Episode 12: Diagnosing Health Care

This transcript was generated automatically. Its accuracy may vary.
Cara Lunsford    
    Oh, hey, nurses. Welcome to the Nurse podcast, Giving nurses validation resources and hope. One episode at a time. Oh, today on Nurse Dot podcast.
Will Sanderson    
    If you start incentivizing some of these things, it could solve the underlying the foundation here of health care systems. If you start finding a way to truly incentivize that, I think you will find the financial savings that could be had this massive, massive. But it takes some foresight.
Cara Lunsford    
    Joining us today, Dr. Will Sanderson, fresh from the frontlines of health care in the United States. Will has recently made his way back home to Canada and is currently serving the community in Vancouver as a dedicated E.R. doctor. His unique perspective, shaped by extensive experience in two vastly different health care systems, brings us invaluable insights as to clinicians with our fingers on the pulse of health care.
    We're here to have a heart to heart and diagnose the state of our health care systems. I'm your host, Kara Lunsford, registered nurse and VP of community at Nurse dot com. Oh, Dr. Will Sanderson, How are you?
Will Sanderson    
    I'm so good.
Cara Lunsford    
    I want you first and foremost. You have to introduce yourself. Tell us who you are, what do you do? And then we'll kind of get into a little bit of how you see the world of medicine, your personal experience. And then, you know, we can talk about just other things that we think we know about. But first and foremost, I really want you to introduce yourself, tell our listeners who you are and what you do.
Will Sanderson    
    So my name is Will Sanderson. I'm an emergency doc. I grew up in the wonderful city of Vancouver, B.C., Canada. I moved to the States in my twenties after I met my wonderful wife, who is from Texas. I did my medical school down in Texas and we kind of moved around the States for the last 15 years. I did my residency at the University of Wisconsin, my emergency medicine residency, which was wonderful.
    Madison is a beautiful, beautiful city. And then the academics for a couple of years at the University of Kentucky, which was interesting, a lot of great people there and then wanted to get back close to home and so moved to Bellingham, Washington, which is right on the border of the U.S. and Canada. So we could be close to where I grew up.
    And then this past year, I got my B.S., my British Columbia medical license. And so we're in the process of moving back up to Vancouver. So really happy. It's all kind of come full circle and very, very fortunate.
Cara Lunsford    
    Well, I'm excited that you're here with me because a couple of things that I'm really passionate about talking about is, first of all, emergency room medicine. We know that there is a lot of nurses, doctors, health care workers that are leaving the profession. And for a variety of reasons, some of that is definitely tied to moral injury. The ability to do the work that you signed up to do and to be able to do it safely, ethically, morally.
    And the more that nurses and doctors and just everyone in health care, health care workers in general don't feel like they can do that work and that they can't do it in a way that meets with their own set of values and ethics. I think we're going to see even more people leaving. So I wanted to ask you first, how do you feel your experience has been maybe prepare pandemic post-pandemic of your experience within the health care system, specifically the the.
Will Sanderson    
    E.D. Yeah, it's a great question. So workers, nurses, doctors, therapists, tax, then the emergency department, we kind of get we truly are the frontline 24 seven 365. Anyone any time any place where there and that is already pre-pandemic kind of a sometimes a tough place to be or in a resource limited environment to start with. Right. No matter whether or not you're in a socialized medicine setting or whether you're in the States and you've got a private hospital, we're always going to be resource limited.
    They're going to want us to do work at the very limits of what we are able to do. And so that's a tough place to be to start even before all of the issues with the pandemic came in. So boarding, for example, in the emergency department where we've got patients, we don't have beds in the hospital for patients who need to be admitted.
    That has been an issue for a while, but it was exacerbated by the pandemic. And what happens then is you've got people doing work that they're not trained to do. So you've got, as I'm sure you know, there are nurses that are specialized in emergency medicine. There are nurses who are more comfortable being on the floor of their ICU nurses.
    There's there's just like within the physicians space, their specialization, the same thing happens in nursing. And so you've got emergency nurses doing floor nurse work that they're not comfortable with. They're overworked, they're understaffed, the ratios are off and you've got people burning out in record time down on the there. And so even with unions trying to come in and protect nurses, they're still dealing with ratios that are unsustainable.
    And so naturally that's going to lead to just massive burnout and we're going to lose some of the robust people. And I don't blame some people for leaving.
