Wednesday, March 03, 2010

Not Enough Primary Care Doctors

A piece of the health care reform issue we don't hear much about is the very serious shortage of primary care physicians

The annual number of American medical students who go into primary care has dropped by more than half since 1997. It's hard to get an appointment with the doctors who remain. In some surveys, as many as half of primary-care providers have stopped taking new patients. The other half are increasingly overworked and harried. Clearly we need to find a way to increase their ranks, and both the congressional health-care bills and President Obama's reform proposal make moves in that direction. But those efforts are somewhat limited, and a more comprehensive solution could be thwarted by the same thing that's stalled the rest of health-care reform so far: politics.

The reason behind America's doctor gap is a matter of money. The average income in primary care is somewhere in the mid-$100,000s, which sounds like a lot but is less than half what specialists such as radiologists and dermatologists make. Given that doctors may graduate with as much as $200,000 in med-school debt, it's easy to see why primary care started hemorrhaging recruits more than a decade ago and why radiology and other well-paid, high-tech specialties took off in popularity.

The field has since entered a vicious cycle. As fewer people have entered primary care, the doctors who are left have been forced by tight schedules to shortchange some patients, forgoing the long, meandering chats that used to be a big part of checkups in favor of 15-minute, checklist-style appointments. The close relationships that general practitioners once had with patients drew many idealistic students into the field. Now recruiters face an extra-tough sell: they have to convince bright young would-be docs to pursue a career that won't pay very well and won't be as emotionally fulfilling as it once was.

Some medical schools around the country now have programs that pay a portion of the med student's tuition, in exchange for them doing their training in rural areas. There is also the National Health Service Corps where scholarships and loan repayment are available to medical professionals who go to work in an underserved area. Programs like this are especially important in rural areas. From their website:

About the National Health Service Corps
Since 1972, more than 30,000 clinicians have served in the Corps, bringing high quality health care to places and people without access to even basic services.

Nearly 80 percent stay in the underserved area after fulfilling the NHSC service commitment; more than half make a career of caring for underserved people.

Last year, about 3,500 NHSC providers cared for 4 million people — changing their own and their patients' lives.

According to the Journal of the American Medical Association doctors are working fewer hours than they used to:

Average hours dropped from about 55 to 51 hours per week from 1996 to 2008, according to the analysis, appearing in Wednesday's Journal of the American Medical Association.

That's the equivalent of losing 36,000 doctors in a decade, according to the researchers. And it raises policy questions amid a looming primary care doctor shortage and Congress considering an expansion of health insurance coverage that would mean more patients.

One can certainly suppose (correctly) that overwork and burnout may be reasons why doctors are working fewer hours, but money also seems to be a big motivator:

Payment issues may have played more of a role. The overall decrease in hours coincided with a 25% decline in pay for doctors' services, adjusted for inflation. And when the researchers looked closely at U.S. cities with the lowest and highest doctor fees, they found doctors working shorter hours in the low-fee cities and longer hours in the high-fee cities.

One way to address the problem of doctor shortages is to have patients see nurses, physician's assistants, and nurse practitioners for routine care - all of whom can detect a serious problem and pass it on to a doctor. In some rural areas this is already happening, out of necessity.

The American Medical Association and doctors groups don't like this. Even though there is a serious shortage of primary care docs, the AMA is opposed to letting nurse practioners have a greater role in primary care.

The American Medical Association sparked harsh criticism from nursing groups when it released a report in October bluntly questioning whether nurse practitioners "are adequately trained to provide appropriate care." To back up its claims, the report cites recent studies that question the prescription methods of some nurse practitioners, as well as a survey that reported only 10 percent of nurse practitioners questioned felt well prepared to practice primary care.

The nurses are fighting back:
Responding to the AMA in December, the American Nurses Association and more than two dozen other nurses' organizations termed the report "misleading," saying it "contains numerous factual misrepresentations." Their letter rebuked the AMA for its "attempt to change the perceptions of NP practice as anything other than fully qualified professionals working within a legally established scope of practice."

In addition to the common sense aspect, using nurse practitioners also saves money:
In September, the nonpartisan Brookings Institution's Engelberg Center for Health Care Reform issued a report by 10 experts that said one way to curb health care spending is to encourage states to permit "greater use of nurse practitioners, pharmacists, physician assistants, and community health workers." Meanwhile, a blue-ribbon committee working under the aegis of the Institute of Medicine and Robert Wood Johnson Foundation is planning to make extensive recommendations later this year on the future of nursing.

Instead of big, howling egos, it would be nice to see more creative solutions. A small town in northern NH was fortunate enough to have one solution given to them. A wealthy summer resident of Tamworth, NH started the Tamworth Community Nurses Association. Mrs. Elizabeth Whittemore left behind an endowment, so that all residents of Tamworth could have access to health care. That was over 80 years ago. The town of Tamworth still has a nurse that sees patients in her office or makes house calls. Free.

In the interest of full disclosure, I know JoAnn Rainville, the Tamworth Community Nurse. I live in a nearby town. The kind of care she provides, saves money. In rural areas, duplicating this kind of service makes sense, especially as we face a shortage of primary care doctors and the possibility of millions of Americans becoming insured.

Cross posted at

No comments: