A debate on what we need our doctors to do

It’s a strange business we are in.

Doctors are spending less time seeing patients, and the nation declares a doctor shortage, best remedied by having more non-physicians delivering patient care while doctors do more and more non-doctor work.

Usually, in cases of limited resources, we start talking about conservation: Make cars more fuel efficient, reduce waste in manufacturing, etc.

Funny, then, that in health care there seems to be so little discussion about how a limited supply of doctors can best serve the needs of their patients.

One novel idea is to have pharmacists treat high blood pressure. That would have to mean sending them back to school to learn physical exam skills and enough physiology and pathology about heart disease and kidney disease, which are often interrelated with hypertension. Not only would this cause fragmentation of care, but it would probably soon take up enough of our pharmacists’ time that we would end up with a serious shortage of pharmacists.

Within medical offices there are many more staff members who interact with patients about their health issues: case managers, health coaches, accountable care organization nurses, medical assistants and many others are assuming more responsibilities. We call this “working to the top of their license.”

Doctors, on the other hand, are spending more time on data entry than thirty years ago, as servants of the big data funnels that the government and insurance companies put in our offices to better control where their money (which we all paid them) ultimately goes.

In primary care we are also spending more time on public health issues, even though this has shown little success and is quite costly. We are treating patients one at a time for lifestyle-related conditions affecting large subgroups of the population: obesity, prediabetes, prehypertension and smoking, to name a few that would be more suitable for non-physician management than hard core hypertension.

It is high time we have a serious national debate, not yet about how many doctors we need, but what we need our doctors to do. Only then can we talk numbers.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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  • EmilyAnon

    Well, California thinks it might have the answer to the doctor shortage. Currently there is legislation pending that will allow people here illegally to apply for professional licenses of all kinds. Based on the success of the undocumented now being able to practice law here, other licensures currently excluding this group will now be challenged, including medical. Judges and politicians next? Interesting times ahead.

    • Lisa

      I would like to point out that if an undocumented person was able to to obtain a medical license here in CA that still would not allow them to be employed as a doctor here in CA,

      • EmilyAnon

        The bill in question “proposes licensing undocumented immigrants to practice medicine”. What’s to stop them from being hired? Especially now that a federal taxpaper ID number will be accepted as proof of identification in lieu of a SS number.

        http://www.bizjournals.com/losangeles/news/2014/05/12/bill-proposes-licensing-undocumented-immigrants-to.html

        http://www.latimes.com/local/la-me-immigrants-doctors-20140512-story.html

        • Lisa

          The federal taxpayer ID number could be used as ID when taking licensing exams, not as proof of citizenship for employment.

          The proposed California law has nothing to do with federal employment law.Any employer would still be subject to federal law and would have to determine the citizenship status or visa status of any potential hire.

          I live in California and I really think this law is more of a political statement about of current immigration laws than a real attempt to deal with a shortage of doctors.

          • EmilyAnon

            Lisa, I live in California too. Do you really think that anybody will go through the grueling ordeal of medical school without assurances that they can practice medicine afterwards. An illegal who graduated law school recently sued for the right to practice law without citizenship, and it was granted by a judge. This landmark decision will now be used to challenge all the other professional licensing restrictions. I doubt any politician in the legislature will attempt an appeal. With the current demographics, It would be political suicide. The bill is SB1159.
            As for the federal government policing the rules of the federal taxpayer ID number, what do they care as long as the person pays their taxes.

          • Lisa

            You miss my point – employers are responsible for determining if prospective employees are either citizens or have the requisite visas. If they do not do this, they are subject to large fines. Employers such as clinics, and hospitals do take this seriously. When was the last time you were hired for a job? The last time I was hired, I had to show proof of citizenship or the legal right to work in this country, besides providing a social security number. BTW, people who are not US citizens but are working legally in this country can get a social security number.

            I still say this law is more of a political statement about immigration law than anything else, but despite that I have no problem with anyone who can pass the licensing exams being licensed and having the ability to practice as a physician in this state.

          • ak123

            Wow. Nice talking points everyone. As someone who spend a year separated from my parents when I was eight to legally come to this county, I sincerily disagree.
            A) Illegal is illegal. It is deeply offensive to anyone who has gone through the trouble of immigrating here legally to reward illegal immigration. If you are concerned about your children, then plesase, go through the legal channels.
            B) How about all those doctors struggling to get here on J1 visas? Look how difficult it is for them. Why give others a shortcut?
            C) Would we make these “dreamer” illegal immigrants also work three years in an underserved area like regular J1 docs?
            D) How about adults who might feel compelled to cross the border illegally to practice medicine here?
            E) They need to be hired, employed? Not really. Set up a nice cash practice as an MD here and no employment needed. Sorry, but someone can just go out and hang a shingle.
            I don’t think illegal immigration needs to be a deal breaker and lead to deportation. But, there needs to be penance before amnesty and illegals should have to pay a price to gain their “legality.” Moral hazard is a very important concept and having young children doesn’t absolve you of this. Such a bill is an insult to the hundreds of thousands who go through the trouble of immigrating legally.