Cara Lunsford    
    Yeah, for me, and I haven't been quote unquote, at the bedside. I've done Home Health Hospice. I still do some of that. I did it yesterday. I went and saw a patient yesterday. But I'm not in that acute care setting anymore. But I have lots of friends that are.
Will Sanderson    
    And how are they doing it?
Cara Lunsford    
    Struggling. You have get really struggling to what you just said about the safety. Being able to provide safe patient care is number one because nobody wants to walk in and do crummy care. Oh, nobody wants to walk into work. Right. And wonder if today's the day that they're going to be stretched too thin, they're going to make a mistake and someone's going to die or get sick, something bad is going to happen.
    That level of stress is not sustainable. No one can keep going back into work feeling like it's a bad game of Russian roulette.
Will Sanderson    
    You know, What's one of the things that leads to job satisfaction in any profession is feeling like you're good at what you do and you do it in an environment that's supportive, right? That's what all of us want to do. We want to be good at what we do and we want to feel supported. We're getting the opposite right?
    Right. We don't feel like we're doing necessarily a great job because we're being asked to do things that we're not trained to do, and that goes for both nurses and physicians, right? When there's a board and patients sitting in the emergency department for an extended period of time, that's not that normally would be on the floor, that normally would have floor nurses taking care of them, normally would have a hospitalist or an internist taking care of them.
    They're still physically they're sitting five feet that way. And I can't just ignore that they're there. Yes, they might be on somebody else's service, but if they're still down with me, it kind of falls to me and it falls to my nurse, who I've got with two other patients. Well, now she's tied up doing things that she's not come to work with this patient.
    And so inevitably, if you don't feel like you're doing a good job or you don't feel like you're doing something that you're good at, it just wears you, you know, it's just like the river keeps rubbing on the, you know, the side of the beach or whatever it's called the mountain, you know. You know what I'm saying?
Cara Lunsford    
    Yeah, you're talking about it's getting what you're eroding, right?
Will Sanderson    
    So, yeah, if you didn't know I provide visual help or spades, some would say, and here's here's my water.
Cara Lunsford    
    Going over your rock.
Will Sanderson    
    You see that?
Cara Lunsford    
    Yes, It looks lovely. Yeah, they look lovely. They're very buffed. Buffed is what I would say, through the erosion process.
Will Sanderson    
    That's what happens. I'm well eroded.
Cara Lunsford    
    You're well.
Will Sanderson    
    Eroded. Yes. And that's like that's not to complain. It's just the way things are. And I think from a physician perspective, from a doc perspective, at least in the doc perspective, one of the great things about emergency medicine is the camaraderie within your team more than maybe any other area of medicine. The emergency medicine team is super tight knit.
    And so if my tax of my nurses or other members of my team are under stress and not at their best, it hurts me and hurts patients both directly and indirectly. Yeah, it's just too much. And you know everybody right now I don't know of a doc, I won't name names, but I don't know of very many docs.
    Let me be more specific. I don't know very many docs within emergency medicine that have been doing it for about 10 to 15 years, which is where I am, who haven't thought of an exit strategy in some regard. Right. Which is insane because we've spent most of us over ten years, ten, 10 to 10 plus years, including undergrad, med school and residency training to do this.
    And then ten years and you're already looking for a way out. Something's not right.
Cara Lunsford    
    Something's not right. And so when you say that of the docs that, you know, most of those people are here in the US or some are also.
Will Sanderson    
    Most of the docs I know are in the States, so I can't really speak to the Canadian emergency physician perspective. My suspicion and this may be a bias, but my suspicion is that the same type of things are present, but maybe not to the same degree.
Cara Lunsford    
    Fair. I think that's fair. Okay. I know that you haven't had as much experience in Canadian health care as you've had in the US as a physician.
Will Sanderson    
    Yeah.
Cara Lunsford    
    But would it be fair to say that you have been a patient of Canadian health care?
Will Sanderson    
    Yeah, for sure. Yeah. I was here till I was 23, 24, so definitely. Yeah.
Cara Lunsford    
    Okay. So not to say that things don't change, but let's just be honest. Things in health care slow to change. Yeah, well, we'll go with that.
Will Sanderson    
    Yeah.
Cara Lunsford    
    In your experience, even just going into an emergency room as a patient in Canada and in the U.S., what are the things that you feel are pretty similar and things that you feel are pretty different?
Will Sanderson    
    That's a great question. So I think this is a common misperception from some people in the States is that wait times are crazy long for everything, and that's just not true. If you have a STEMI in Canada, you go to the cath lab in the same amount of time that you would if you were in the States.
