Patients at Risk
Niran Al-Agba, M.D. and Rebekah Bernard, M.D. dedicated this book to the memory of Alexus Jamel Ochoa-Dockins, a 19-year-old college honor student, who died September 28, 2015, of a pulmonary embolus—a blood clot in the lungs more fatal if not treated in time. Alexis Jamel Ochoa-Dockins was on birth control pills. Pulmonary embolus is a known rare side effect that can stem from birth control pill use. Alexus spent 11 hours in the Mercy El Reno Hospital emergency room under the care of a Nurse Practitioner Antoinette Thompson. After fumbling about with misdiagnosis, Antoinette Thompson sent Alexus to the University of Oklahoma Medical Center, where she finally received a correct diagnosis and was administered the necessary blood thinners too late. The grim details of her life-ending ordeal are interwoven throughout Al-Agba and Bernard’s book.
Medical Doctor’s Al-Agba and Bernard take on the U.S. Healthcare system’s replacement of medical doctors by nurse practitioners and physician assistants. It was an act of great courage to write this book, risking backlash from the healthcare profiteers. As an example, in the introduction of “Patients at Risk,” Al-Agba and Bernard explain the reason why doctors dare not speak out:
“Steven Maron, MD, a pediatrician with 31 years’ experience, was fired from United Community Health Center in southern Arizona after writing a newspaper article explaining the difference in training between a physician and a nurse practitioner. As Maron pointed out in his op-ed, while there are excellent and experienced nurse practitioners and physician assistants, their education and training are not the same as that of a physician. He suggested that to make an informed decision about medical care, the public should know who is treating them and the critical differences in the training of clinicians. Although Maron had worked for the community health center serving socioeconomically depressed children for ten years without any disciplinary actions, he was terminated just days after the op-ed appeared in the Green Valley News. Steven Maron MD explained, ‘I was told that my article stood in opposition the principles of the organization, specifically the principle of mutual respect.’” (Introduction, Page xiii)
Al-Agba and Bernard summarize that “Maron’s firing likely stemmed not from a lack of respect, but from a vested interest in keeping patients in the dark about the difference in training between clinicians, After all, if patients begin to demand a doctor, organizations like United Community Health Center, which currently employs twice as many non-physician practitioners as physicians, would be forced to restructure their entire staffing model.”1
Medical Doctors Al-Agba and Bernard write in their dedication, “Alexus Jamel Ochoa-Dockins and the countless others who have been harmed by a healthcare system corrupted by greed. May the telling of her story give a voice to those who have been silenced and lead to changes in healthcare policy that will ensure that all patients receive equitable, high quality medical care.”
Training
Our human bodies are complex organisms. This complexity requires highly trained medical personnel to keep us maintained and alive. It really does take years of study and hands on practice. The American healthcare system is based on driving down costs, quality, and access so that corporations can reap huge profits.
On page 1, in the introduction, the authors inform us, “The cost of the 15,000 hours of training required of physicians before being permitted to practice medicine is much higher than the minimum 500 hours required of nurse practitioners.”
In the Appendix for Patients at Risk (page 183) a comparison of clinical and residency hours is laid out, showing how much risk American patients are submitting to the care of far less trained Physician Assistants and Nurse Practitioners:”
“Nurse Practitioner: clinical hours—500-1,500; residency not required; total clinical hours—500-1,500.
“Physician Assistant: clinical hours—2,000; residency not required; total clinical hours—2,000.
“Physician: clinical hours—6,000 (medical school); residency hours—9,000-10,000; total clinical hours—15,000-16,000.
“By 2019 legislators in 23 states and Washington, D.C. were convinced. Despite opposition from physician and patient advocacy groups, lawmakers in these states granted nurse practitioners the right to provide medical care to patients without physician supervision. Corporations and private equity markets were delighted. Instead of paying top dollar for fully trained physicians, these organizations now had the green light to hire less expensive nurse practitioners.”
In 1904, the American Medical Association commissioned Abraham Flexner, an American educator, to travel the world touring and assessing medical schools. Flexner was a non-physician who was most impressed with the Germanic approach to teaching. Flexner’s report was published in 1910 and included the following recommendations to improve and standardize the education of medical doctors:
- Increase medical school admission requirements to include a minimum of two years of college study, primarily devoted to science.
- Increase the length of medical education to four years.
- Incorporate all medical schools into colleges or universities.
- Focus on standardized scientific training and research.
- Appoint full time clinical professors at medical schools.
