A spectrum of medical talent to solve the primary care shortage

We’ve all seen the data projecting a shortage of physicians in the United States, expected to reach a shortfall of more than 90,000 by 2020. The lack of nurses is equally well documented. These trends raise concern for all medical specialties, but especially for primary care.

More and more Americans are expected to need these services in the coming years, at a time when fewer and fewer students are committing to careers in primary care – either because the field is perceived to be less prestigious, the hours expected to be unmanageable, or the pay viewed as too low. Amidst the statistics are streams of reports from professional societies, suggesting that their particular profession is best equipped to lead the health care team into the future and provide the primary care services the nation so clearly needs.

The reality is one health profession cannot provide the proverbial magic bullet. It is going to take a spectrum of medical talent – doctors, nurses, physician assistants and others – to ensure adequate delivery of high-quality primary care to all who need it. Rather than jockey for hierarchy within the medical team, we should focus on the concerns we share, particularly insufficient numbers of educators and clinical training sites to teach and guide the next generation of health care professionals. One of the reasons we have too few primary care providers flowing into the workforce is that this clinical training bottleneck prevents or delays many students from practicing, and it limits the expansion of primary care.

Consider the facts. In 2011, more than 75,000 qualified applicants were turned away from nursing programs because schools did not have adequate faculty, clinical sites, classroom space and clinical educators to teach additional students. For physician assistants, one of the fastest growing professions in America, colleges and universities with physician assistant programs cannot keep up with the demand. The majority of physician assistant programs are at capacity for first-year slots and most schools don’t have sufficient public or private funding for expansion. Too few clinical training sites is a major obstacle to expanding the pool of physician assistants ready to work in primary care. And while billions are spent on residency programs for doctors, funding for residency slots has been frozen since 1997, even as medical schools have increased enrollment. Something has to give – and there are some sensible ways to approach the problem.

If we want to have a 21st century, patient-centered health care system where health professionals work as a coordinated team, we need to first reevaluate how everyone on the team is trained and educated before they work together as graduates. While each profession has its respective licenses and certification, and our roles and responsibilities to the patient can vary, we hang our hat under the same medical principles and ethics. Together we are called to ensure the welfare of the patient is primary; and in practice, the team-based approach is key to optimizing the delivery of quality care. For optimum patient care, we must embrace interprofessional education and start to train together. Today, there are so few preceptors and so few sites available to train students, the professions are all scrambling for the same slots and bumping each other out of them. We can be much more efficient and effective in using the slots we have if we apply the principles of interprofessional education.

The first step is for medical, nursing and physician assistant schools to collaborate and develop curricula models that maximize use of existing clinical sites and educators. The next step is to develop and test more innovative ways of training, including the use of high-fidelity simulations that do not rely on the current model of in-person interactions and still maintain quality. The facts are plain: we do not have enough facilities for clinical training, nor do we have enough willing preceptors to oversee the training. This is not a PA problem, or a nursing problem, or a physician problem. It’s a health system problem, and it’s particularly acute in primary care – where we can least afford another roadblock.

Developing a more interprofessional model of education for our professions will also help us more effectively advocate for necessary and impending reforms on the policy level. As the regulation and financing of graduate medical education for doctors is currently being reexamined, policy makers at all levels should also consider supporting the training and educating of physician assistants as part of the health care team. Additionally, we need to ensure that training in primary care, especially in rural and medically underserved parts of the country, is emphasized in proposals for additional funding of medical education for all of our professions.

As we embrace new models for a more coordinated and patient-centered health care system, we need to ensure that the next generation of health care professionals can meet patient demand. Our challenge will be for our schools to address the educational infrastructure and resource issues hindering the deployment of more highly trained nurses, physicians and physicians assistants to help fill the primary care shortage. Until we solve this critical pipeline issue of insufficient clinical education sites, all members of the patient-centered medical team will be unable to realize their full potential in helping to reduce the shortage of primary care providers.

Anthony Brenneman is President, Physician Assistant Education Association.

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  • http://www.thehappymd.com/ Dike Drummond MD

    I agree with you that the coming “shortages” of primary care doctors demand “all hands on deck” when it comes to meeting the primary care demands here in the USA.

    The challenge comes when the governing bodies of the various primary care provider organizations begin to square off in turf battles … as if there is not enough work to go around.