Cara Lunsford    
    Tell people what the STEMI is. For Anybody who doesn't know what a STEMI is, tell them what is it? Because some people might be like not nurses listening.
Will Sanderson    
    Yes, that was presumptuous.
Cara Lunsford    
    Look.
Will Sanderson    
    A STEMI is what's called an AC elevation myocardial infarction. It's a heart attack. Okay, So you're having a big heart attack and you come in. There's different types of heart attacks, but the big ones are what we call STEMI. And you come in, you say, I'm having this chest pain, we get an EKG and it shows a certain pattern that says, Oh, one of the blood vessels are blocked.
    They're feeding the muscles of your heart and we need to open that blood vessel really quickly, otherwise your heart's going to die or that part of your heart is going to die. And so we have to get in there quick. And so when that's recognized in Canada, you go to the cath lab where they unblock it quickly. When that's recognized in the States, you go to the cath lab to unblock it quickly.
    I think I don't have numbers in front of me, but they're going to be very similar, right? So for emergent conditions, I think you're going to get very similar care.
Cara Lunsford    
    Do you feel like the triage is the same? Right. So you come in, you say I have chest pain or I'm having some sort of symptom, and then they prioritize you?
Will Sanderson    
    Correct. So triage really becomes and again, this is somewhat of an uneducated position on this, but I have seen it to some extent, and that is that the trio system truly becomes a triage system if you have a sprained ankle and there are a whole bunch of people with chest pain ahead of you, you are going to have to wait a long time.
    And that is a big difference, right? So if you go to Vancouver General Hospital on a monday night and you have a sore ankle after you turned two and it's a busy night, you're going to wait probably a really long time. You're going to wait longer, I think, than you would in the States.
Cara Lunsford    
    What do you think the reason is for that?
Will Sanderson    
    Well, I think the feeling is that they're under-resourced as well. And things that can wait will weigh. Whereas, you know, I don't want to be going to turn here.
Cara Lunsford    
    It's okay. We can totally hypothesize about a lot of this stuff because I think that we don't all know the answers. Right? So some of it is just that we have theories. I know we love to have everything based in data and we like to be pretty sure, Right. But in this situation, I think what we're trying to tease out here is between you, a physician and me, a nurse.
    Now, can we try to diagnose this problem? But we don't necessarily have all the answers. We have some knowns and then we have a bunch of unknowns. And we're going to be really clear about the unknowns that we have in the process of of trying to diagnose this problem, because I think that you're making really good points. And I think, like this is how we start to peel back an onion.
    This is how we start to get to solutions and ideas around what can we do to make an impact.
Will Sanderson    
    Yeah, I think one of the things that would make a big impact on both sides of the border and I think something they do really well in Australia and New Zealand is improve primary care. That's a big one, improve primary care, improve access to primary care, not just for prevention of illness, but for a appropriate self triage of certain things.
    Right? Maybe that's one of the reasons as bad as primary care is in the States. My suspicion and my bias is that it's even tougher up here to get a primary care doc. And so I think there are a lot of people that come to the emergency department in Canada for primary care type things they don't have there.
    They ran out of their diabetes medication and they ran out of the high blood pressure medication. They're wondering where they're supposed to go next for something simple, like they had blood in their stool and they were told they're supposed to follow up with somebody at some point to make sure they got a colonoscopy. Well, I don't know where to do that.
    If I don't have somebody that's going to affirm in the right direction. And so I guess I'll just go to the hospital. Right. And so I think there's some of that there now.
Cara Lunsford    
    So like education access, just a really good way of helping people to understand and coordinate their own care in a way that is accessible to people no matter what level of education they have, what language they speak. Because those are barriers, right? Those are barriers right away that if we don't make this more seamless for people.
Will Sanderson    
    Well, and having that central point of contact, having that primary care provider that can do that, that can translate, that can improve health literacy. Yes. I mean, that is one of the biggest inefficiencies in any system, right. Is that if you have those people there, the downstream effects are mitigated better. The more we can incentivize, no matter where we are, the improved access to high quality primary care, a lot of the downstream things that we are complaining about are going to be relegated, not necessarily saw, but mitigated for sure.
Cara Lunsford    
    So really the reimbursement, because we know, okay, like, right, you go follow the money and follow the money. I don't know necessarily how this applies in Canada, but here it's corporate health care. So we prioritize things that are reimbursed procedures. And so if we prioritize primary care and the reimbursement is there, then.
Will Sanderson    
    To go there.