          • Lisa

            The law has would have no effect on immigration laws, as that is a federal matter.

          • querywoman

            When I worked in public welfare, I quite easily verified alien cards by phone.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I don’t get it Emily. If a kid was brought here by parents that were willing to work hard and see the child through school, and the State made it possible for the young person to graduate with a law degree and pass the bar, or a medical degree and pass the boards, why shouldn’t we allow them to practice their profession? Would you want to send them, and all that education, back to Mexico, or wherever the parents came from? I would attach their citizenship papers to the bar/boards results and wish them all the best….

          • EmilyAnon

            Why the lecture? I never gave my views on whether illegal immigrants should or should not work here or obtain professional licenses. I only stated that the rules of professional licensing in California are being challenged. And that some politicians are using the doctor shortage to support passage of a new bill allowing undocumented to apply for these licenses. And that a lot of political pandering is going on. This is precendent setting legislation that is sure to pass. I didn’t bring it up to be debated. I just thought it would be of interest in a medical forum, especially to those who might not be aware of changes that will surely come their way in the future.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            It wasn’t a lecture. It was a question, maybe a couple of questions…. I admit that I may have misunderstood your remark regarding what’s next for judges and politicians…. My apologies if I did.

          • EmilyAnon

            OK, maybe I was a bit snarky, it was too tempting. This young man who is now licensed to practice law is talking about running for office. The breaking of barriers will continue.

          • querywoman

            Should the child get government aid for college when I never got any for my undergraduate degree and I’m a US citizen?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I do understand the question, but I am not sure it is valid. There are only 5 States that provide some sort of financial aid to these children and there is no federal aid for them, and pending federal legislation does not include financial aid, other than loans availability. There are 18 States that charge undocumented kids in-state tuition, while all the others charge them much higher out of state rates. The total number of undocumented college students is around 65,000 (maybe a bit more by now), with at least half in community colleges. So basically, I don’t think that whatever we do for them has a measurable impact on the availability of financial help for other citizens.

          • querywoman

            It’s just one of my personal axes to grind. I don’t have a problem with educating them through the 12th grade.
            The cost of a public education for the children of undocumented aliens surely fantastically exceeds the cost of health care for these children.

  • SteveCaley

    OOW, they call it – the plague of having civilians running military policy. Armies are designed to engage and destroy hostile forces in a territory. But then, they wind up with – Operations Other than War. Directing traffic. Building homes. Doing all sorts of stuff they’re not trained and equipped for. In Afghanistan, our local National Guard troops were teaching bee-keeping to the local Afghanis, as thought it were a completely new concept to them like Angry Birds. They do, after all, manage to grow opium poppies quite well up in the mountains; they must know SOMETHING about the keeping of bees already. (Wouldn’t eat the honey, myself.)
    Beekeeping. Building schools. All sorts of humane and wonderful things, but it’s not what Armies do. It’s the sort of foolishness that comes from people with too much free time, and the arrogance commensurate with high Government rank.
    Rather than finding exciting and novel ways of doing something, let’s focus on the doing of the job, not the entertainment value. Maybe if something doesn’t work, it’s already broken, and doesn’t need “creative destruction.”

  • EmilyAnon

    California politics in action. Any opposition to this movement is characterized as bigotry.

  • buzzkillerjsmith

    Serious national debates get us nowhere. Serious national debates are engaged in by those with the biggest mouths, not those with knowledge and wisdom.

    What should be done? Which of course is not likely to be done.

    Really a hard question to answer. In the best of all possible worlds, family docs and general internists would be seeing many if not most primary care pts. We have the knowledge to evaluate and treat almost all common conditions, and, don’t fool yourselves, many if not most complicated conditions that do not require procedures. I know how to manage stable and unstable coronary artery disease and so does every internist and family doc at this blog. We just don’t do the caths.

    We know how to manage a diabetic out of control with a little renal failure who comes in feeling “crappy” and has a bit of a fever.

    But we don’t manage these patients much because we don’t have the time to do it and we don’t get paid to do it. We don’t get paid to go to the hospital.