    Here is the AAFP statement that all care teams be headed by doctors
    http://www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf

    And an article on nurses organizations backing legislation for nurses to be allowed to practice independently … already allowed in 18 states and the District of Columbia
    http://www.fiercehealthcare.com/story/supervision-laws-worsen-care-access-amid-doc-shortage/2012-11-14?utm_medium=nl&utm_source=internal

    What is needed is a coordinated primary care strategy to answer the needs that will be exposed in the next decade as the Obamacare Provisions come online. Does our mishmash of private insurance companies and government agencies – often with competing financial incentives – have what it takes to answer the call? Time will tell.

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • buzzkillersmith

    As the PAs and NPs move in, the MDs move out, turning over the hamster wheel to those who will tread upon it.

    • http://www.thehappymd.com/ Dike Drummond MD

      Hey BuzzKiller – the doctors are not giving up the hamster wheel … just hopping on a different one … the wheel of leader of a team of PA’s and NP’s … and leadership is not a skill set we ever learn in our training. This will be a very interesting ride.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

      • http://twitter.com/rboates Randall Oates, MD

        Over the next 2-3 years there will largely be 3 tracks for primary care physicians with only 2 of them being sustainable afterward, and only one track having the ability to scale in order to satisfactorily care for the majority of the populace.

        Track #1 – Probably 10-20% will be successful in a direct care or concierge, high touch model. The doctor here will typically continue to spend a significant portion of their work time doing unrewarding data entry and administrative tasks, but at least they are not having to do it in volume, and they are getting fairly paid for doing it. This is particularly appealing because it involves mostly familiar, legacy skills they already have while allowing for a greater degree of independence than Track #2.

        Track #2 – Probably 40-60% will initially continue on the current track of physicians as distracted data trolls on the hamster wheel of needing to see more patients while doing more and more of the necessary data collection at the same time. These physicians will eventually, either burn-out or live in increasing misery as they are pressured to work harder and not smarter chasing the decreasing revenues of waning fees for services. I suppose this track actually feeds a potential fourth track of physicians who can’t see the opportunities and just quit.

        Track #3 – Probably 10-20% make a transformation, and will be successful because they are focused on the ultimate high touch model of focusing on increasing the value stream to the patient and physician more than increasing volume. I have recently visited dozens of practices where physicians are using the next generation EHR and workflow changes to recover 2-3 hours daily of wasted time (e.g. data entry and administrivia) to either see more patients or go home earlier (usually a balance of both) and delegate the capture of the necessary structured data in order to participate in ACO and other initiatives focused on quality measures, etc. Some are going home 2-3 hours earlier and others have increased their income by more than 6 figures. In most of these, there is far less physician work than when they were on paper/dictation seeing fewer patients. The satisfaction of patients, doctors, and staff are certainly way up. So, it is possible to be both higher volume and be higher touch with better doctor-patient experience; less physician work; and higher quality in all areas.

        After 2-3 years of mostly Track #2 for the majority, in order to take care of the 80-90% of patients not in direct or concierge care, Track #3 will become predominant out of necessity and survival of the fittest. This track will be delayed a bit because it requires very different I.T. systems, and thinking than what is in place in most healthcare settings now. Interestingly, most of the Track #3 doctor practices I have recently visited have been 1-2 doc, independent practices without NP or PA. Several of them are already enrolled in either comprehensive primary care initiatives or other emerging models that rewards them more for better, high touch care rather than volume. Some are now considering adding PA or NP as their need for capacity is growing.

        • http://www.thehappymd.com/ Dike Drummond MD

          Wow .. Dr. Oates … thank you for your well reasoned and detailed
          comment. I must say you have a remarkably clear and detailed crystal
          ball there… AND my purpose in pointing out what I am calling this
          “fork in the road” is so that doctors can see their ability to make a
          choice here which path they might take.

          This strategic level
          practice model choice – high touch/low volume or high volume/low touch -
          is the single largest factor in determining the day to day experience
          of their practice.

          Dike

          Dike Drummond MD
          http://www.thehappymd.com

        • buzzkillersmith

          You’ve done a good job of laying out some of the possible scenarios. Best perhaps not to let the med students know your prediction that they have an 80% to 90% chance of either not that great of a job or frank misery if they choose primary care, at least for a number of years while waiting for a satisfying occupation that might never arrive.