Cara Lunsford    
    It'll start to go there because the primary doctors will want to do that work. They'll want to do it. We have to make sure that we're we're prioritizing the right things and that we're reimbursing the right things.
Will Sanderson    
    Because right now what they're doing is they rely, at least on the physician side, they rely on the the medical because this is this goes back to medical school. Right. Because you choose what type of medicine you're going to practice while you're in medical school. Right. So you get access to all of these things in medical school while you're training to become a doctor, You get some exposure to a number of different specialties, not all of them.
    And then you choose some time in your medical schools for years. So you sometimes people start thinking in their third year and choose in their fourth year what type of medicine they want to specialize in.
Cara Lunsford    
    Is that the same if you're in Canada, like if you're in Canada and you go to schools, it's pretty similar.
Will Sanderson    
    Yeah, it's four years. Yeah.
Cara Lunsford    
    And you have to pick your specialty during that time.
Will Sanderson    
    You start to get an idea and third year and then usually picked by fourth year, you can do your away rotations to audition for a residency program and a residency. For those that don't know is that after medical school you go to medical school, you become a doctor and then you spend anywhere from 3 to 7 or eight years training in a specialty like emergency medicine or orthopedic surgery or neurosurgery, or your nose and throat or primary care, right.
    To be a family physician, an internal medicine physician. And so the medical students know what those positions get paid. And when you've got hundreds and hundreds and hundreds of thousands of dollars of student debt and you know that one of them is at the very low end of the pay scale, and some of them are the very high end of the pay scale.
    You need to follow the running care. You need to follow the money you can't always just appeal to their sense of altruism, altruism and goodwill. Like, you can't do that. But that's what they try to do. They try to tell medical students, you know, do the right thing, go into primary care.
Cara Lunsford    
    Then you should relieve my student loans and you should. Really? Yeah.
Will Sanderson    
    To be fair, there are some programs that the government puts out to try to help relieve the student loans and everything else. But you know, you're going to end up making over the course of your career a fraction of what you would make with one of these other specialties, which is why and again, there are definitely exceptions here, okay?
    But the higher paid the specialty, the higher in the medical school class rank, you'll get the better grades you get to medical school. There's a strong correlation between those groups and the ones that have the higher paid specialties. It's just a fact. And so if you start incentivizing some of these things that could solve the underlying the foundation here of health care systems, if you start finding a way to truly incentivize that, I think you will find some of these problems five, ten, 15 years down the road will begin to be met.
Cara Lunsford    
    Again because what I hear you saying is that if some of these really smart people in medical school turned that intelligence towards primary care, because primary care is what pays. And so they take all of that amazing intelligence and they bring it into primary care. Imagine in the ripple effect.
Will Sanderson    
    There's no doubt. And I mean in primary care and internal medicine, these are very broad specialties that need really bright people doing them effectively. And you're absolutely right. If we could find a way to incentivize that appropriately, I think we need to not rely to your point, we need to not just rely on medical students sense of altruism.
    They chose to go to medical school just like nurses choose to nurse. You'd like to think because they like to take care of patients and they're doing it for the right reasons, right? So we've already kind of established that to some degree, but you can't keep taking advantage of it. And I feel like there is some of that and there's some push to like, come on, you know, do the right thing, pick the right specialty.
Cara Lunsford    
    Well, it's your calling. It's your calling.
Will Sanderson    
    It's your calling right?
Cara Lunsford    
    Like, if you were a nun or a priest or something like that, it's this is what they equate people in health care to, is literally jobs that don't have any kind of compensation. And on top of that, I will say that what people don't take into consideration is the enormous amount of personal risk that people are taking in these professions exposure to pathogens, exposure to violence, exposure to workplace injury and you have to consider those things when you are considering someone's compensation.
    I can't imagine that a police officer or fire fighter or anyone who has a potential going into danger, that that is somehow their risk is not evaluated when they are considering compensation.
Will Sanderson    
    You're absolutely right. I think on top of that, even if you just want to be, you know, pessimistic about this or I don't know, you might say realistic, but the financial burden on the system, if we start thinking long term and so if we start thinking two or three years in the future and we start thinking 15 to 20 years in the future, that the efficiency gains, the financial savings that could be had by incentivizing this on the front end is massive, massive.
    But it takes some foresight. And when you're dealing with something so politically charged where the incentive on the political side is getting reelected and not necessarily in the longer term gains, it's hard to make those changes.
Cara Lunsford    
    Yeah, reform is difficult when there are lobbyists that are lobbying for a personal something that's kind of a personal incentive.
