What differentiates mid-skilled from low-skilled healthcare workers?

January 6, 2012 6:31 AM

What is the dividing line between mid-skilled and lower skilled workers in the health care industry, besides a degree? Is there a consistent set of responsibilities, qualifications that set them apart? Any kind of consensus as to what it required?
posted by LeonBernstein to Work & Money (7 answers total)

Not entirely clear what you mean by "dividing line" or the difference between "mid-skilled" and "low-skilled" workers. It's sort of hard to separate the latter from formal training though.

So you've got some people with high school degrees, though fewer and fewer these days, as orderlies have largely been replaced by CNAs and their equivalents, who are required to pass a state-mandated exam. Many CNAs have a two-year degree to that end, but I don't think it's strictly required everywhere. Same goes for various "technicians". These people can touch patients, take vitals, etc., but can't usually administer medicine. You see a lot of them in places like nursing homes, where there needs to be a lot of hands-on care, but it's mostly changing bedpans, rotating bedridden patients, etc.

Then you've got Registered Nurses with two-year degrees, but RNs with bachelors, i.e. a BSN, are increasingly preferred. These people can administer medicines, but not prescribe them. These are the rank-and-file of any hospital floor or doctor's office and provide the majority of front-line care in those environments. They're the ones who check in on the patients every hour or so, or take preliminary histories and vitals to save the physician time, etc.

Then you've got people with graduate degrees, mostly Physicians' Assistants and Nurse Practitioners. These professionals usually have Masters' degrees, though some have doctorates. These professionals can administer and prescribe medicine and make diagnoses, but sometimes need to practice under the supervision of a physician. That supervision can be pretty nominal, but in many states they can't just go out on their own. But even when they can, they're generally limited to GP-type stuff, i.e. you find many PAs or NPs serving as the functional equivalent of family doctors or workplace health providers, but you don't see them doing surgery or doing things like endocrinology or cardiology. They can, however, assist physicians in performing more complex procedures, and it's not uncommon to have a surgeon assisted by a PA. The PA can't do surgery by himself, but he can assist a physician.

At the top you've got people with doctorates, i.e. physicians, i.e. people who went to medical school and residency. Physicians can do it all, at least within their specialty, though they frequently delegate a lot of the "hands on" stuff like taking routine vitals, administering patients, moving patients around, etc. to their support staff.

In essence, what we've got is a spectrum of activities arranged from least to greatest risk to the patient. One could also describe it as arranged from least to greatest autonomy/discretion. So an unqualified volunteer probably won't be able to touch patients at all, but a technician of some sort could. But taking vitals and placing IV lines is less risky than actually administering medicine, which is in turn less risky than prescribing medicine and making diagnoses, which in turn is less risky than operating an independent medical practice and treating more serious/specialized diseases. As you move up the chain, you also see that people have more and more discretion about patient care. Technicians and RNs basically do what they're told, but PAs and NPs can make a lot of choices about patient care, while physicians can prescribe and perform complex procedures and surgeries.

This setup is not entirely without controversy. Physicians, being the most highly trained professionals in the country, don't come cheap. So there's an argument to be made that we should have "less qualified" people doing more patient care, especially where the input of a physician looks more like a formality than a requirement. Need stitches? Got a runny nose? Need a booster shot? Do we really need to have the physician doing all of these things, or is a PA or NP going to be able to take care of that just fine? Increasingly, hospitals and even physician practices are doing more and more with PAs and NPs, as they're cheaper, and saving money is a bigger and bigger priority for the entities that wind up paying for health care. Billing $1,000 and getting paid 20% of that is, in some sense, worse than billing $300 and getting paid 50% of it, because the latter frees up the person billing $1,000 to do more stuff that only he can do.

This is actually part of why emergency departments are so expensive. You never know when someone's going to walk through the door who absolutely needs advanced trauma care or immediate and significant medical intervention. Need stitches? Go see the nurse. Oh, you're in acute renal failure? Or your arm is hanging by a thread? Yeah, maybe you should see the doctor. So you need an emergency physician on staff round the clock. But odds are pretty good that the vast majority of any given emergency physician's cases on any given day are not only entirely capable of being handled by a PA or NP, but aren't even emergent. It's just that having them do something is more efficient than just having them sit around.

