Sunday, March 02, 2008, 9:20 PM
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Too few to help

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PART TWO OF A THREE PART SERIES,
Atlanta’s Struggle for Quality Health Care

Part I: Through the Eyes of a Patient, Feb. 24
Part III: Whatever happened to patient power? March 9


By Stephanie Ramage

Valerie is visibly angry as she talks about her experience in a hospital in Atlanta that she refuses to name, just as she refuses to give her own name. She wants to remain anonymous because, first of all, the potentially fatal illness that resulted in her admission to the hospital is a little embarrassing, and second, she’s not so sure that what happened there, or, rather, who happened there is entirely the hospital’s fault.

“I was so very, very sick that I thought I was going to die,” she says, “and here is this jerk, this overgrown frat boy they call a ‘hospitalist’—whatever that is—who thinks that what is happening to me is all a joke.”

A retiree on Medicare, Valerie was stricken by a staph infection that causes toxic shock syndrome. Its symptoms include high fever, low blood pressure, malaise, confusion and, in the most serious cases, organ failure, coma and even death. She had been examined at the emergency room of the hospital and then admitted. That’s when the trouble with the hospitalist began.

“They didn’t know what was wrong with me,” says Valerie, explaining that she knew she was very ill, which made her very scared. She called her general practitioner.

“She told me that she didn’t come to the hospital, that ‘that’s what the hospitalist is for,’” says Valerie. “But I didn’t know the hospitalist and he didn’t know me. I had picked my GP, but I never picked this idiot who was the ‘hospitalist.’”

Generally, hospitalists are medical school graduates who are hired by hospitals to act as a sort of on-location general practitioner—he or she sees patients in the hospital that general practitioners don’t have time to see.

“I would ask to see a real doctor, and he would just say ‘I am a real doctor. I graduated from med school,’” she says. “But he didn’t act like a real doctor. He was not mature. He was so insulting and condescending to me. He would talk to me like I was a child or someone who was retarded.”

For example, she says, mimicking his baby talk, he told her that she had suffered “a teeny, weeny, eensy bit of kidney failure.”

“When they gave me antibiotics and I felt better, I desperately wanted to go home,” she says. “I would beg to go home. He would come in every morning and say ‘We’re going to get you out of here today,’ and then they would just move me to another room. He was toying with me, and I did not appreciate it. I wanted to go home. I don’t know why they have these so-called ‘hospitalists,’ but it’s not a good idea.”

Elliott Fisher, director of the Center for Healthcare Research and Reform at Dartmouth Medical School, explains that hospitals have hospitalists because there aren’t enough primary care physicians.

“We are over-investing in specialists, and we have a shortage of general practitioners and primary care doctors,” says Fisher.

This means that there are not enough doctors doing rounds at hospitals. So, says Fisher, some hospitals have hired hospitalists to manage patients and their illnesses as a primary care physician would if he or she had time to visit patients in the hospital. But, as Valerie suggests, he says that hospitalists aren’t the answer.

“Hospitalists are not going to solve the problem,” Fisher says. “By using hospitalists, hospitals are putting a Band-Aid on a fragmented system. I don’t think the hospitals are evil for doing it; I think they are just trying to do the best they can.”

The critical shortage of primary care physicians—general practitioners, family practice doctors, internal medicine doctors and OB/GYNs—is compounded by an alarming shortage of nurses. These health care worker shortages are affecting Georgia more than most states.

Georgia’s desperate straits

On Jan. 31, the state Senate Study Committee on the Shortage of Doctors and Nurses in Georgia issued a report that revealed some startling findings:

• Georgia ranks 44th in the nation for its ratio of primary care physicians to population.
• If immediate action isn’t taken, Georgia will rank last in the nation in the ratio of physicians (of any kind) to population by the year 2020—just 12 years away—with an “overwhelming shortage of more than 2,500 physicians.”
• Georgia ranks 42nd in the nation in its supply of RNs (registered nurses) and will need an additional 20,000 nurses by 2012—just four years away—to meet the demands of a growing and aging population. Even with a best-case scenario, and assuming all nursing graduates who pass the licensure exam remain in Georgia and work full-time, it’s estimated that the state will only be able to produce a maximum of 12,000 RNs by 2012.
• If nothing is done to alleviate the nurse shortage, Georgia will have a shortfall of 37,000 RNs by 2020.
• The American Medical Association estimates that with every additional patient added to a nurse’s workload, patient deaths increase by 7 percent; for example, increasing a nurse’s workload from four to eight patients would lead to a 31 percent increase in patient mortality.
• Nurses often work continuous 12-hour shifts, and 93 percent of nurses report problems with maintaining patient safety because of increased workloads and mandatory overtime shifts.
• There are approximately 12,000 RNs currently licensed in Georgia who choose not to work as a nurse due to job dissatisfaction.

The committee recommends that Georgia’s four medical schools—the Medical College of Georgia in Augusta, Mercer University School of Medicine in Macon, Emory University School of Medicine, and Morehouse School of Medicine—increase their enrollment. (The committee also lists the Philadelphia College of Osteopathic Medicine in Suwanee, which opened in 2006, as a medical school, although its graduates are not designated as medical doctors.)

The report notes that this recommendation will require the General Assembly to allocate special funding to the schools. Five years ago, the Association of American Medical Colleges recommended an enrollment increase of 30 percent; since that time, Georgia’s schools have all opened up more slots for students or made plans to do so. 

