Physician shortage raises questions

06/20/2013 12:00 AM

06/19/2013 2:07 PM

Right now, we simply don't have enough doctors to deliver high-quality primary care. Add to this the 25 million uninsured Americans who will have access to care in January when the Affordable Care Act goes into effect and we have the makings of a disaster.

Medical schools across the country are doing an exceptionally poor job of addressing this shortage.

Their press releases tout large numbers of medical students going into residencies that produce primary care doctors, yet these numbers are grossly misleading.

Yes, they have large numbers of interns starting off in primary care fields like pediatrics and internal medicine but the vast majority – something like 80 percent of them – will end up as some sort of "ologists," meaning subspecialists like cardiologists, gastroenterologists, endocrinologists and the like. These subspecialists are not being trained as primary care doctors nor do they intend to practice as primary care doctors.

It would be far more honest and useful for medical schools to report how many of their graduates from six years ago are practicing in primary care fields. But that number would embarrass the schools.

To fill this gap, it is not surprising that other fields such as nurse practitioners and physicians assistants have made the case that they can offer many types of primary care as well as, and cheaper, than physicians.

Of course, doctors don't believe this. A recent survey published in the New England Journal of medicine suggests that doctors feel that these non-doctors would not improve the quality of care. Doctors felt they provided a higher quality of care compared with nurse practitioners. (The nurses surveyed strongly disagreed.)

It shouldn't be difficult to answer the question of whether doctors or nurse practitioners provide better care. There is no shortage of studies. Of the more than 4,000 studies on this topic, 16 have been judged to be high-quality studies. In those studies nurses, compared with doctors, were found to have higher patient satisfaction ratings, to spend more time with patients and give more information to patients, but they had more frequent visits with patients than did doctors. There were no differences in tests ordered, drugs prescribed, or the health outcomes of the patient.

Many state governments are now considering new rules to expand the practice for non-physician providers. These are long overdue. But what is really needed is a fundamental rethinking of how we practice medicine, not who practices. Physicians with a minimum of seven years of training clearly have more to offer in complex situations than physician assistants and nurse practitioners who have only two years of training. The tent is large enough for all these providers if they don't compete with each other, but work together in complementary ways.

Of course there remain dicey questions, such as how much salary should nurse practitioners make? In some settings, primary care nurse practitioners now make more money than pediatricians and family physicians. This clearly reduces any hope of cost savings that might come from using providers with a far less costly education. Also, if nurses ask patients to return to the office more often than doctors, this could also add to the cost of their care – all areas that need careful study.

The far more important question is whether we can use the Affordable Care Act to redesign health care delivery to create teams of doctors, nurses, psychologists, nutritionists and pharmacists who can work together to actually improve our health.

Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Identifying characteristics of patients mentioned in his column are changed to protect their confidentiality. Reach him at drwilkes@sacbee.com.

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