Turf Wars

So many folks express views that are obviously self-serving, but they try to masquerade them as altruistic positions that benefit some other constituency. These attempts usually fool no one, but yet these performances are common and ongoing. They are potent fertilizer for cynicism.

Teachers’ unions have been performing for us for decades. Their positions on charter schools, school vouchers, merit pay and the tenure system are clear examples of professional advocacy to protect teachers’ jobs and benefits; yet the stated reasons are to protect our kids. Yeah, right. While our kids are not receiving a top flight education, the public has gotten smart in a hurry on what’s really needed to reform our public educational system. This is why these unions are now retreating and regrouping, grudgingly ‘welcoming’ some reform proposals that have been on the table for decades. This was no epiphany on their part. They were exposed and vulnerable. They wisely sensed that the public lost faith in their arguments and was turning against them. Once the public walked away, or became adversaries, established and entrenched teachers’ union views and policies would be aggressively targeted. Those of us in the medical profession have learned the risk of alienating the public. Teachers have been smarter than we were.

The medical profession is full of ‘performances’ where the stated view is mere camouflage. For example, there is a turf war between gastroenterologists (GI) and anesthesiologists whether GI physicians can safely administer the drug propofol to sedate our patients before colonoscopies and other glamorous procedures. This drug may be familiar to ordinary readers as it was involved in the death of a superstar pop music legend in 2009. GI doctors insist that with proper training we can safely administer this drug to our patients. Indeed, there are numerous scientific publications that support this view. Anesthesiologists have pushed back hard and they have prevailed. “It’s too dangerous,” they warn. “No one can use this drug unless you have advanced anesthesia training,” Of course, the only physicians who have ‘advanced anesthesia training’ are anesthesiologists. I’m not claiming that my anesthesia friends don’t have a legitimate point. But, let’s be clear. Their position is not merely an effort to protect patients, it is also meant to protect their turf.

See the equation below for a mathematical depiction of this issue.

Protecting(Turf) = $$$

Gastroenterology, my specialty is in the game also. This is transparent when our GI professional societies issue ‘guidelines’ for recommended GI procedure volumes and training for obtaining hospital privileges. For example, if these societies, who are dominated by academic physicians who work at medical schools and teaching institutions, issue procedure volume standards that are unreasonably high, this will serve to siphon procedures toward their medical centers where they work, and away from community gastroenterologists like me. In other words, if I do 20 procedures a year, but the ‘guidelines’ state that at 40 cases annually are required for competency, then I may be denied hospital privileges for this procedure and must then refer these patients to an academic center. The argument, of course, is to protect patients, but I suggest that there may be an unstated agenda. Interestingly, these medical centers and academicians do not issue ‘guidelines’ and volume standards for treating patients with cirrhosis, Crohn’s disease, irritable bowel disease or gastroesophageal reflux (GERD)? Why does my procedure count matter so much, but my case load for specific diseases doesn’t? Is it really only about safety? Perhaps, physician readers will offer views on this point.

National leaders in gastroenterology are very concerned about surgeons and other physicians performing endoscopic procedures, which represent a major proportion of our incomes. Of course, we don’t want untrained physicians performing colonoscopies. But, there is a turf issue at play here also.

Everyone is grabbing for a piece of turf. Politics is so rife with turf protection that it is nearly impossible to divine what someone is really thinking. So much of what these guys and gals say and do have little to do with the merits of the issue, and plenty to do with elections and self-preservation. Wouldn’t it be nice if all of our elective representatives were equipped with a B.S. (barnyard epithet) meter that could distinguish truthfulness from turfulness? Could our best engineers design such a device? I doubt it. After 2 or 3 sentences, the needles would all snap.

Michael Kirsch, MD, is a private practice gastroenterologist in the Cleveland, OH, area. He shares his thoughts about issues in medicine and medical practice at MD Whistleblower.

6 replies »

  1. To clarify, nurse practitioners are not physician extenders or extenders of anyone’s practice any more than physicians practice acting as a nurse extenders. How about looking outside allopathic myopia for what really works. That is, if you want to look. Look at the patients who are cared for and managed by NPs which includes CRNAs (certified registered nurse anesthetists). NPs have provided blue-chip care for longer than most of us have been alive. Your anesthesia friends have a point however, it’s important to note that their point is unfounded. Teachers aren’t the only ones who have been smarter.

  2. The fight is always over highly paid procedures. The solution: stop paying so much for procedures so that there is less to squabble over. I recall too many medical staff meetings at hospitals in which specialties debate who ought be ‘allowed’ to do a specific procedure, such as radiology and cardiology each holding forth about which of them should stick a catheter in an artery.
    The author writes that Gastroenterology doesn’t want untrained individuals doing colonoscopy. My guess is that if it became an unprofitable burden it would get shuttled off quickly – probably to a mid-level.
    That is exactly what happened with stress testing. When it was lucrative, cardiologists would carry on about patient safety and not allow hospital privileges to the less worthy family doctor to do a treadmill. Once reimbursement dropped, things changed. Now the NP does it…
    Bottom line: stop overpaying procedures

  3. Thank you for highlighting a point that is incredibly frustrating to anyone attempting to achieve an objective understanding of an issue: the public positions of interest groups are always be framed and crafted to their own advantage. It is impossible to understand most public debate on health policy without discounting for self-interest. On the other hand – any group that actually tried to be objective would be unilaterally handicapping themselves by failing to set the terms of debate! I didn’t notice anyone chiming in with examples that illustrate their own self-interest.

  4. As a general internist with 30 years’ experience and hundreds of hours yearly on Uptodate, I feel competent to treat those GI diseases, but not to do endoscopy or ERCP. What exactly is your point?

  5. The health professions are the worst at rent seeking, and physicians are right at the top! They are able to construct massive barriers to market entry, thus creating a faux shortage of practitioners. If you couple this with a broken price setting system (Medicare), then you have the recipe for what the US health system is currently experiencing.

    Of course, we can all take comfort in knowing that all of our patients are that much safer!

  6. One cost-saving piece of healthcare reform in general and ACOs in particular will be extending lower-level decision making to physician extender groups, like flu shots to nurses and ankle sprains to physical therapists.

    Right now, however, ankle sprains are simple cases that add volume to an orthopedic surgeons’ schedule.

    State legislatures are annually petitioned with extender legislation that seeks to expand scope of practice which is routinely rebuffed by state physicians’ organizations.

    In Florida, legislation allowing nurses additional prescription writing authority has been rejected by the legislature for 16 years. This year looks to be no different.