Medical school training
Most medical schools in Europe and Cuba train medical doctors on a six-year model. There is no waste of time forcing medical doctors into four-year bachelor programs. According to a February 10, 2022, Forbes report, authored by Brianna McGurran and Alicia Hahn, U.S. medical school students pay $265,617-$337,584. Most medical school students walk away with their certifications owing $100,000. Cuba trains their doctors, encouraging international student enrollment, for $69,300.
The authors breakdown the U.S. healthcare systems lack of doctors compared to Europe:
“Americans enjoy a better quality of life than ever before, and until recently, mortality rates have steadily declined over the last thirty years. Despite this good news, studies show that the U.S. lags behind many other industrialized nations in certain health quality measures, including mortality. Why does the U.S. fare worse than similar nations?
“One possibility is that Americans have less access to expert physician care. There are far fewer physicians per capita in our country compared to other industrialized nations. Here are the facts: In 2013, the U.S. ranked 24th of 28 countries in the number of practicing physicians, with only 2.56 physicians for every 1000 people. The only countries ranking worse than the U.S, were Canada (2.46 physicians per 1000), Poland (2.24), Mexico (2.17), Korea (2.16). For contrast, the top physician ratios occur in Austria (4.99 doctors per 1000), Norway (4.31), Sweden (4.13), Germany (4.04), Switzerland (4.04), Italy (3.81), Spain (3.69)”
“This is important because continuity of care with a regular doctor is associated with lower rates of death. Increasing the number of specialists by ten physicians per 100,000 people led to a 19.2 day increase in life expectancy over ten years. Even more benefit occurs by increasing the number of primary care physicians by the same proportion, increasing life expectancy by 51.5 days over ten years.” (Page 79)
“The designation of ‘nurse practitioner’ was first described in 1964, when pediatrician Henry Silver and nursing professor Loretta Ford created a pediatric nurse practitioner program at the University of Colorado. The program opened its doors in 1965 with the goal of graduating advanced nurses who would work alongside physicians to provide ‘well childcare.’” (Page 3)
“The first physician assistant training program was opened in 1965, the same year that the first nurse practitioner program began. Eugene Stead MD, a physician at Duke University, invited four Navy veterans to attend a two-year training program. Stead hoped to build upon the experience of military corpsmen who had served during the Vietnam War and were returning home to civilian life.” (Page 41)
“Physicians created both the nurse practitioner and physician assistant professions. The roles were designed for the two to work side by side to provide complimentary care, with physicians providing careful supervision and mentoring, and treating the most complex patients.” (Page xiii, introduction)
“Quack” is a popular term we are all familiar with, describing an incompetent medical doctor. There are inept doctors unfortunately, yet strict licensing, malpractice suits, and the rigors of their education keeps the numbers of “quacks” from infesting the U.S. healthcare system. As of 2024, the American public is becoming victim of a long-term ruling class quack scam, forcing patients to submit to under-qualified, unsupervised care of nurse practitioners and physician assistants. Following are nurse Practitioner and physician assistant misdiagnosis accounts:
“On Sunday, November 5, 2017, ten-year-old Mya-Louise Perrin began vomiting. Two days later, she vomited again and had trouble standing up, so her parents brought her to Cromwell Primary Care Centre on the coast of England where nurse practitioner Ruth Loveday evaluated her. When she arrived at the clinic, the previously healthy child could barely walk down the hall. Despite the severity of her symptoms, this nurse practitioner diagnosed a urinary tract infection. That same night, Mya-Louise died of an appendicitis.” (Page 64)
“Sixty-nine-year-old John Dalman experienced this type of unnecessary treatment. After enduring ten skin lesion biopsies by a physician assistant during one visit, John was told that other lesions would require radiation and surgery. Worried that a physician assistant would be performing the surgery, he fled from the waiting room of the dermatology office. A second opinion from a dermatologist proved his instinct correct: not only did not need radiation or surgery, but the physician assistant had missed a malignant melanoma on his shoulder. (Page 142)
“Henry Travers, MD, a clinical professor of pathology at the university of South Dakota, Sanford School of Medicine, describes this type of thinking as ‘foreclosure of the diagnoses’” (pertaining to the above examples of misdiagnosis.) He notes that the novice thinker often limits diagnoses possibilities very quickly, latching on to the first diagnosis that occurs to them and failing to consider other potential causes. “Furthermore, novice thinkers fail to incorporate additional evidence to support or reject their preliminary reasoning.” (Page 68)
“The perils of ‘foreclosing the diagnosis’ include the chance of jumping to conclusions about which diagnosis ‘seems right’ while overlooking rarer, life threatening conditions with deadly consequences.’ ‘Physicians do not diagnose this way. Instead, through the process of forward reasoning, physicians learn to pick out salient clinical details to determine which conditions should be included on the extensive list of diagnostic possibilities.’ ‘This skill is not about being smart or good; rather, it is about internalizing a methodology that requires at least 10,000 clinical hours to master.’” (Page 69)
Patients at Risk claims that over booking patients with doctors can diminish the doctor’s effectiveness in providing more “thought time” in rendering solid diagnosis and treatment follow-up. Al-Agba, and Bernard, lay out ways that individual patients can navigate the U.S. healthcare system. The appendix of Patients at Risk, explains the abbreviations that healthcare workers wear on their name tags, enabling a patient to understand the caregiver’s title. In chapter 8, Doctor’s Al-Agba and Bernard give tips empowering patients to see a medical doctor.
