PERS PE C T IV E
ify for targeted scholarships sup- force aren’t new, and neither are
ported by state or federal funds.
Expansion of the CMS Graduate
Nurse Education demonstration
project could substantially increase
the number of qualified nurse
practitioners, who could also
serve as clinical nursing faculty.
State legislation that eliminates
onerous scope-of-practice regula-
tions for advanced practice pro-
viders would enable nurse practi-
tioners, including midwives, to
practice independently and could
increase access to health care. In
Michigan, Senate Bill 680 would
implement these reforms, thereby
allowing nurse practitioners to
prescribe tests, medications, and
services. This bill could increase
the state’s supply of clinicians
and potentially attract nurses plan-
ning to pursue advanced degrees.
Without Question
Threats to the nursing work-
Without Question
Jason Liebowitz, M.D.​​
“W hat have I done?”
The words escaped my
mouth like a punctured tire hiss-
ing air. I stared at the screen and
read it again: Rheumatoid factor:
negative, anti-CCP antibodies: negative.
For months, I had been caring
for Mr. B. and treating what I
presumed was severe, deforming
rheumatoid arthritis. That was,
after all, the condition invoked
by his two previous rheumatolo-
gists, both of whom are highly
respected clinicians in our region.
Mr. B. had come to me for care
when he felt his tumor necrosis
factor inhibitor therapy, which had
worked moderately well for him
in the past, was waning in effi-
cacy. When we met, I saw what
looked like erosive changes in his
hands and large rheumatoid nod-
ules just distal to his elbows, and
we began the process of trying
2456
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Copyright © 2022 Massachusetts Medical Society. All rights reserved.
Addressing Threats to the Nursing Workforce
tute for Healthcare Policy and Innovation
proposals to address them.5 Al-
though policies aimed at individ-
ual components of this problem
could be helpful, a comprehen-
sive package of federal, state, and
local efforts would probably be
the most effective approach for
averting health care system dys-
function and adverse outcomes.
We believe federal and state poli-
cies should both prevent the loss
of current nurses and increase the
supply of nurses. Without timely
investments in the nursing work-
force, the United States may have
enough hospital beds for seriously
ill patients, but not enough nurs-
es to deliver essential, safe care.
Disclosure forms provided by the authors
are available at NEJM.org.
From the Department of Systems, Popula-
tions, and Leadership and the Center for
Improving Patient and Population Health,
School of Nursing (D.K.C., C.R.F.), the Insti-
to find the best therapy for his
disease.
But in the months that fol-
lowed, each change we made —
switching to a new medication,
adjusting the dose, combining
medications — seemed only to
worsen his symptoms. His liveli-
hood as a cabinetmaker whose
exceptional skill had found him
clients among the rich and fa-
mous was being shattered by un-
ending pain and joint swelling.
He could not manipulate the tools
of his trade, and soon, despite
his self-medicating with increas-
ing doses of prednisone, he was
walking with crutches and barely
leaving his house.
At our most recent visit, I had
been shocked by his bulging eyes
and flushed, large cheeks protrud-
ing from behind his face mask.
Though his cushingoid appear-
n engl j med 386;26  nejm.org  June 30, 2022
(D.K.C., C.R.F.), and the Rogel Cancer Center
(C.R.F.), University of Michigan, Ann Arbor.
This article was published on April 20, 2022,
at NEJM.org.
1. Staiger DO, Auerbach DI, Buerhaus PI.
Registered nurse labor supply and the reces-
sion — are we in a bubble? N Engl J Med
2012;​366:​1463-5.
2. Kane RL, Shamliyan TA, Mueller C, Du-
val S, Wilt TJ. The association of registered
nurse staffing levels and patient outcomes:
systematic review and meta-analysis. Med
Care 2007;​45:​1195-204.
3. Aiken LH, Sloane DM, Cimiotti JP, et al.
Implications of the California nurse staffing
mandate for other states. Health Serv Res
2010;​45:​904-21.
4. American Association of Colleges of
Nursing. Charting the future of academic
nursing: AACN 2021 annual report. 2021
(https://www​.­a acnnursing​.­org/​­Portals/​­42/​
­P ublications/​­A nnual​-­Reports/​­2021​-­A ACN​
-­Annual​-­Report​.­pdf).
5. Lynch J, Evans N, Ice E, Costa DK. Ig-
noring nurses: media coverage during the
COVID-19 pandemic. Ann Am Thorac Soc
2021;​18:​1278-82.
DOI: 10.1056/NEJMp2202662
Copyright © 2022 Massachusetts Medical Society.
Addressing Threats to the Nursing Workforce
ance was quite worrisome, even
more concerning were the joints
in his hands, swollen and purple
and exquisitely tender to touch.
Seeing all these symptoms, I final­
ly paused in the exam room to
wonder: What if I have things all wrong?
A mentor of mine had warned
me never to accept the rumor of
a diagnosis, but isn’t that what I
had, in essence, done with Mr. B.
when he entered my care? I had
not seen all the primary data
from years before — his findings
on antibody studies and radio-
graphs — so I set to work order-
ing new tests. As the results trick-
led in, the diagnosis of rheumatoid
arthritis began to seem less and
less likely. Gout emerged as a
potential alternative explanation
for Mr. B.’s symptoms, though I
couldn’t comprehend how a gout
flare would last so many months.
PE R S PE C T IV E
By the time we obtained a dual-
energy CT scan that all but
proved the diagnosis of gout, it
was abundantly clear to me that
I had failed Mr. B.
