A tale of two professions: Why you may know a hospitalist but not an RCT

Since their first appearance some 20 years ago, "hospitalists" — doctors who manage patient care during a hospital stay — have assumed an increasingly complex role in the healthcare system. Conversely, the attempt by the AMA to address a nursing shortage by the creation of a bedside care worker called the "registered care technician" was a short-lived and unsuccessful experiment. Professor Eugene Schneller of the School of Health Management and Policy at the W. P. Carey School, examined the successful hospitalist movement and the failed RCT implementation in a chapter for the recently-published "Managing Change in the Public Services."

A new kind of doctor has quietly entered the healthcare system in the United States. "Hospitalists" manage patient care during a hospital stay, acting as the agent of the patient, the primary care physician, the hospital and sometimes even the insurance company. Since their first appearance some 20 years ago, hospitalists have shifted the relationship between community and hospital health care in many areas across the United States.

But the "registered care technician" (RCT), a bedside care worker that was introduced by the American Medical Association (AMA) in 1987, was an idea that never came to fruition. The move was an attempt on the part of the AMA to address a nursing shortage; however, the RCT turned out to be a short-lived experiment, and the need for nurses continues to outstrip supply to this day. The emergence of the hospitalist to assume an increasingly complex role in the healthcare system and the lack of innovation in designing new bedside care providers illustrates the delicate balance of relationships between health disciplines in the United States.

It is a case study about change in a decentralized system controlled by professional associations. Professor Eugene Schneller of the School of Health Management and Policy at the W. P. Carey School, examined the successful hospitalist movement and the failed RCT implementation in a chapter for the recently-published "Managing Change in the Public Services."

Managing change

Schneller co-edited "Managing Change" with Mike Wallace, a professor of management at the University of Cardiff, and Michael Fertig, a lecturer in education at the University of Bath (both in the United Kingdom). The book was the result of a project funded by the Advanced Institute of Management Research, which sponsors research to improve management practice in the U.K. Wallace and others studied how complex change occurs in education. "Managing Change" applies what they learned to other public services.

Wallace sets the theme for the book by describing the dilemma faced by public service providers: how to respond to the impetus for change, yet continue to deliver uninterrupted service? Change, he says, results from "the press of political, economic, social and technological forces that may bring reform from without and stimulate innovation from within." Change in this context is unplanned and often disruptive, frequently entwining various agencies and groups.

It's complex and unpredictable. Meantime, providers are expected to deliver service without a misstep. In this dynamic environment, agencies that successfully navigate change do so by "coping," according to Wallace, a process where key players at various levels in organizations orchestrate new approaches by incorporating changes while attending to the details of the established day-to-day tasks.

They combine the skills of leaders and managers, sometimes working in the background and sometimes in public. Schneller, whose long term research interests include leadership and change in the healthcare sector and the development of new health professions, looked at how interaction — or lack thereof — between health associations affected the adoption of two new hospital-based care professions.

Registered Care Technicians

In 1987, the American Medical Association waded into uneasy waters, attempting to alleviate the seemingly perpetual shortage of nurses by implementing a new occupation: the registered care technician, or RCT. The RCT was to be a non-nurse care worker who, under the supervision of nurses but reporting to physicians, would shoulder specific routine nursing tasks such as monitoring patients and carrying out certain physicians' orders.

The aim was to lighten the load for nurses. Implementation, Schneller points out, required "nationwide acceptance among multiple groups of stakeholders over which the AMA did not have jurisdictional authority." The AMA acted alone, however, "consistent with the unique level of authority over health care long claimed by the medical profession." The AMA was attempting to address an underlying problem: the nursing shortage. The association ignored the fact that its efforts would impact the jurisdiction of another profession, however, most notably the very well-organized American Nursing Association (ANA).

This proved to be a fatal mistake, because the AMA's attempt to solve an underlying problem was perceived by the ANA as an external threat to the nursing profession. Nurses viewed the RCT as a challenge to their professional jurisdiction. The ANA response, Schneller writes, was based on "a well-articulated and widely accepted ideology that … [positioned] qualified nurses as the sole providers of bedside care."

