, and overcompensate by insisting on a thorough System 2 review before committing to anything.  Being able to rapidly do a System 2 check of System 1’s snap judgment, and recognizing the strengths and limitations of both, is key to successful decision making with incomplete information.

It can be a challenge to efficiently bring our System 2 to bear on decisions that seem time sensitive, especially when there are many such decisions to be made in a brief period.  Interruptions and distractions, things that keep us from focusing attention, will tend to degrade the quality of decisions.  The ED is rife with those distractions.  It requires a certain amount of mindfulness, of “being here now,” to use our System 2 most effectively.  It is that mindfulness that we can exercise as a way to make better decisions when we do not yet have all the facts.

Getting ready to leave the Medical College of Wisconsin and move to Children’s Hospital of Wisconsin has made me a bit nostalgic.  I recalled recently when I was interviewing for my first job after fellowship, I was asked by my soon-to-be boss how I would design the ideal academic position.  I described what was the predominant model at academic children’s hospitals for my specialty of emergency medicine: approximately 60% clinical time, with the rest devoted to scholarly activity (education and research).  To my chagrin, he replied that model was becoming extinct.  People would have to choose to be 80-90% clinical or 80-90% academic (and get the external funding to support that).  I ended up in the 80% academic track.

Here it is 20 years later, and in many places, including ours, that is still the model.  But Brian Strom was correct.  The death of that model occurred earlier in Philadelphia and some other places than here, and perhaps in adult medicine ahead of pediatrics, but the trends are clear.  For a long time we have heard that the “triple threat” (i.e., the superhero physician who is clinician, educator, and researcher all rolled into one) was no longer possible because only those with a singular focus on research could compete successfully for extramural funding.  But many academic physicians do research that is internally funded with excess clinical revenue. The idea that the margin generated by spending 60% of one’s time in clinical work can support the other 40% is simply no longer tenable.

This was underscored by a set of articles about the future of academic health centers that appeared recently in JAMA and NEJM.  The articles talk about a variety of challenges and potential responses.  But a common theme is the unsustainability of cross-subsidization of the academic missions by the margin generated by clinical activity.  That margin is being eroded by downward pressure on reimbursements, at the same time alternative sources of funding for research and education are drying up.  The relative size of the clinical and academic activities is going to have to change.

For children’s hospitals, especially, where the paradigm of the triple threat has tended to hang on, we will have to rethink what it means to be an academic physician.  Rather than every faculty member participating in all activities, we will need to specialize.  The majority of faculty will be excellent clinicians who may do some bedside teaching, and provide access to patient material for clinical and translational researchers, but who will not themselves be expected to generate traditional “scholarly products” such as peer-reviewed articles, abstracts, book chapters, etc.  Their efforts, however, will generate sufficient margin to allow a smaller cadre of colleagues to engage in research and core educational activities.

This would represent a significant cultural change for us, leading to some serious soul-searching.  How do we continue to provide adequate intellectual stimulation to people who are “only” clinicians?  Would the pay scale be similar for clinicians and academics?   How do we ensure that prestige and career advancement are equally available to those doing the clinical work, when the traditional path to promotion and success has been via grant funding and publication?  What is it exactly that makes someplace an “academic health center?”

Fortunately, we are not the first to face these questions.  An article about the experience of Brigham and Women’s Hospital, for example, provides some encouragement.  But I wonder if someone who trained at the Brigham 20 years ago would recognize the place anymore.  Nostalgia may be fun, but we can’t reminisce our way forward.

When people find out what I do for a living, the first response is most often something along the lines of “That must be so hard.”  (That’s when they find out I’m a pediatric emergency physician; when they hear I’m also an administrator, it’s more of a sneer.)  My reply is typically that most kids are pretty healthy, and most of what I see is fortunately not that serious or ends well.  Which is true.  But the fact is, sometimes it is hard.  All of us in medicine have ways of coping with those difficult times, with patients who suffer and whom we can’t help as much as we’d hope to, with the child that dies.  But, as discussed in a recent New York Times article, too often that coping mechanism is to distance ourselves.  This detachment – which can cross over into callousness or cynicism, as documented famously in Samuel Shem’s novel The House of God – is contrary to the various oaths we take when entering the medical profession, in which we pledge to be compassionate and empathetic to the sufferings of those we care for.  It can play out in several ways.  Some physicians focus on the intellectual aspects and science of medicine.  For others, emotional detachment along with time and economic pressures can lead to burnout.

