I was fortunate (and humbled) to recently be nominated for a leadership award. See details or vote for me (Eric Sholes – the very last one listed) here -> Multiplier of the Year Award. By far the best part of the Multipliers nomination has been opening up discussions on leadership and talent development across a broad range of professions and disciplines I typically don’t interact with. Those conversations have helped me become more aware of potential intersections of my research interests and other career fields outside of engineering. One of the most interesting of those has been the topic of the expanding role of nurse practitioners in healthcare.
For those who do not know, the role of the nurse practitioner is expanding in a variety of ways, including increased numbers of nurse practitioners in the health care system and delivery of unsupervised care. There are a number of reasons for this change, the most commonly cited being a means to address the impending shortage of primary care physicians and to reduce costs. The New York Times provides some context and information in the article Nurses Are Not Doctors. The Times reports that a ‘national panel of experts recommended that nurses be able to practice “to the full extent of their education and training,” leading medical teams and practices, admitting patients to hospitals and being paid at the same rate as physicians for the same work.’ While this trend is most evident within primary care, it is not limited to general practitioners – Meet the Nurse Who Will Soon Perform Surgery Alone.
As one might imagine, this has raised some concern – Gulf Between Doctors and Nurse Practitioners. Notably, ‘physician organizations opposed many of the specific suggestions, citing a lack of data or well-designed studies to support the recommendations.’ However, supporters and lobbyists of expanded nurse practitioner policies and privileges disagree – NAPNAP responds to NYT . Meanwhile, lawmakers are moving forward. An increasing number of states are presenting legislation to allow nurse practitioners to deliver independent and expanded care – American Healthcare Current and Future Trends – 2014 – and opponents of this legislation are accused of inhibiting the evolution and viability of healthcare (Barriers to NP Practice).
If you examine the data and studies within those links, you find a lot of conflicting claims. The primary method used to support these claims is tracking outcomes from equivalent medical services. I worry about the efficacy of this approach. Let’s examine articles on another recent event to show an example of why I’m concerned. If you were to go to a news page on the date this was written, you would find articles with these competing titles: ‘Why and How the Republican Tax Bill Will Help Middle Class (Spectator)’, ‘Middle Class Gets Cold Shoulder from the GOP Tax Bill (Washington Times)’, ‘Why It Is Impossible to Model Tax Bill’s Growth (MarketWatch)’. That pretty much covers the left and the right and middle, doesn’t it. Of course, those contrasting conclusions are partially drawn from partisan perspectives. But, they are not presented as simple editorial opinions. They are presented as research-supported exposition. How could evidence-based studies based on sound methodologies disagree so violently? These studies are seeking to characterize big, complex, dynamic systems that are impossible to model accurately. Any small nuance that is modeled incorrectly or left out potentially has a propogating effect through the whole system. Further, even if you could model these systems accurately, the model could still yield contradictory data because the underlying methodology – caveats and assumptions and statistical techniques – differed. If you examine other recent hot topic issues, you will find the same. You can find competing studies which draw opposing conclusions about the effect of an increased minimum wage, for example. Outside financial issues, climate science has suffered from similar modeling issues.
A specific claim that is very common in the NP care debate is that patient outcomes are the same or better than MD/ DO- delivered care. Similar to the topics above, studies provide both supporting and contradicting data. My goal in this article is to explore if cognitive psychology methods which determine the specific cognitive mechanisms that enable expert performance in medicine might provide a bottoms-up a priori insight to supplement and inform the top down ad-hoc modeling approach currently being utilized.
Before I go on, let me confess this is a mission to collect insight rather than to recommend a solution. I also realize this topic is heavily political and many people on both sides are heavily invested professionally and personally. The perspective I present is that of a patient first and an expert on managing personnel within highly complex and dynamic technical systems second (my PhD is in Systems Engineering with a focus on Engineering Management and my professional role is project lead within aerospace projects which span multiple scientific and engineering disciplines). From that perspective, my concern is that the lawmakers and administrators seem committed to a path forward that will fundamentally change the health care system without conducting the studies and pilot programs necessary to fully understand the impact of that change.