But this still isn't all that efficient, so we're starting to see a lot more urgent care centers, which are typically staffed by one or two physicians supervising a small army of PAs, NPs, and nurses. These are for minor injuries, routine colds, the kind of thing that you need to see someone about but not necessarily right away, and not necessarily a specialist physician. Anyone with access to a prescription pad will do.
posted by valkyryn at 7:03 AM on January 6, 2012 [3 favorites]

Off hand I do not think is is degrees--actually I am not sure what you mean by mid/lower skilled. As a general matter I would suggest that the dividing lines are basically along the axes of:
1) Does professional/occupational intervention with the patient increase the patients medical vulnerability/safety: housekeeper/dietary/phlebotomy/nurse/etc.
2) Specific training/experience required to preform the service--drawing blood versus executing laboratory tests
3) The physical intrusiveness of the procedure--giving a shot (nurse) versus doing a bone biopsy (physician)
4) Scarcity/availability of skill--scheduling office appointments versus reading/interpreting lab results.
I think all in all it is a combination of the specific skills, education/training to acquire the skills, the extent the skill puts the patient at risk and the supply demand for the skills.
Usual educational levels are H.S diploma > Certification for a skill(s) no degree > Associate Degree with certification/License> Bachelors Degree certification/license> Masters Degree License > Ph.D License > M.D. License > M.D. Specialty.
posted by rmhsinc at 7:20 AM on January 6, 2012

Medical assistants (MAs) are another layer of below-nurse but with a license and maybe an Associate's. In some settings, they might do a lot of the checking patients in and taking vitals. Nurses are expensive, relative to MAs and so forth, so offices trying to save money will get as much out of lower-level people as they can before they hire another nurse- a private practice might have two doctors supported by two MAs, two medical secretaries, and one nurse.

Experience also plays a huge role. Medicine is a fast paced environment, and if you screw up, it's pretty obvious. In private practices, especially, an MA with a ton of experience working in a particular environment might function with responsibilities identical to those of a nurse. Someone with an MA who doesn't do good work (because they're sloppy, or forget things, or whatever) will work with more supervision and on less important tasks.
posted by MadamM at 8:11 AM on January 6, 2012

Valkyryn did a great job of explaining, but I have to take issue with this one statement:

RNs basically do what they're told

In a hospital, at least, this is entirely untrue. Yes, RNs carry out a physician/PA/NP's orders to administer medications and some other treatments, but they are also responsible for understanding these orders and questioning or refusing to do any that they think are not in the patient's best interest. RN's also have the autonomy and responsibility to initiate and carry out a huge range of important care that the doctors never really notice or think about. RNs assess patients' knowledge about their health and provide tons of education to help people recover faster and stay safe in the hospital. RNs assess risk and initiate interventions to prevent potentially deadly complications of hospitalization, things like pressure ulcers and pneumonia and deep vein thrombosis. RNs monitor vital signs, lab work, imaging results, and the patient's condition, and know when changes warrant a call to the doctor vs. letting the rounding physician check it out when they come by tomorrow. Hospital RNs frequently suggest changes to a patient's medications or care, and although they need a doctor to approve these changes, the physicians definitely respect the opinion of an experienced RN and will usually sign off on the suggestions.

Back to the original question, I would define the difference between mid and lower-skilled workers based on specialization. Patient care assistants work with the same patients all shift and do things like turning people, bedpans, helping people walk or bathe, etc. I would call that more skilled than the work of, for instance, phlebotomists, who are highly skilled at drawing blood but don't really do much else.
posted by vytae at 9:46 AM on January 6, 2012

In a hospital, at least, this is entirely untrue.

I should have phrased it differently, but what you've said is basically what I meant. RNs have a significant amount of autonomy in day-to-day patient care, and this gives them unique insight into how the physician-prescribed course of treatment is actually going. If you want to know how patient [x] is doing right this minute, you don't ask the doctor, who usually sees each patient once or twice a day, you ask the nurse, who checks in several times an hour.

That being said, RNs do not have any authority to direct patient care. They can carry out orders to that effect and have fairly wide discretion in doing so, but they don't really give orders of their own.
posted by valkyryn at 12:20 PM on January 6, 2012

Better: A Surgeon's Notes on Performance

Gawande has some talks on YouTube that might be relevant as well.
posted by callmejay at 7:51 AM on January 8, 2012

Never mind, I think I may have misunderstood the question.
posted by callmejay at 7:51 AM on January 8, 2012