          • http://twitter.com/rboates Randall Oates, MD

            An overwhelming majority of the Track #3 primary care practices are thriving in every fashion. By removing the scut work the doctors are thrilled and patients really appreciate getting the attention of their doctors back. We will soon see a mass movement of doctors out of the doctor as data troll and getting their lives back.

      • buzzkillersmith

        Agreed. But docs might also end up leading MAs and maybe even lay people and not actually being even vaguely aware of what they are up to with your panel of thousands and thousands of patients. After all, we have to delegate. So what happens when the first pt is sent out of the office by some numbskull with a bp of 240/130 and then strokes out? “Well, doctor, this is your patient. Do you think a blood pressure of 240/130 should be treated?” Try explaining that you’ve never even heard that patient’s name before.

  • http://twitter.com/rboates Randall Oates, MD

    The doctor shortage will be solved in 2-3 years by removing the waste in most doctor’s day. Most are now doing 2-3 hours of documentation and administrtivia that can now be mostly delegated via new generation I.T. solutions (i.e. EHR and patient engagement) and redesigned workflows. This is the worst of times where doctors have been increasingly turned into stressed, low capacity, distracted data trolls, or who are creating a lot of canned/cloned data just to survive the insanities. It will take 2-3 yeas for this transformation to become mainstream because the current legacy of expensive/obsolete EHR approaches and old practice habits die hard.

    • buzzkillersmith

      Two to three years is very optimistic. Give it more like a decade, and don’t bet the farm that it will ever even arrive.

  • pippaken

    Don’t forget the other “team players” who can add great value when their skills are tapped effectively – optometrists, pharmacists, and various therapists (OT, PT, RT) …. I continue to be surprised to discover what their training and expertise encompasses and that no-one in med school or residency taught me to tap into!

  • http://twitter.com/OurH_careSucks John Lynch

    There’s little in the history of medical education in America to cause us to be optimistic about its ability to rise to the enormous challenge outlined here. Case-in-point: geriatrics. The Institute of Medicine pointed out the growing need for more geriatrics training to meet the enormous growth in geriatric demand accompanying the aging baby boom population.

    That was over a quarter century ago. Instead of rising to the challenge, they shrunk from it and the geriatric gap between supply and demand is greater than ever. And most practicing doctors failed a test of their knowledge of the special medication needs of their elder patients.

    Asking them to look beyond the confines of the medical profession itself to a more holistic manpower solution seems unlikely, but we can always hope. It isn’t rocket science – or brain surgery – after all.

    • buzzkillersmith

      Your first two paragraphs are right on. Your last one talks about hope. Abandon hope for a better medical system. It is the beginning of wisdom or at least of buzzkillerdom.

  • Dave Mittman, PA, DFAAPA

    Firstly the author says nurses many times, but does not say nurse practitioners. I find it curious as they need to be included in any solution because they are good and they provide primary care as do physicians and PAs.
    After reading the comments below, I find them amusing. NPs and PAs will be “taking over” over a very broken system. One where reimbursement devalues prevention. Where the system devalues talking to patients. Where primary care itself, is looked down upon. Where physicians are still worried about people (PAs and NPs) who are well trained being able to give a physical to vets returning from the Army (where PAs and NPs practice as fully autonomous clinicians) without them “supervising us. As a PA for 35 years I can’t even give a flu shot without a physician being “involved” although they can be 300 miles away and never have entered my clinic. Would it be good for public health to allow PAs to do some things because the evidence shows we are plain good enough to do it? These laws were written 40 years ago and need to be looked at. I bet that we would all agree that any attempt to modernize them will be blocked by the AMA/AAFP who seemed to say in their recent statements that “mid-levels” offer inferior care. Funny, 50% their members or more work right along with us inferior care givers. Why would they?
    My long winded point is that for this system to be healed in any way it needs to be re-designed and any attempt will be blocked whether it makes sense or not. How do we get around that?
    Dave

  • http://www.stephaniefrederick.com Stephanie Frederick, RN, M.Ed.

    “How to collaborate” should be the educational message for all practitioners. In my business as an (RN) Integrative and Holistic Advocate, I oversee and coordinate care in a variety of scenarios. Unfortunately, our “healthcare” system operates under a “fear” based model, and the facility/practitioner silos become tightly guarded. Is the patient’s interest our primary concern? In most situations…no, and that’s a tragedy.