Will Sanderson    
    Sure.
Cara Lunsford    
    Or kind of a I guess not personal, but more of like a myopic incentive in a way.
Will Sanderson    
    Because their lobbies are focused on.
Cara Lunsford    
    Their one thing.
Will Sanderson    
    Yes. Right.
Cara Lunsford    
    And the the success of that one thing and whether that is, you know, hospital associations, their their interest is in the success of hospitals from a fiscal perspective. Right. I'm not saying that they're not interested in patient safety outcomes, etc.. No, I'm not saying that. But I am saying that one of the things that they are interested in is the profitability.
Will Sanderson    
    Sure.
Cara Lunsford    
    Now that's here.
Will Sanderson    
    Yeah, that's scary. Yeah, I think that's okay. And I don't think that's going to change any time soon. Right. But who is looking out for the longer who's in the lobby for a patient's right? Who who's in the lobby for health care professionals. Do you have the nurse lobby? You have you kind of have a physician lobby, but it's it's really you kind of don't we won't go down that rabbit hole.
    But who is who is advocating in Washington for patients first? Right. I don't think that group, if there is a lobby and again, I don't know, but if there is a lobby for some reason, I don't think they're the most well-funded lobby. Right. So who's looking out for those people? And I guess that's where you start to think about is that your government?
    I don't know. Maybe it is, right?
Cara Lunsford    
    Yeah. So I think that this is where there's this really distinct difference between a more socialized health care system and a more corporate health care system, which people would call a for profit nonprofit. But those are all still very corporate health care. So do you feel personally, as a citizen of Canada, do you feel like there's more of a prioritization portion of you as a citizen, you as a person.
Will Sanderson    
    From a health care perspective? Yeah, Yeah, I think so. I think most Canadians are pretty, if you ask Canadians, I'm sure there's polls out there. If you ask Canadians if they're happy with their health care, I think most would say yes, there are definite downsides. Long wait times for elective procedures. Right? So my dad needed his knee replaced.
    He's getting another knee replaced. I'm sure he would have liked to have had it done as soon as he needed it right away. But they said, well, you know, it'll be 12 months, it'll be 18 months or whatever it's going to be. And I think his his perspective is like, all right, well, it is what it is, right?
    I mean, this is not an emergent thing. It can wait. And so I'm going to wait. But it's the price I pay to have free health care essentially for free. But to me, it's free. And I would argue fairly equitable health care. Right. And there are still social determinants of health that affect and cause disparities in Canada, but not to the same extent that they do in the States.
    I think we can all agree on that, that that gap between certain socioeconomic groups and racial groups is a bigger the gap is bigger in the state.
Cara Lunsford    
    The chasm is a bit larger than me.
Will Sanderson    
    I said that the river runs through the chasm and it's just laughing it all right. There is no chasm. Like if I do this, it looks like my head is a rock.
Cara Lunsford    
    In the chasm.
Will Sanderson    
    In the chasm. I don't like using my head. It's too round.
Cara Lunsford    
    Although it is bald. And so therefore, I.
Will Sanderson    
    Actually I actually used to have hair, but. But health care has caused all the rough has caused all of my head to become bald because it's eroded.
Cara Lunsford    
    Polished.
Will Sanderson    
    Full circle, baby.
Cara Lunsford    
    Full circle. We've come all the way back to the polishing and the erosion.
Will Sanderson    
    Yes. Thank you. Thank you. This is erosion. This is erosion that is best. So where were we? It was something really profound and important.
Cara Lunsford    
    It was really that I think we're talking about. You were saying that there's definitely inequities. It doesn't matter if you're in Canada, if you're here, there's inequities, but there are larger sometimes inequities and gaps, especially in certain socio economic or different ethnicity. All of that might be experiencing a bigger.
Will Sanderson    
    I think that's fair. So it gets back to, well, who's looking out for the patients? And, you know, as a Canadian, I remember growing up, I could just tell you how I felt growing up. I always felt we were proud of our Canadian health care. It was one of the things that was was Canadian was that everybody got access to health care.
    It was hockey and maple sirup, but Wayne Gretzky and health care, like that's what we have. And now it's Michael Bublé. But really, those are the things that we're most proud of in Canada. Are those five things at least in Vancouver. The rest of Canada doesn't like them, but really it was something that I was proud of growing up.
    I'm still proud of, and that's one of the reasons I wanted to come home. I wanted to be a part of the system, and I know that I'm treating one set of problems for another. But for me, it's I feel better about it. I feel really good about it.
