Do We Need More Doctors? Maybe Not.

Posted on | October 25, 2012 | 4 Comments

Mike Magee

With the election just two weeks away, the status quo as a choice- whether it be Grover Norquist tax pledges, Congressional stalemate, underwater municipal bonds, or a century old health delivery model – would seem unwise in the extreme. Were we as a country to chose it, we would live to regret it. Why? Because the status quo has been overtaken already by irreversible trends that gain more steam, day by day.

Regardless of who wins the election, we will be forced to evolve one way or another. And many of our citizens are not waiting for permission. Let’s take health care workforce issues as an example.

One of our valued Health Commentary subscribers wrote this week:

“Dr. Magee, just wanted to say thanks for the article.(1) I am an RN now and in school to become NP in about year and a half. I’ve read your article, and it gave me even more confidence that I am doing the right thing for my patients, my family and myself. The Affordable Care Act will create high demand for quality primary care, and I saw this as an opportunity to grow in the field that I enjoy. There is no doubt in my mind that “new” health care reform will, most definitely, require more NP in the field. I am still not sure how the ACA will be financed and who will end up paying for increased expenses, but one thing I know for sure; nurse practitioners (NP) will play a vital part in health care system in a few very short years.”

The air has been thick of late with articles about an impending doctor shortage – especially primary care doctors. But for leading nurse practitioners, the current conditions spell opportunity not threat.(2) Take Patricia Dennehy RN NP for example. She is the director of GLIDE Health Services in San Francisco and a professor at the UC San Francisco School of Nursing. Here’s what she has to say: “Nurse practitioners can help fill this gap. We are registered nurses with graduate school education and training to provide a wide range of both preventive and acute healthcare services. We’re trained to provide complete physical exams, diagnose many problems, interpret lab results and X-rays, and prescribe and manage medications. In other words, we’re fully prepared to provide excellent primary care. Moreover, there are plenty of us waiting to do just that. The most recent federal government statistics show there were nearly 160,000 of us in 2008, an increase of 12% over 2004, and our numbers continue to rise.” (2)

Why the focus now? Because the Affordable Care Act will bring an additional 30 million uninsured Americans into the ranks of the insured within the next two years.(3) There are already about 250 Nurse Practitioner run sites like Patricia Dennehy’s with varying levels of reimbursement and independence and/or cooperation with physicians.(2) The Institute of Medicine in its 2010 “The Future of Nursing” report, endorsed the use of nurses as “full partners, with physicians and other health care professionals, in redesigning health care in the United States.”(4)

President Obama’s Affordable Care Act arguably signaled that the status quo in health delivery was no longer acceptable. This was not the result of politics or a desire for social engineering, but a reflection of changing dynamic forces reshaping an out-of-date sector.

The three key trends that outpaced our delivery system were an aging population (with resultant 4 and 5 generation family complexity), Internet connectivity (and the capacity to built new virtual networks at low cost), and health consumerism (and its ability to emphasize personal resposibility and place individuals at risk for poor health behaviors). The end point? Personalized, prospective, and preventive health care.(5)

Of the many challenges this end point entails, none is more serious than human resources – creating a affordable and efficient workforce that is up to the task. This likely will require new job descriptions for every caring professional including the physician, massive retraining of existing workers, and critical re-thinking of workforce plans for new entrants into the various health care fields.

As health policy expert John K. Iglehart outlined in a 2011 article in the New England Journal of Medicine, health care human resource issues are rapidly coming to a head.(6)

Physician organizations say we need more doctors. The Association of American Medical Colleges says we’ll be short 62,900 doctors by 2015.(6) Inspite of the crushing debt imposed on graduating medical students and the delayed earning power resulting from an additional 3 to 5 years of residency training after medical school graduation, tons of kids still want to go to medical school. This helps explain, in part, why 16 new medical schools have opened in the past decade with another 12 in development.(6) To do what? To largely train kids how to practice medicine the way it has always been practiced – rather then as it soon will be practiced.

So will health care demand exceed physician supply? Well that depends on what kind of delivery system we develop, what we expect these new physicians to do, and how well trained they are to do it efficiently. It also depends on how many other clinicians like Patricia Dennehy are helping care for all these people.

Dr. Bill Frist recently said, “To meet the explosive demand of primary health services will require a truly disruptive reform of how primary care is delivered. Delivering primary care will not remain the sole purview of doctors. There are not enough of them, and they are too expensive. Expanding the scope of practice of Physicians Assistants and advanced practice nurses simply has to occur.”(6)

Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, tied this expansion (supported by a recent Institute of Medicine panel) back to training with this commentary: “…This creates an imperative for academic medical centers to respond with new approaches to training, as well as research regarding which educational and care models work best.”(6)

Money is tight. The health sector is out-of-date. Job descriptions haven’t been fundamentally updated in a century.

Do we need more doctors? Maybe not. In the long run, we may be better off holding tight and using all the human resources we have to maximum benefit.

For Health Commentary, I’m Mike Magee.

References:

1. Magee M. Will nurse practitioners fill the primary care gap? http://healthcommentary.org/?p=4877

2. Dennehy P. Healthcare Reform’s Missing Link – Nurse Practitioners. Los Angeles Times. February 22, 2012.http://thehealthcareblog.com/blog/2012/09/08/healthcare-reforms-missing-link-—-nurse-practitio/

3. Affordable Care Act – Implementation Timeline. The White House. http://www.whitehouse.gov/healthreform/timeline

4. IOM: The Future of Nursing – Leading Change, Advancing Health. October 5, 2010. http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

5. Snyderman R, Yoediono Z. Perspective: Prospective health care and the role of academic medicine: lead, follow, or get out of the way. http://www.ncbi.nlm.nih.gov/pubmed/18667879

6. Iglehart JK. The Uncertain Future of Medicare and Graduate Medical Education. http://www.nejm.org/doi/full/10.1056/NEJMhpr1107519

7. Association of American Medical Colleges. Physician shortages to worsen without increases in residency training https://www.aamc.org/download/150584/data/physician_shortages_factsheet.pdf

Comments

4 Responses to “Do We Need More Doctors? Maybe Not.”

  1. Lindsey
    October 25th, 2012 @ 8:53 pm

    I like your interesting view point. As an RN myself, it’s not every day you see an article like this. I agree, maybe we don’t need more physicians. We are having a increasing number of nurse practitioners that need to be utilized. According to an article posted by American Medical News there will be a 94% increase of nurse practitioners by 2025.(1) Financially this would be a great move to allow nurse practitioners to offer more primary care and would absorb the increase in number practicing. Thank You for your excellent article.

    Lindsey

    1.American Medical News:
    http://www.ama-assn.org/amednews/2012/07/02/bisb0702.htm

  2. Jeffrey Cain, MD, President, AAFP
    October 31st, 2012 @ 12:12 pm

    The American Academy of Family Physicians shares your concern that our country needs a larger primary care workforce and your hope for a disruptive change that will address our country’s expanding need for health care. A new report on this topic, Primary Care for the 21st Century(1), offers our perspective on this important issue.

    That disruptive change is here, right now, in the form of the patient-centered medical home (PCMH), which has already been proven to provide higher quality care for patients and decreased costs(2). The PCMH is based on a team approach, where every patient has a personal physician, and that physician leads a team of professionals including nurse practitioners, physician assistants, nurses and other health care professionals
    Every American deserves to have access to a personal doctor and a nurse.

    But nurses are not physicians. Family physicians receive 21,700 hours of education and clinical training over 11 years. Nurse practitioners complete 5,350 hours of education and clinical training during five to seven years. The additional training of family physicians brings extra breadth and depth to the diagnosis and treatment of all health problems, from chronic obstructive pulmonary disease to refractory multiple sclerosis.

    The American people need to know that if advocates of replacing primary care physicians with nurses have their way, soon they won’t have a personal physician — they’ll have a nurse. Their children won’t have a pediatrician — their children will have a nurse.

    We value nurse practitioners. Family physicians work every day with nurse practitioners across the country. They are critical players on the health care team — but they are not doctors. A physician-led team ensures the patient gets the right care from the right medical professional at the right time.

    Yes, there is a primary shortage that is expected to grow as more Americans gain insurance coverage under the Affordable Care Act. We believe the answer is more doctors and more nurses working together in integrated, coordinated, physician-led health care teams through the patient-centered medical home.

    Jeffrey J. Cain, MD
    President, American Academy of Family Physicians

    1.http://www.aafp.org/online/en/home/membership/initiatives/nps/patientcare.html
    2.http://www.pcpcc.net/guide/benefits-implementing-pcmh

  3. Mike Magee
    November 1st, 2012 @ 11:41 am

    Dear Dr. Cain-

    Thanks very much for sharing your insights and important point of you, and for your leadership at the AAFP.

    I share many of your concerns but come to somewhat different conclusions. For example, while I recognize that doctors consume 4 times as many hours in training as do nurses, I am concerned that the physician job description has not been fundamentally reassessed in nearly a century, and that the medical education curricula is largely the same as when my father and my brothers attended medical school (plus and minus multiple scientific understandings ).

    As for Medical Home, I applaud the values and intentions of the AAFP and others that ground the concept, but stand by my 6 word IOM critique of the execution of the concept: “Too Much Medical, Not Enough Home.” For the values and intentions of Medical Home to be truly patient-centered, physicians will need to demonstrate greater mobility and familiarity with the home setting and actively train, promote and engage in the engineering of “healthy homes” and individualized “strategic health planning” as anchors of a new preventive health care system.

    Finally, I think the time has passed for intense focus on nurses as competitors of physicians. Rather I believe we should take a fresh look at what we are trying to accomplish together – both in preventive lifespan health planning and chronic disease management – and match the need to the available human resources (including physicians, nurses, other health care professionals, family caregivers, educators, financial planners, governmental and non-govermental public servants and more).

    What is the minimum training required to efficiently and reliably deliver the various outcomes we all desire? Are we using the immense training and public investment in our physicians, nurses and others as wisely as we could? Have we adequately defined the responsibilities of individual, family, community and society – and developed and advocated for a government relations program that would deliver necessary resources to support citizen participation in their own health and the creation of a healthy, forward-facing society? Have our physician leaders, including association presidents and CEO’s and medical school deans proactively challenged bad science (from creationists to “legitimate rape” to global warming denial) proactively and publicly? Have our physician associations developed policies and concrete plans that acknowledge the roles of health consumers as both consumers and providers of care in today’s modern, mobile and complex world – and do they have an effective plan for the “planetary patient”, increasingly at risk for lack of enlightened human leadership (witness Sandy)?

    These are some of my concerns. Rather than focusing on more physicians, I believe we need to stop for a moment and seriously consider how we might do more with the tremendous physician resources we already have. Perhaps this question might be considered at the next AAFP Board Meeting.

    Best Regards, Mike

  4. Katherine Woodfield
    November 7th, 2012 @ 1:35 pm

    This is a very important topic. I work with people to understand how their health insurance works. Among our conversations, I often point out that as a patient they need to use the health care resources more wisely.

    If my son has an ear infection (and as a mother of 3, I can spot those ear infections a wriggle away) on a Sunday afternoon, I do not need to go to an emergency room. As an educated patient, I might elect to seek the opinion of a Nurse Practioner at a local retail pharmacy for a fraction of the cost of the emergency dept visit and with easy access to the prescription. These professionals can easily manage mild dilemas and proper use of all the available community resources would releive pressure on the medical system.

    As consumers, we need to manage more of our health care decisions and worry less about how our insurance will pay for our services.

    Katherine

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