    Should we be seeing sore throats and runny noses and simple pneumonias and stable hypertension and diabetes and dyslipidemia and mild depression and anxiety? Maybe not. Those cases are “brainrot.” Not a nice term, but one used frequently among docs. Those patients should probably be seen by folks with less training. But it’s really hard to know when the patient makes the appointment if it will be a simple case or something bad. This argues for a generalist in every clinic, to provide immediate consultation. Will that save money? I don’t know, but it is good medical care.

    Of course we all know that in many cases simple cases are not seen by docs. Heck, in many areas serious cases are not seen by docs. Moreover, there is a very reasonable argument to be made that we PCPs should see patients when they are not seriously ill or not complicated cases, that we should get to know them and care for them. I agree with this, which is why I went into family med. But that model is gone, doornail dead, except perhaps with concierge, which might be great on a micro scale but not for the whole country.

    Reasonable measures will likely not be taken, as most everyone who reads this blog knows. In practice those “outpatient consultants” would be so abused that only the most foolish medical students would sign up for the job. Every PCP here knows this. I’ll let them explain this to non-docs here who query or challenge me on this, if the docs would be kind enough to do so.

    As a clear-eyed buzzkiller, my best guess is that care will continue to fragment, with pharmacists and others skimming off the easy (and more lucrative) patients. Primary care has entered a death spiral.

    • NPPCP

      Hi Buzz,
      Only thing I would add – maybe I’m the exception. I care for all those cases – all the time. But you already know that. I think a lot of the things the docs think are complicated (see above) are already treated and have been for years by the likes of me. At this point in my private practice NP clinic I have almost 30,000 hours of OJT. It’s just me here. Not much gets by me. I know not all NPs are in this situation. But a lot are. So the ones that are need to go ahead and be cut loose. I’m not scared. No need to have an outpatient physician consultant around. I feel like physicians would be thankful for those like me to help take the load off. Just additional perspective. Thank you my friend.

      • buzzkillerjsmith

        No problem. I think NPs should do whatever they feel comfortable with as long as they’re licensed to do it. Here in WA they are.

  • querywoman

    An “illegal” alien is one who has been subjected to some kind of federal government action, like having received deportation papers.
    An “undocumented” alien is one who is here without the papers and the feds haven’t got after yet.

  • querywoman

    The reason we educate their children through high school is the children are not responsible for their parents having brought them here.

  • Maggie Keavey Kozel

    Thank you Country Doctor for being an important part of the conversation. Since using EHR’s I am more and more convinced that the software was designed by nonclinicians to maximize billing. The potential for EHR’s that put the actual doctor-patient experience at the center of the “encounter” ( i have come to hate that word as much as “provider” ) is there, but has not been the focus. I often feel that my primary job has become data entry.
    I was really looking forward to hearing from my colleagues on this one. But as I read throught the comments on this piece , there was a lot of cranky off-topic stuff – the kind of stuff that finally led me to put SERMO on my junk mail setting. I hope that’s not the direction we’re going in here. I’m all for free speech. But in my limited time to engage on the important topics of the day, I need to be selective. I need the professional sources I go to and the conversations I engage in to be well informed, focused and well articulated. I realize that can mean many different things to many different physicians. I can only speak for myself.

  • Richard Stanton

    Wow! After a quick review of the comments, I remained amazed that neither the article nor the respondents raised the obvious and long avoided answer the the shortage of physicians. Educate & train more of them. There is no shortage of intelligence outside of the medical community. There is a shortage of training institutions.

    I fully agree that physicians are becoming overwhelmed by data demands. It has been developing for a few decades, and it will get much worse if/when the ICD-10 greatly increases the demand for physician production of data.

    Has the medical world simply decided to retard the development of an adequate supply to meet this demand? Yes, this approach does boost the profit potential – shortages of supply customarily increase prices. But, the cost to MD’s in terms of quality of practice and quality of life outside of their professional roles is enormous.

    RDS

  • Randolph Fenninger

    As the occasional patient, this only confirms my fundamental tenet about medical care, “reforms”, “progress”, etc. The basic issue we have to address in our medical care is the interaction between the person who needs medical services and the person who provides it. All of our collective efforts should be directed to making sure that this interaction is as successful as it can be. Anything that contributes to that success we should keep. Anything that does not should be discarded. I think that is much harder to do than to articulate. To me that is why so much healthcare discussion drifts into talk about “systems”. Much easier to deal with abstract concepts than sick people and their individual needs. When I am ill or injured, I don’t need a “system”, I need a physician or other competent health professional to care for my illness or injury.