Cara Lunsford    
    So what do you think it's going to ask you? I know you say like you're treating one set of problems for another. Okay, let's say you're coming into the now the Canadian health care system. You have all of this experience coming from here. If you were to create the perfect utopian health care system, what do you think? Perfect world.
    Because I'm going to go back for a second. I'm going to talk about something you said, which was your dad needed a knee replacement and they were going to take a year. Now, the nurse in me says, Fair, okay, I get it. You got to prioritize it. It's going to take longer. But then what I do is I go, What are the results of being sedentary?
Will Sanderson    
    That's good point.
Cara Lunsford    
    Right? So how are you actually causing more problems? Could be obesity, could be high blood pressure. It could be a lot of things that just being active lead into preventative medicine and keep you out of the hospital and heart disease and all kinds of things. And how does being less active for an entire year at an older age, how does that affect you?
Will Sanderson    
    Right. I think it's a it's a great point and one that I hadn't really thought of before. And you're.
Cara Lunsford    
    Welcome.
Will Sanderson    
    Yeah, no, it's a really good point. I hadn't thought about it, but if you think about it, in his particular case, he was still able to walk. And so what he did is he walked he took responsibility for himself to some extent, and he would walk. He couldn't run or it hurt too much to run. Now, if he was truly immobile, I wonder if that would a bump, too.
    But I don't know. I don't know. I don't know if it would help. And maybe you're right. Maybe that could lead to poor outcomes en masse. Having those kinds of delays. So I think in the perfect system you've got well, there is no perfect system, but if you were going to come up with a perfect system, it would be probably some sort.
    It's support glitch. It would probably be some sort of a hybrid system that was socialized medicine, but with access to private, you know, I agree or some kind of way to ease the burden on the system by allowing people that want to pay a way to get it done sooner. Now, here's the argument against that. The argument against that is twofold.
    One is it creates more inequality. Right? And so you're having a bigger gap between the haves and the have nots. The other part of that is that there are as of right now, there are a finite number of doctors and nurses to go around with in their system. And if you pull them out into the private system, you're not adding more physicians for this private part.
    All you're doing is taking from the public part and taking those providers and moving them into the private part. And so then you're left with staff shortages in the public system. So those are the arguments against. Having said that, I think given that there is no perfect system, probably the utopian system is somewhat of a hybrid with everybody, truly everybody getting access to low cost, high quality health care, primarily in the in a primary care setting, putting a lot of money towards primary care and prevention, and then having a private option for those that want expedited care.
    I think that's probably the closest to a utopian that I can come up with.
Cara Lunsford    
    And probably more utilization of things like telehealth.
Will Sanderson    
    Yeah, for sure.
Cara Lunsford    
    I think we have not done a great job of utilizing technology to help us bring more health care to more people on a regular basis.
Will Sanderson    
    I have a great I had a great example for you on this, which is, let's say an emergency doc gets paid ten bucks an hour. Let's say that's what it is. Okay? I do not or I'd say half of the docs I know would be willing to get paid half of that five bucks an hour to be able to sit and do telehealth triage or do the first after a nurse charges somebody in the emergency department, they see a physician to be a telehealth on a little monitor, on my iPad, on a stick, and I can do most of what needs to be done or at least get the process started to make it more
    efficient. I could do that from my office. I could do that sitting here and there is a movement towards that. Now we still need docs in the emergency department. There's things I won't be able to do remotely, but there is a lot but I can do starting from a remote position. And I know that at my old hospital they had been talking about adding a telehealth shift essentially, and you wouldn't have to pay as much because you're sitting at home.
    But gosh, you do like this. Great. I can just sit around. I get I get a little break in between. I'm in my own house. I'm sitting in my chair. You know.
Cara Lunsford    
    It's a good trade off.
Will Sanderson    
    It's a good trade off. And I know that even here in Canada, they're looking at doing that at one of the sites. Now and again, you're probably get paid less for that shirt, but doctors want to do it. It's called longevity. It's called wellness for the physician. And you're such a great point is that we need to do a better job of using technology to make things better.
Cara Lunsford    
    And obviously, when I think about this in my head, I kind of I have this like triangle, I think in my head where there's just this foundation that you're operating off of, that the foundation really is to provide good, accessible primary care, preventative care to everyone, right? And it's like, you just do that.
Will Sanderson    
    What do you think we need to do to provide that foundation? What do you think needs to be done?