Doctors Al-Agba and Bernard present their ideas for reforms such as government funding for more residencies in hospitals, increasing the numbers of medical doctors, a return to physician-centered care without dictatorial interference from corporations. Doctors Al-Agba and Bernard’s altruism is conveyed by this anecdote:
“When Bill Clinton and Arnold Schwarzenegger had open-heart surgery, you can be sure that a physician anesthesiologist oversaw their care rather than a certified nurse anesthetist. These politicians signed legislation that allowed nurse anesthetists to provide anesthesia without physician supervision, but when their own lives were at stake, they wanted nothing but the best. Why should any other patient deserve less?” (Page 157)
Patients at Risk. The Rise of the Nurse Practitioner and Physician Assistant in Healthcare has not been reviewed by the biggest ruling class papers, neither the New York Times nor the Wall Street Journal. It shows that this book takes on a lucrative, entrenched aspect of the U.S. economy that the rulers and owners of this country do not want called out and compromised.
In the March 15, 2012, New England Journal of Medicine, an article entitled, “Major Trends in the U.S. Health Economy,” the author, Victor R. Fuchs, PhD, writes, “In 1950, health expenditures accounted for only 4.6 percent of the Gross Domestic Product. In 2009 they accounted for more than 17 percent, a larger share than all of manufacturing, wholesale and retail trade, finance, and insurance.”
A colorful chart called “Visualizing U.S. GDP by Industry in 2023,” by Govind Bhutada rates the contributing industries and services to the U.S. Gross Domestic Product. Health, social, and educational services rank five-out-of-13 contributors to this country’s colossal wealth and productivity, generating $2.3 trillion a year. Health, social, and educational services beat out finance and insurance at $2 trillion; wholesale at $1.7 trillion; retail at $1.5 trillion; construction at $1.1 trillion; arts, food, hospitality at $1.2 trillion.
The United States capitalist class’s for-profit healthcare system is now a massive contributor to the GDP. The Democrats and Republicans will never tackle this crisis with any meaningful reforms that strike at the heart of healthcare profits. What the Democrats and Republicans will do is reform Medicare and Medicaid, reducing the payouts to the healthcare for-profit titans for services rendered.
Unscrupulous physicians, albeit a minority, are starting to quietly not see Medicare/Medicaid patients because the payouts are unreasonably stingy for care provided. Wall Street is already bellowing like cattle crying for feed:
“Federal payment rates to Medicare insurers next year will come in lower than Wall Street had expected. A decision that weighed down shares in the sector.” —Wall Street Journal, April 2, 2024, “Health Stocks Fall on Medicare Rate Surprise” by Anna Wild.
It begs the question as to whether seniors are going to have to pay out of pocket or go without the care. Healthcare providers from doctors to nurse practitioners will withhold care if they are not reimbursed adequately.
A good article to read on physician refusal of Medicare patients is found on the AMA Journal of Ethics website. “Should Physicians Be Able to Refuse Care for Patients Insured by Medicare” by Kaarkuzhali Krishnamurthy.
Patients at Risk: The Rise of The Nurse Practitioner and Physician Assistant in Healthcare, is a handbook for navigating the complexities and understanding the origins of merging medicine with super profits.
Wresting healthcare away from the profiteers and corporate parasites is going to require mass action and the building of a mass socialist party led by the working classes that can contest for power, with intelligence, belligerence, and strength in numbers to restore quality and affordability back to healthcare.