For all of us, underemphasizing the humanism and altruism, combined with the increasing emphasis on medicine as a business, can lead us to feel like we are in an occupation, rather than a profession – a calling.  We can forget what it is about medicine that gives it real meaning.  Work hour restrictions, preauthorizations, shared savings and pay-for-performance:  these are some of the reasons why many long-practicing physicians say medicine has changed for the worse, and they wouldn’t recommend it to their children.

Perhaps we need to be reminded of the old-fashioned commitment to the well-being of a patient, to being a healer, as a counterweight to economic and administrative pressures to be efficient.  Lest we get too nostalgic, however, let me put in a plug for the administrators.  As noble as the sentiments expressed in the Oaths of Hippocrates and Maimonides are, the singular focus on the individual patient can blind to the equally real needs of others, and more importantly, the fact that those needs must be balanced.  There is only so much health care to go around.  While we like to think that when we are sick, we want everything done and money is no object, that sentiment is typically expressed when we are not paying for it.  The decrease in health care utilization that accompanied the economic downturn of 2008 and beyond shows that money is, in fact, an object, at least for many people.  And with a few extraordinary exceptions, not many of us providers are willing to work without pay (and quite decent pay at that).  In a world of limited resources, we need to balance our commitment to healing the person in front of us with the commitment to the health of society as a whole.

Those who provide the care and those who manage it need to understand each other better. We need to recognize the filters through which we see the world, accepting that a diversity of views is the best way to see the big picture.  I believe as a provider, I may need to err on the side of connecting with and advocating for my individual patient.  The administrator may need to be more vigilant about the efficient use of resources.  But we must appreciate that we are all working toward a common purpose – serving our patients and their families – and a common vision of having the healthiest kids in the country here in our own community.  Each of us can find meaning in what we do, and have an impact in our own way.

It shouldn’t be surprising, in a time of shrinking payments to providers, that turf battles among those providers are increasingly common.  But we need to make sure that we don’t just hurt ourselves in the rumble.  Or worse, forget about what is best for our patients.

Round 1 in the gang war seems to be between physicians and advanced practice providers.  Many see APPs as an important part of addressing both the excessive cost of healthcare and the access issues that arise from an inadequate supply (or maldistribution) of physicians.  On the one side are the APPs, who are advocating for changes in state regulations that place limitations on their scope of practice.  Currently, 17 states and DC allow independent NP practice, 21 (including Wisconsin) require a collaborative agreement with a physician, and the rest require direct physician supervision.  Although the evidence is mixed on whether expanded scope of practice contributes to lower cost or better access, there is no evidence that it leads to worse outcomes.

Yet lined up on the other side is organized medicine.  The AMA, American Academy of Pediatrics, and American Academy of Family Practice have all issued reports decrying expansion of scope of practice for NPs.  (The politics indeed makes for strange bedfellows.  For example, both the AAFP and AAP emphasize the additional years of training for physicians compared with NPs.  Yet the total pediatric training for family physicians is far less than that for pediatricians, and is likely very comparable to the duration of pediatric training for a pediatric NP.  And certainly, a PNP with several years of experience after training has seen a whole lot more pediatrics than a new FP residency grad.)  In addition to lobbying state legislatures to maintain practice restrictions, the medical associations pressure insurers to limit payments for NP services.  Even when permitted by state law to practice to the full extent of their license and training, NPs are frequently not credentialed by insurers to bill directly.  In response, nurses are lobbying for a requirement that NPs be included in any plans offered in the new health insurance exchanges.

There is a real discussion to be had about how we develop a workforce to meet the medical needs of children in the evolving healthcare environment.  But can we call a truce and focus on the real issues?  Let’s be honest: this is not primarily about patient safety, or quality of care – it’s about preserving jobs and incomes.  One (not normally extreme) columnist went so far as to call the medical profession’s efforts to limit NPs “a protection racket.”  That’s harsh.  But it doesn’t serve us or our patients for health professionals to be rumbling with each other.  It seems clear that there is a legitimate role for advanced practice providers in meeting the primary and specialty care needs of children, and that role includes independent or collaborative practice in many cases.   That doesn’t mean NPs and MDs are interchangeable.  But the two disciplines need to acknowledge the filters through which they see the world and come to agreement on how we can ensure the right provider for the right patient in the right circumstance.  Or our patients may get caught in the crossfire.