This ideology — the "primary care" nursing model, "protected the nurses' jurisdictional interest through the idea that only professional nursing staff should be involved in bedside care — even for non-technical skills." The ANA asserted that presence at the bedside is essential in order for nurses to accumulate enough information to understand the patient's needs, Schneller explains.

The ANA pursued countermeasures that focused on culture-building and communication — effective orchestration tools that the AMA had neglected to use. The nursing association conducted a campaign to persuade other stakeholder groups — managers and other professionals in health care settings, patients, patients' relatives and people who might need health care in the future — that the RCT was a bad idea.

The ANA even sought support from physician specialties that were not consulted by the AMA when it was cooking up the RCT idea. In 1990 the AMA House of Delegates voted to end its efforts to implement the RCT. The ANA had successfully orchestrated protections for its jurisdiction from encroachment at the hands of the traditionally powerful AMA using culture-building and communication.

Hospitalists

Around the time that the drama was playing out between the AMA and the ANA, another change was taking shape in the division of medical labor in hospitals around the country. "The hospitalist movement emerged at the local level during the 1990s, gradually becoming conceived as a single entity and spreading across the U.S. healthcare system without significant conflict," Schneller writes.

The term "hospitalist" first turned up in a 1996 article in the New England Journal of Medicine written by and Lee Goldman, medical school professors who championed the movement. The Society of Hospital Medicine (SHM), formed a year later, reports that there are 20,200 hospitalists practicing in the U.S. today — a number that is projected to grow to 30,000 in 2010. The SHM defines a hospitalist as a physician "whose primary professional focus is the general medical care of hospitalized patients.

Their activities include patient care, teaching, research, and leadership related to hospital medicine." Schneller identifies several reasons why the hospitalist became a new member of the medical professions family. One is that "there is no unequivocal point where the hospitalist movement can be said to have begun." Change in U.S. health care, Schneller observes, "tends to follow revelations that the system is failing."

Healthcare providers respond to failure with adaptations and innovations locally. Information travels fast, however, and innovation is eventually broadly accepted. The hospitalist idea eventually "diffused" around the country, without government intervention, thanks to local and finally national orchestration. It was a bottom up evolution that contrasts with the AMA's top down imposition of the RCT.

A change like the hospitalist movement had the potential to create intra-professional conflict (remember the reaction of the nurses to RCT?), however the hospitalist movement was not a battlefield. In the healthcare institutions Schneller analyzed for this chapter, the change in the division of medical labor was accepted because it was perceived as advancing the good of the patient by providing consistency, improving safety and reducing potential for infection.

And, the locally-engineered arrangements solved rather than created organizational and business problems. In fact, Schneller writes, "the confluence of interests between hospitalists, clients, other medical professions, managers and payers seems sufficient to underpin further expansion and consolidation" of the movement.

Effect on reform

Schneller's analysis uncovers some of the forces that will impact the chances for any change to occur in the nation's sprawling health care system. The "old health care hierarchy topped by the medical profession" is being undermined by technology advances and the adjustments that are being made in the workplace, Schneller writes. The astute application of culture-building and communications can facilitate innovations, or terminate them.

Change agents who ignore this cut their odds of success. Healthcare in the United States is under tremendous pressure to transform itself. Proposals to address insurance issues are under consideration in many states, and national reform promises to become an issue in the presidential election. Advocacy groups and policy makers would be wise to heed the tale of the two professions.

Bottom Line:

• The American Medical Association attempted to create a new, non-nursing bedside care position (the Registered Care Technician) in 1987, but was forced to abandon the project three years later after a successful counter-campaign by the American Nursing Association.
• The hospitalist movement, which was in the nascent stages of development when the AMA was trying to implement the RCT, has evolved into a new in-hospital medical profession with 20,200 practitioners nationwide.
• Mike Wallace, a researcher from the United Kingdom, has developed a new theory of managing change in the public service. Change in a complex environment involving numerous agencies who are all under pressure to perform must be orchestrated, he says, which involves managers at various levels in all affected organizations in the coordination of communications and culture change.
• The RCT case is an example of a change initiative that failed in large part due to orchestration. The AMA neglected to orchestrate the groups affected by the RCT, which contrasts with the ANA's masterful orchestration of the opposition.
• The lesson of the hospitalist and the RCT can be applied to other sectors where a systemic change involves multiple groups.