Dental insurance companies love me. I've only used the McMaster student dental plan twice in the last four years. Both times involved a regular checkup and two sets of X-rays. During my second time, which was last week, I saw a new dentist on campus. The cleaning and X-ray imaging was performed by an assistant, while the dentist did a thorough assessment and inspection of my teeth, palate, jaw, and other parts of the mouth. She also interpreted the X-ray findings and found three impacted wisdom teeth and a cavity between a molar and pre-molar (egad!). I was impressed by the efficiency of this system and it reminded me of the setup of the primary care clinic in the McMaster Student Centre. At this clinic, a nurse records a patient's history on a computer software program, which is then thoroughly examined and followed through by a doctor. Having a system like this in place provides a few benefits: nurses and doctors learn to work cooperatively together, the doctor can determine the complexity of a case before actually meeting the patient, and a proper division of responsibility ensures that services are carried out at the least possible cost.
However, there are also potential pitfalls to this system. With any history-taking procedure, the type of questions asked directs what the patient will reveal. Information that the nurses gather will be filtered according to their interview style. Therefore, the doctor who follows up with the patient will only be able to build on the nurse's foundation - a bad thing if it turns out that he/she missed something important. This is the price that is paid for efficiency. Of course, one can make the counter-argument that improper diagnoses do not happen frequently, that a more efficient system allows for more patients to be seen per hour.
Bringing it back to my dental experience, a dental assistant's responsibilities are uniquely different from a nurse's. The assistant does not do any history-taking (at least mine didn't) and they are highly specialized in performing certain tasks, such as cleaning teeth and taking X-rays. With practice, an assistant can become more efficient in doing their selected responsibilities than a dentist. On the surface, this type of system does not seem to come with the same bag of problems that may be present in a primary care setting where nurses and doctors have to work together. In fact, as a client, I prefer this system because I will pay less if an assistant performs most of the mundane tasks. With this in mind, can the argument for more highly specialized roles be extended to a primary care setting? This seems to contradict the very nature of this field, which is purposely wide in scope to ensure a first point of consultation for patients.
WC
However, there are also potential pitfalls to this system. With any history-taking procedure, the type of questions asked directs what the patient will reveal. Information that the nurses gather will be filtered according to their interview style. Therefore, the doctor who follows up with the patient will only be able to build on the nurse's foundation - a bad thing if it turns out that he/she missed something important. This is the price that is paid for efficiency. Of course, one can make the counter-argument that improper diagnoses do not happen frequently, that a more efficient system allows for more patients to be seen per hour.
Bringing it back to my dental experience, a dental assistant's responsibilities are uniquely different from a nurse's. The assistant does not do any history-taking (at least mine didn't) and they are highly specialized in performing certain tasks, such as cleaning teeth and taking X-rays. With practice, an assistant can become more efficient in doing their selected responsibilities than a dentist. On the surface, this type of system does not seem to come with the same bag of problems that may be present in a primary care setting where nurses and doctors have to work together. In fact, as a client, I prefer this system because I will pay less if an assistant performs most of the mundane tasks. With this in mind, can the argument for more highly specialized roles be extended to a primary care setting? This seems to contradict the very nature of this field, which is purposely wide in scope to ensure a first point of consultation for patients.
WC
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ReplyDeleteHey Channerz.
ReplyDeletein response to this I would like to come at the problem from the other end. The number one benefit of having nurses take history instead of docs and dental assitants perform certain tasks instead of dentists is efficiency. Why then do we ubiquitously see dental assistants at dentists offices and only sometimes see nurses working under docs? I would say it is for the same reason, efficiency. Rather than focusing on the drawbacks of having more responsibilities for nurses in primary care, I think the real reason for this difference is in the reward.
In Canada the need for efficiency differs greatly between doctors and dentists. Dentists work privately and recieve most of their funding from either third party insurance companies and/or straight from their patients. As you mentioned, WC, it is quite often a combination of both. Therefore dentists operate based on funding from a somewhat restricted yet mostly private marketplace. Docotors, on the other hand, operate privately but are publicly funded. There is very little compition within this latter model. Because of this distinction, doctors and dentists are differentially rewarded for efficiency; dentists pursue it to survive in a competitive marketplace and doctors do it to, well, "promote a sustainable system" (I guess?).
Now, focusing on the example of a nurse's role in a GP's office, what are the drawbacks? Well, as you suggested WC, having a nurse perform certain tasks such as history taking could have a negative impact on patient care. But does it and, if so, how much of an impact does it have? Is it worth the amount we are saving the system? These are complex questions but fortunately we have tools to answer them. A cost-effectiveness or cost-utility analysis could be done to operationalize this data. This information could be viewed by health economists, bioethicists, health policy analysts and patient representatives. It could be used with other data and opinions to generate an equitable and research based policy solution. These mechanisms are in place. Perhaps, as you suggested WC, the answer will reveal that the cost to patient care is too great. At that point we can look at getting nurses to perform certain procedures in family doctors offices instead, maybe that will increase efficiency while providing an acceptable level of patient care.
So, while these mechanisms are in place to address our main question of the benefits and drawbacks of having nurses more involved in primary care, why hasn't this question been better answered? If we have some data in this area already, why havent those solutions been implemented? It comes back to incentive or lack thereof, efficiency. The basic structure of health care system remains the same and there is very litte reward for saving money. The case of nurses working under physicians is only one example; this is a systemic problem. While I support a publicly funded system overall, there are internal changes that could occur. Perhaps the Canadian government could look at the NHS system of competitive health districts in England. Provide something to reward efficiency...