My primary research interest is the application of the Expertise and Expert Performance Framework (EPF) within highly dynamic and complex professional disciplines. I am interested in questions such as ‘what common characteristics, habits, and/or experiences foster an elite rocket scientist?’, ‘what is the difference between an elite and an average rocket scientist’, and ‘how can an external observer differentiate between an average and elite rocket scientists’. Essentially, we utilize a skills-and-knowledge driven approach to distribute technical tasks to a team of mixed specializations, skills, and abilities to optimize technical capability while managing risk. I am wondering if it is possible to apply the same principles to examine how to distribute tasks within the healthcare system.
Although the Expertise Performance Framework is not well known, the expertise concepts it represents are. The popular press book Peak by K. Anders Ericsson examines the topic of expertise. The foundational 10 year, 10000 hour rule has essentially become conventional wisdom – it was recently quoted to me by a Kindergarten soccer player. Many 1000s of journal pages have been dedicated to expertise concepts but that level of depth is not needed here. So, here is a very brief introduction to expertise theory needed for this discussion:
- 1) the widespread assumption is that personal efficacy and productivity stem from inherent or genetic qualities but an extremely strong research base refutes this idea
- 2) rather, elite performance comes from many incremental improvements over a long period
- 3) further, only a specific type of study or practice methods results in improved skills and knowledge which aid elevated performance – this specific set of methods is referred to a ‘deliberative practice’ or ‘purposeful engagement’.
- 4) in cognitive disciplines, this process leads to advanced mental representations that enable enhanced systems thinking, problem solving, and decision making
- 5) the level of skill, ability, and knowledge an individual holds at any given time is determined by the amount of cumulative time invested in purposeful engagement – the standard guideline is 10 years, 10000 hours (this is an oversimplification and in reality some arenas take less and some take more but 10000 hours is a good rule of thumb.)
Even though awareness of expertise concepts has become widespread, an effective understanding of how to aid expertise development in real life unfortunately has not. The most common (and also the most damaging) gap is a misunderstanding of what constitutes deliberate practice. Effective practice is distinguished by intensity, duration, and content. Quality practice is high intensity. Because of this, practice sessions are allocated into periods of moderate length. A common estimate is approximately two hours, as beyond this duration focus and intensity decrease and the yield of additional practice decreases accordingly. Finally, practice sessions are organized to divide a large and complex topic into achievable subcomponents and conducted within a development environment that provides both accessible domain task and knowledge decomposition, and constructive feedback. Over time and successive practices, gaps in skill and knowledge are systematically mitigated incrementally resulting in increasing performance levels and consistency. (The Making of an Expert – Cokely, Ericsson, and Prietula – 2007).
Let’s apply the EPF to assess what we might expect within the health care system.
If you examine the links on nurse practitioners within the health care system, an assertion is made that the quality of care is similar or equivalent (i.e. studies indicate there is not a statistically significant difference between MD/DO and NP delivered care). However, other studies point to metrics such as prescription of antibiotics or ordering an increased level of diagnostic tests which indicate that there are discernible differences between MD/DO and NP delivered care. What would the EPF predict? Let’s examine 2 dimensions – 1) hours of training and 2) training environment.
As already discussed, research suggests that roughly 10000-12000 hours are required to reach expertise in a difficult cognitive field. Expert research tells us that the number of hours of deliberative practice (i.e. legitimate optimally effective practice) is a very accurate predictor or performance level. In studies spanning multiple disciplines, 4000 hours enables journeymen level performance while 10000 or more hours have been required to reach elite performance which is consistently and reproducibly superior to lower levels. As an example, in music 4000 hours enables one to achieve distinguished instructor class, 8000 hours enables one to reach orchestral performance class, and 10000 hours enables one to reach international soloist status. Multiple studies show that there is NO discernible upwards crossover between these groups – no one with only 4000 hours reaches orchestral or soloist class. This makes intuitive sense – expert performance depends on enhanced cognitive mechanisms (i.e. mental representations) that enable advanced skills and knowledge which can be applied to enable consistently superior cognitive problems. If cognitive mechanisms can only be established through a specified amount or structured, rigorous application or practice (similar to how a muscle gains strength only through rigorous, structured repetition), then it is not possible to circumvent these limits and produce equivalent performance via lower levels of practice.