There are many ways in which
we can fail our patients and many
reasons for these failures. We may
falter in addressing the emotion-
al needs of a patient even as we
provide technically excellent care.
We can neglect to offer clear ex-
planations or leave too little time
for patients to ask questions, there-
by robbing them of their right to
engage fully in treatment deci-
sions. Overloaded schedules, lack
of knowledge or awareness, stress,
burnout, and any number of other
obstacles can prevent us from pro-
viding ideal care. Yet perhaps the
most fundamental way in which
we can fail our patients is by not
questioning the basic premise of
their diagnosis before treating
them. It is true that some diag-
noses may be self-evident — a
hip fracture or a myocardial in-
farction, for instance — while
others, particularly in rheumatol-
ogy, may be vague, difficult to
confirm, and require observation
of the patient over time. Never-
theless, keeping an open mind
and constantly revisiting the ac-
curacy of a diagnosis is key if we
are to best care for our patients
and prevent misdiagnosis.
Cognitive diagnostic errors re-
main extremely common, account-
ing for up to 70% of all medical
errors.1-3 The role of these errors
in increasing morbidity and mor-
tality is now recognized,4 and ef-
forts are being made to improve
the teaching of critical thinking
in medical training and to make
physicians aware of cognitive bias-
es and other issues that can in-
crease the risk of diagnostic error.5
However, even in the era of
electronic medical records, clini-
cians often meet new patients
n engl j med 386;26  nejm.org  June 30, 2022
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Copyright © 2022 Massachusetts Medical Society. All rights reserved.
without having access to the pri-
mary data that were used to es-
tablish their diagnosis. In such
instances, the physician must de-
cide whether or not to accept at
face value each part of the report-
ed medical history. For some diag-
noses, it may simply be practical
and reasonable to trust the rec-
ords, but physicians promulgate
at the patient’s peril any previous
diagnosis that they accept blindly.
During my rheumatology elec-
tive in medical school, our consult
team was asked to evaluate a pa-
tient with a large, painful knee ef-
fusion. The attending physician
provided oversight as I aspirated
synovial fluid from the knee. I as-
sumed we would await the lab re-
sults and then make a diagnosis,
but instead the attending led us to
the hospital basement, prepared a
slide with a few drops of the fluid,
and examined the specimen using
a polarized light microscope. Af-
ter scanning the field for a few
seconds, he stepped aside so that I
could view the abundant monoso-
dium urate crystals. This physi-
cian applied the same approach to
his evaluation of nearly every piece
of clinical data. Together, we
looked at radiographs in the dim-
ly lit hospital reading room, we
swung by the neuromuscular pa-
thology laboratory to peer at mus-
cle-biopsy slides and learn from
the reading pathologist, and so
forth. What my attending was
seeking to teach me was that in
the axiom “trust but verify,” verifi-
cation is the more crucial step.
One would think that such ex-
periences would have solidified
that lesson in my consciousness
forever, but the siren’s call of
heuristics and premature closure
can be overpowering. When a pa-
tient’s story or physical exam
seems to fit neatly into the diag-
nosis that we’ve been handed by
a previous clinician, the impulse
Without Question
to go with the flow can be strong.
Often, it’s only when things don’t
proceed as expected that we find
ourselves asking more probing
questions: Why is the clinical course
diverging from the common trajectory?
Is this an unusual presentation of the
condition I’ve been treating? Or is it
something else altogether?
In the meantime, the patient
suffers until something different
is done.
Mr. B. was ultimately started
on pegloticase, which has dramat-
ically improved his joint pain and
swelling and caused his tophi to
shrink significantly. He is no
longer taking prednisone and is
slowly returning to his normal
life. At our last visit, I apologized
for having taken so long to ques-
tion the original diagnosis and
arrive at the right answer. “It’s
OK, Doc,” he said, “better late
than never.” But if we all bear in
mind the hard-won lessons of our
past diagnostic failures, perhaps
we’ll remember to ask the right
questions early and often.
Identifying details have been changed to
protect the patient’s privacy.
Disclosure forms provided by the author
are available at NEJM.org.
From Skylands Medical Group, Rockaway, NJ.
This article was published on June 25, 2022,
at NEJM.org.
1. Saber Tehrani AS, Lee H, Mathews SC,
et al. 25-Year summary of US malpractice
claims for diagnostic errors 1986-2010: an
analysis from the National Practitioner Data
Bank. BMJ Qual Saf 2013;​22:​672-80.
2. Schiff GD, Puopolo AL, Huben-Kearney
A, et al. Primary care closed claims experi-
ence of Massachusetts malpractice insurers.
JAMA Intern Med 2013;​173:​2063-8.
3. Kachalia A, Gandhi TK, Puopolo AL, et al.
Missed and delayed diagnoses in the emer-
gency department: a study of closed mal-
practice claims from 4 liability insurers.
Ann Emerg Med 2007;​49:​196-205.
4. Balogh EP, Miller BT, Ball JR, eds. Im-
proving diagnosis in health care. Washing-
ton, DC:​National Academies Press, 2015.
5. Royce CS, Hayes MM, Schwartzstein
RM. Teaching critical thinking: a case for
instruction in cognitive biases to reduce di-
agnostic errors and improve patient safety.
Acad Med 2019;​94:​187-94.
DOI: 10.1056/NEJMp2204361
Copyright © 2022 Massachusetts Medical Society.
Without Question
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