Cara Lunsford    
    So I think that we need to see more as nurse practitioners standing up clinics. I think we need to see more of that because we have so many nurses that have moved into we're seeing this huge jump in nurses that are going back to school to become nurse practitioners. I think that nurse practitioners need to have more autonomy.
    I think PaaS need to have more autonomy around basic primary care. I don't think that you really need to have the level of oversight from a physician on basic primary care and that if we had more of those brick and mortar clinics all over where people just knew they could walk into that clinic, just the same is like what you said about emergency rooms.
    People walk in because that's the place to go. They know that if they walk in there, there's someone on the other side of that desk who can help them. And as long as we start to utilize our workforce to the best of their ability, to their skill level and create more access and say this is it doesn't matter who you are, everyone has access to this kind of care, know, no matter who you are.
    And then I think moving on from there to what you said earlier about. Yes, sometimes you have to have those other options. Maybe people want to pay out of pocket for, you know, for private care. Maybe they want to pay out of pocket for a certain level of insurance that helps them navigate the system a little bit differently above and beyond primary care.
    So they need it. They need a surgery, they need a specialist, they need this, they need that. But I do think that we have to start somewhere. And I think the start is providing that that.
Will Sanderson    
    If you're a nurse who's worked for a while and has made the decision to become a nurse practitioner and again, maybe you can educate me on this, but my understanding is that they can kind of choose to go whichever direction they want to go to, right, in terms of specialties. So in an emergency department, we have nurse practitioners up here.
    I know that on surgical services they do as well, maybe with a little bit less autonomy, but but they do. So what's going to push a nurse practitioner to choose primary care over one of these others?
Cara Lunsford    
    I think autonomy. I think a 100% autonomy is what will drive them into it. Right now, I think it's only about 26 states and I could be wrong about that, but I think it's about 26 states where there are that nurse practitioners have the ability to have some level of autonomy. That really makes a huge difference for them, because if you think about it, if you're there, if you're in a clinic and now everything you do has to run past the desk of a physician who's not there, who do not see the patient that is not involved in.
    But they're. Yes, no, yes, no questioning this and that at the end of the day, come on, this is primary care. This is this some basic stuff here, right? Sure. It's not anything that a nurse practitioner shouldn't be able to do.
Will Sanderson    
    But then you'd need to make a distinction, right? You need to make a distinction and say if you're doing primary care, if you're doing these clinics, then you have autonomy. Because I don't think you can necessarily say across the board, no, that's on me in whatever specialty you want, right?
Cara Lunsford    
    No, no, no. It would be primary care. Primary care. You have autonomy.
Will Sanderson    
    But there are some that want more autonomy across the board. Right. And so you'd have that within the group. There needs to be a unified front in a way. Right. Because I think what you're saying makes a lot of sense. And I think if it came across as autonomy in any specialty, no matter what, I think you would get more resistance.
Cara Lunsford    
    Oh, for sure you'd get more resistance. And I really don't think that that's the case. I think that if you want to drive more nurse practitioners into primary care, the way to drive them is through a tone and.
Will Sanderson    
    Honesty with that within.
Cara Lunsford    
    That, within that, within that area. And then I think you would see, you know, if we were then through government helping to fund those nurse who want to stand up a clinic in an area that does not have a lot of access to health care, maybe that gets more government funding. Maybe that gets some support in some way.
    If you choose as a nurse practitioner, maybe you get some loan forgiveness or something like that because you're deciding to go and stand up a clinic in an area that doesn't have access. I think that there's like so many things that we could absolutely be doing.
Will Sanderson    
    I love your idea. I think that's such a great idea. How do you feel about this has been a hot button issue? So within medical schools we have or is it AMC? I think that has standards for who gets a medical degree in the United States, right. And that you have to meet certain standards from the outsider's perspective.
    I hear chatter amongst physicians about diploma mills, online diploma mills for nurse practitioners. Is that real? Is that something that is that a boy?
Cara Lunsford    
    That's an opening for we could do a whole we could do a whole podcast just about the for profit private IT university type of thing, going from having your BSN to having your MP and how much.
Will Sanderson    
    Give me your 32nd.
Cara Lunsford    
    My 32nd pitch.
Will Sanderson    
    I want to see how you feel about it. I want to hear if it bothers you or if you're like, No more access is better. We're like, How do you where do you fall on that?
Cara Lunsford    
    I think that this is the reason why it's really important to have a very strong licensure test. So if you're going to get your R.N., if you're going to get your NP, if you go to a university that is maybe not providing the best education and really could be potentially a disservice to the public, there is a safe here's the safety, right?