The link Education Gap: MD/DO vs NP shows the chart which got me interested in this question from a expertise perspective. A family physician spends 11 years in training and engages in 20,700-21,700 hours of training. In comparison, a nurse practitioner spends 5.5 – 7 years and between 2,800 and 5,350 hours in training. A lot of articles cite this difference but fail to articulate why it matters, and when. However, the expertise research cited above informs this question. The medical training is equivalent to or may in fact exceed the level of volume (assuming consistently with the principles of deliberative practice, more on that in a minute) elite or expert performance training demands for complex, dynamic cognitive disciplines. In comparison, the NP training is equivalent with distinguished but not elite performance.
Moreover, the conclusions above assume the hours of study and practice are equivalently efficient and productive. Ten years or more is required to reach expert performance because the intensity of optimally effective training limits a single training session to 2 hours not more than twice a day. Further, this assumes the practice or engagement to be peak efficiency but in reality many study or practice environments do not facilitate efficient practice. Some elements that aid study or practice efficiency are elevated peer groups which challenge and inform the student, access to learning infrastructure which provides constructive feedback, and access to elite instructors which guide practice and training. Based on these criteria, the medical residency is much more likely to provide efficient, productive study or training that would meet the criteria of deliberative practice.
The conclusion from the analysis so far is that only the MD/DO cohort undergoes training consistent with progression to expert performance levels. Does this matter? It matters more than you think. And also less. Let me explain. The tendency is to compare MD/DO and NP on common, average difficulty tasks. In these tasks, the groups are likely to look very similar, and the research indicated they do. The reason is that expert skills and knowledge are not needed to perform at this level. However, if one were to take a much more difficult problem, one would find only the MD/DO performers capable of solving that class of problem. This problem is compounded in medicine because the simple and difficult problems are not classified in advance. Often, a complex problem may look deceptively simple and the time lost in diagnosing that simple-looking complex problem will likely lead to a deteriorating prognosis the longer it remains undetected. A healthcare blog case study describes such a case – MD/DO and NP: Experience Matters.
The stated purpose of this article is to examine the claim made by NAPNAP that patient outcomes of NP-delivered care are the same or better care as MD/DO-delivered care. The medical healthcare system is very complex and the task of matching medical expertise to medical problems efficiently is similarly complex. This analysis yields the following hypotheses:
- The NP and MD/DO training programs will yield differential levels of medical skills and knowledge as a result of differing maturity of mental representations established during training.
- Even when the tasks or services performed are the same, the content of the service and the level of expertise administered to provide the care are expected to be different.
- There is a set of tasks that NP training prepares a provider to perform at a similar level to MD/DO providers because advanced expertise is not exercised in performance of the medical care.
- There is an increasing delta between MD/DO and NP delivered care as difficulty of medical services increases. Studies which examine an average or common set of medical tasks may overlook this delta.
- There is a set of tasks which only MD/DO training would prepare a provider to perform. It would not be reasonable to expect a NP to deliver equivalent or independent care in these cases, and thus potentially poses a medical risk to do so.
This has simply been a thought exercise to examine how the EPF might predict or inform medical training and delivery policies. These conclusions are hypotheses based on analysis driven by cognitive psychology principles. Further study would be needed to confirm, adapt, or reject these hypotheses. My recommendation would be to perform think-aloud protocol in a representative set of medical tasks of varying levels of complexity or difficulty to determine the specific skills and knowledge required to perform the tasks. This insight may help all parties by:
- Informing patients and legislators how to distribute medical responsibilities within the healthcare system
- Benefit society in realizing flexibility, scalability, and affordability within the health care system
- Mitigate compensation conflicts by informing the content of service as an element of compensation models, which would provide a fair basis for compensation differences in the health care system for similar or equivalent services.
- Aid nurse practitioners in their goal of performing medical services commensurate with the full extent of their education and training within acceptable boundaries of risk and quality of care.
- Aid physicians by identifying the set of medical tasks their training uniquely enables them to perform