Since only one of the schools, the Medical College of Georgia, is public, the committee members recommend that the legislature increase funding for the Medical Student Capitation Program, which allows the state to purchase and reserve slots for Georgia residents at private medical schools. Their reasoning is that students from Georgia are more likely to practice in Georgia. The number of slots was frozen several years ago as a cost-cutting measure. Additionally, the committee recommends that the state legislature:

• Urge Congress to expand the medical residency program in Georgia by increasing federal funding. It’s estimated that Georgia will need at least 200 new residency slots and 2,000 additional residents to meet health care needs.
• Take extra steps to protect THE much-besieged Grady Hospital, since it’s virtually the state’s incubator for doctors; about one-fourth of all doctors in Georgia are trained there. At present, there are only 2,000 residency slots in Georgia, and about half of those are affiliated with Grady.
• Investigate ways to alleviate medical education debt.
• Create a fund to assist medical schools in developing a curriculum for health care economics.

But even if the state takes all those steps, how can anyone guarantee that the students will become primary care physicians? State Sen. Renee Unterman (R-Gwinnett County), who serves on the committee, points to a program at Mercer University Medical School in Macon that offers tuition reimbursement as a way of encouraging medical students to pursue primary care medicine, and to practice in rural areas where the shortage is most critical.

However, during its investigation, The Sunday Paper found that urban and suburban areas need more primary care physicians, too. And money is a concern for medical students who might choose to go into primary care, regardless of location. The students reason that medical school is so expensive that they’ll be saddled with huge student loan debt—especially in Georgia, where only one medical school, the Medical College of Georgia, is public and the other three are more expensive private schools—and that they’ll require large salaries to pay off that debt. Primary care physicians tend to earn substantially less than their specialist colleagues.

Unterman, however, says that might not be as much of a concern as it has been in the past.

“There seems to be a whole new generation that isn’t as interested in money,” she says. “They are more motivated by social concerns.”

And, according to the report, by personal concerns. In an unattributed statement, the committee report claims that “the increasing presence of women in medicine is also contributing to the overall reduction in work contribution. Women often bear a greater responsibility for managing family life and are therefore reducing their workload to meet demands at home.”

Even if they weren’t, doctors in general have changed. According to a 2006 report by the Georgia Board for Physician Workforce, “studies show that the new generation of doctors display different perspectives toward the practice of medicine; they are working fewer hours and placing a greater emphasis on balancing work and home life.”

Is there a nurse in the house?

Nurse shortages have been a perennial concern in America since at least the early ’70s. Unterman, herself a former RN, says she left the profession in the ’80s because, as a critical care nurse, she was overworked and burned out. But today, with Georgia being the ninth most populous state and producing more patients every day, the situation is worse than ever. She describes it as “disastrous.” What’s more, every time a nurse quits the profession, working conditions worsen for those who remain.

“One of the things the committee found out is that because there is a shortage, working conditions have declined,” Unterman says. “People generally want to do a good job at their jobs, and you don’t do a good job when you’re trying to take care of too many patients.”

That, she says, might partially explain those 12,000 licensed RNs who are not practicing. Lucy Marion, dean of the Medical College of Georgia School of Nursing, questions that number. She says many of those are probably retired or have moved out of the state. There’s no way to know for sure. But, she says, it is likely that nurses have left because of stressful conditions, including the level of illness among patients today. With so many Americans lacking insurance or access to primary care, a lot of people wait until they are seriously ill before seeking help.

“When I started, we had people who were very sick—they require more care—but  we also had some who were not,” she says. “Now, everyone is very sick and they are released more quickly. The patient turnover is good for business, but not good for establishing longer-term relationships with nurses who care for the patients.”

Marion also cites a lack of use of electronic medical records—a phenomenon noted in The Sunday Paper’s Feb. 24 installment of this series—as a contributor to nurses’ deteriorating working conditions.

“Our use of information technology is very behind,” she says, explaining that more use of electronic records would help nurses to work more efficiently. They’d know about a patient’s medication, previous allergies and illnesses, and other things that might require a conversation with one of those hard-to-find primary care physicians. But, so far, aside from an electronic records system used by the Veterans Administration, there has not been a system that’s user-friendly enough to be attractive to doctors and nurses.

“It’s really top-quality health care information technology that we need,” she says. “Typically what happens is, you have these great marketing people who come out and they say they can tweak the product to work with what you already have, but then you buy it and it’s not really compatible with anything. Probably the best one out there is the one used by the VA and, to its credit, the federal government has made it available to everyone, but it’s not being used everywhere.”

Nurse training in general—for intensive care and everything else—is in peril. Georgia simply has too few nurse educators. Even if an aspiring nurse meets admission requirements, chances are he or she will have to wait at least several months, or even a year, before a slot in nursing school opens up; there just aren’t enough teachers.

The reason is simple economics: The average salary for a nursing school faculty member with a master’s degree is $46,000; with a doctoral degree, the average is $63,000. But, in hospitals and clinics, the salary for a nurse with only a bachelor’s degree or less is between $63,000 or $78,000 annually. Why teach when you can do for a whole lot more money?

And the problem’s only going to get worse in the next two years. According to the state Senate committee report, by 2010 nursing faculty retirements will reduce the current enrollment capacity in Georgia’s nursing schools by 26 percent.

The committee recommends that nursing school enrollment be expanded, and that the Board of Regents increase nursing faculty salaries to make them more competitive with nurse salaries in hospitals. In the report, committee members also call for implementing more nursing doctoral programs and—so Georgians can find out how bad the situation really is—the creation of a Nursing Data Center that will keep track of how many nurses the state has.

“We are working for things to get better,” says Marion. “But the situation might get very tight before then.” SP