    The safety is you still have to take the same test that everyone else wanted to.
Will Sanderson    
    Use right now.
Cara Lunsford    
    No, it is. It is. It is. So that's why I'm overly concerned, because I do feel like the test in the end collects and the next gen, which is that the updated and Clark's I think.
Will Sanderson    
    Is appropriately rigorous.
Cara Lunsford    
    It's appropriately rigorous. Yeah and so my caution to anybody going into a program that isn't preparing you adequately is that you might be stuck with a shit ton of student loan debt and no license and so don't recommend that. Choose choose carefully. Be diligent about the school that you're choosing to go to. And don't just look at past rates, because sometimes what happens is, is that you may not even make it through graduation because they've weeded you out.
    And now the ones that are actually going to take the test are the ones that are passing, but they've collected a fair amount of tuition from you in the meantime. Right. You know, you've spent a year or two or something in school and then you don't pass school so that their pass rate is really good.
Will Sanderson    
    I think you need an episode coming up with somebody that knows what they're talking about on this for sure.
Cara Lunsford    
    For sure, 100.
Will Sanderson    
    Percent in advance. In fact.
Cara Lunsford    
    I think maybe I've done a little bit of these episodes, which I have a little bit more knowledge about the system, if you will. But I do think that it's not a major concern because I think the people that are getting out there and actually have their license to practice that they've had to go through the proper vetting, that's great.
Will Sanderson    
    That's good to hear. That's helpful.
Cara Lunsford    
    So I'm glad that we've solved all the world's problems.
Will Sanderson    
    Yeah, I can. We could talk forever. Now I see why you're such a good podcasters.
Cara Lunsford    
    Thank you. I think that all the answers are out there. It's about getting curious. It's about sitting here, having a conversation, trying to diagnose a problem. Someone's going to listen to this podcast and someone's going to go, I'm going to run with that. I'm going to run with that. And maybe someone out there is going to listen to this and say, I'm going to do that.
    That's what I'm going to do. That's how I'm going to fix the system. And so really, it's just our job to plant the seeds.
Will Sanderson    
    Yeah, No, I think you're doing such a great job doing that, too. I like the idea of an interdisciplinary discussion too, right? We have so much we can learn from each other. I'm going to be honest from the emergency department. The one thing that I think we do really well is we truly are. And not to sound Pollyanna about it, but we truly are a well running emergency department is truly is team centered.
    Everybody knows the roles and everybody respects all of the members of the team. And we listen to each other.
Cara Lunsford    
    And because you don't have time not to. And I think that that's probably what you you have learned organically for sure.
Will Sanderson    
    And some of my most gratifying moments as a physician have come from interacting with the members of my team. And that's not just me. Pretty much every emergency doctor you speak with would say that one of the best parts of their job is getting to interact with the nurses, getting to know their nurses and being a part of that team together.
    And that's great. That's one part of the job. And when we talk about it, it makes me think, Wow, I still have a good 15, 20 years and the first year.
Cara Lunsford    
    I love that. I just realized that the title of this is going to be called Diagnosing Health Care.
Will Sanderson    
    Oh, that's perfect.
Cara Lunsford    
    Sometimes I don't have a title until it's done.
Will Sanderson    
    Until it just.
Cara Lunsford    
    It just happens and it weaves and it becomes and unfolds. And then you're like, That's it. And that's what our episodes about were diagnosing health care.
Will Sanderson    
    I love it.
Cara Lunsford    
    Well, you were a wonderful guest.
Will Sanderson    
    Wow. That's very kind of you I beg to differ. And I apologize in advance for all of my inaccuracies.
Cara Lunsford    
    No, you were not inaccurate.
Will Sanderson    
    But it was an absolute pleasure chatting with you and keep fighting the good fight. I love listening to your podcast and are very, very proud to call you a friend.
Cara Lunsford    
    Thank you so much. Well, until next time, my friend, if you're a nurse or a nursing student who enjoyed this episode, don't forget to join us on the nurse dot com app where you can find the nurse dot discussion group, a place where we dissect each episode in detail and delve deeper into today's topics. Nurse Dot is a nurse com Original podcast series, production music and sound editing by Dawn Lunsford, Production Coordination by Rhea Wade, Additional editing by John Wells.
    Thank you to all the listeners for tuning in to the Nurse Dot podcast. Until next time, keep spreading the love and the care.