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It was no routine inspection. The investigator who showed up at the Santa Rosa, Calif., hospital that June morning three years ago wasn't interested in checking for germs on table counters. Anonymous reports had come to her agency, the state's department of health services, claiming the hospital was endangering the lives of surgical patients."We all had to go meet with the official, one at a time, in private," says a nurse who is on the hospital staff. "It created quite a stir. But a lot of people were relieved because they knew what was happening was wrong."
The official quickly uncovered the truth: An unlicensed assistant was performing surgical procedures, including suturing deep-tissue wounds and placing pins in bones. "Patients had no idea that the person doing these things could be an assistant without even a college education," the staff nurse says. Although the hospital denies that patient care was ever compromised, a quick end was put to the assistant's illegal operating career. Too bad it didn't put an end to the story. A survey the following year by the California Healthcare Association revealed that unlicensed staff was assisting in surgery in at least 20 California hospitals.
If you think this sounds a little scary, you're in for an even bigger fright. For what unfolded in California is only a symptom of something far more serious. In a six-month investigation, Reader's Digest has uncovered evidence that your health -- even your life -- is being put at risk in the last place you'd expect. In hospitals, doctors' offices and outpatient clinics, the person you have the most contact with may not be a physician or a nurse. He or she could easily be someone whose medical education consists of a few days or weeks of training, much of it provided on the job. It could be someone who doesn't even have a high school degree and who, not long before, was cleaning tables in the hospital cafeteria.
The full price we are paying for this amateur care is tough to know because so many incidents are shrouded in secrecy. Lawsuits stemming from medical-staff errors are usually settled out of court, and then hushed up by gag orders.
Most of the nurses and aides contacted by Reader's Digest were willing to speak only if their names were not used. Several acknowledged that they'd been in situations where unqualified nursing care endangered a patient's health, yet they wouldn't discuss details for fear their employers would punish them.
Among those interviewed was a former aide in a Pennsylvania hospital, who spoke bluntly about her trials as an unlicensed assistant: "I often felt like I had a patient's life in my hands, and I was wondering, 'What do I do here?' I would be scrambling to take vital signs and respond to patients' calls. Then I'd try to evaluate what were the urgent things I should get a nurse for and what I could take on myself. It was wrong because I'm an aide, not a nurse."
It used to be that the duties of unlicensed aides were limited to tasks that required little training, such as taking patients' temperatures, bathing them or helping them move from bed to chair. But during the past decade, pressures to slash costs have changed the aide's job, sometimes radically.
Nowhere was the money squeeze tighter than in hospitals, where Medicare payments were falling even as competition heated up for managed-care contracts. To boost their bottom line, hospitals hustled in management consultants who told them, among other things, to cut labor costs.
You didn't have to be a brain surgeon to figure out the next step: Unlicensed aides typically make $10 an hour, compared with $21 for registered nurses. So hospitals and clinics began hiring more "unlicensed assistive personnel," as they were called, who took on new duties previously carried out by registered nurses or licensed practical nurses (trained to a lesser degree than RNs). Inevitably, too many aides wound up in situations where they were dangerously over their heads.
Early one January morning in 1996, a woman in Hayward, Calif., called her doctor's clinic complaining of symptoms that were classic for an abdominal aortic aneurysm -- an extremely dangerous swelling of the artery that carries blood from the heart. Unknown to her, the medical-advice phone line was manned by unlicensed assistants.
She called four more times during the day, yet the aides decided she didn't need immediate attention. Not until late in the afternoon was the woman allowed to see a doctor, and by then it was too late. The aneurysm ruptured while she was being prepared for emergency surgery, causing her to suffer an excruciating death.
Horror stories like this shouldn't surprise anyone, given the wrenching changes in nursing staffs. According to Peter Buerhaus, senior associate dean for research at Vanderbilt University School of Nursing, some 100,000 unlicensed aides were hired by hospitals from 1995 to 1996, half of whom were let go the following year. Their numbers then remained relatively stable through 1999 -- the last year for which Buerhaus has solid calculations. To come up with his figures, he had to use U.S. Census surveys, since no one tracks the nationwide employment of aides in hospitals anymore.
"The American Hospital Association stopped collecting data on unlicensed aides in 1994, and a lot of nurses think they did it on purpose because they didn't want the public to know what was happening," says Christine Kovner, a nursing professor at New York University.
This suspicion is unfounded, says AHA Senior Vice President Rick Wade. He maintains that survey questions about the number of aides and other support staff hired by hospitals were eliminated for a practical reason. Confusing and inconsistent job titles, he says, made the task of identifying aides too cumbersome.
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