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Thursday, June 2, 2011

How to get more gifted physicians to practice primary care

It is entirely clear that too few medical graduates go into primary care. Although the number of family physicians is increasing modestly, there are very few internal medicine residents becoming primary care doctors. This year there will be only about 200 new internal medicine doctors entering the workforce from training programs, which will not even begin to cover the attrition of older and more efficient physicians, and due to improvements in access with the affordable care act, demand will be increasing significantly.  The main reason that very few physicians are choosing primary care is that specialty fields are just about as rewarding personally and way more rewarding financially.

Insurance companies in our present, primarily fee for service, payment system, pay generously for operations and procedures, but much less for complex interactions such as counseling patients on their multiple medical problems, medications, and managing their many diseases. A cataract operation is reimbursed at around $1500 or more, and an ophthalmologist can perform one of these in less than an hour. A similar hour of seeing patients will net a physician a small fraction of that amount of money, and will require many more decisions and neuron firings. Many other procedures have similar high reimbursement for very low amounts of work. If a physician specializes in a field that involves many procedures, he or she can make truly absurd amounts of money if there are sufficient numbers of patients who need that procedure.

Because of the shortage of primary care doctors, more and more people are getting their primary care from nurse practitioners and physician's assistants, who have many fewer years of education than a physician. These providers are paid less than physicians and are more plentiful. Many of them are very competent, but patients often prefer an MD over a PA because the MD has a greater depth of knowledge. A primary care visit is often a combination of counseling about psychological issues, medications and interactions, review of tests, recommendations about prevention and careful examination (at its best). MDs can be very good at this.  Midlevel practitioners are often quicker, having been trained to treat urgent problems more than chronic ones.

Training to be a primary care physician requires at least 7 years after completing a bachelors or higher level college degree. The first year is spent learning basic science and physiology, the second involves absorbing huge amounts of information about human beings in health and disease. The third and fourth years bring the student in direct contact with patients, providing supervised clinical care along with classes and individual teaching by practicing physicians and academics. After these 4 years we have an MD degree, and must pass a licensing exam that assures a certain level of competence in all fields of medicine. At this point we can still choose to become surgeons, radiologists, pathologists or go on to academic medicine or research.  Those of us who intend to be primary care docs then spend at least 3 years in residency, taking care of patients under the supervision of more experienced physicians, with an increasing level of independence. When we finish these residency years we are broadly competent in taking care of most of what can go wrong with a human, with fresh and extensive knowledge of psychiatry, critical care, well patient care and the vast variety of other illnesses we have been exposed to.  After those residency years we have the opportunity to take another year or more of specialty training in fields such as cardiology, oncology, infections disease or rheumatology. Most physicians who specialize limit their practices to specific diseases and no longer do general medicine.

Nurse practitioners and physicians assistants must complete 2-3 years of training after getting their undergraduate degrees and in most states are then certified to practice independently. Although they are often gifted and become increasingly capable with years of practice, they do start out with considerably less training than physicians and the programs that train them are significantly less competitive.

So what would a midlevel practitioner be really excellent at doing? In what kind of a situation would a provider with less extensive experience and education really shine? Procedures. A midlevel such as a nurse practitioner or physicians assistant could learn to do an excellent cataract extraction or colonoscopy. Advanced level nurses already act as surgical assistants and have been providing anesthesia services at a high level for longer than MDs have done. In developing countries with less medical regulations, it is often the janitors or former patients who learn to do operations and act as surgeons when the foreign trained doctors are not available. I have read that some of the most skillful surgeons for vaginal fistulas, a very delicate and specialized condition of women who have had disastrous labors, are lay people.

What else would midlevels really excel at? Already much of diabetes care is delivered by nurse practitioners who limit themselves to issues related to that disease. They do an excellent job, often better than MDs. Specific disease states, as are now managed by subspecialists, would be perfect for nurse practitioners and PAs. In fact, this is already starting to gain momentum.

How would shifting procedural work to midlevel providers affect the health care equation? If less well paid providers did this work market forces would drive down costs, which would make procedure rich specialties less desirable. Health care costs would also go down, and if cognitive specialties such as primary care were even somewhat better reimbursed it would increase the number of talented folks choosing those careers.

A recent article in the New England Journal of Medicine obliquely addressed this question. Here is the link:

http://www.nejm.org/doi/full/10.1056/NEJMoa1009370

In this article authors looked at the success of treatment of hepatitis C by specialists vs primary care doctors after an online course in treating this common and deadly disease.  Primary care providers were slightly more successful than the gastroenterology clinic which trained them in curing the disease. This does, of course, involve MD providers in both cases, but gives very strong support for the idea that specialization can be taught effectively and quickly.

A move in this direction will be very unpopular among just those who are most needed to make it work, the MDs who make their livings doing procedures. These folks have years of practical experience and have skills that are not available in books or videos. Excellent surgeons will always be necessary and appreciated. A supremely skilled surgeon is an artist and deserves money and acclaim. Wise subspecialists will always be needed and appreciated in taking care of patients with diseases that are rare or so complicated that primary care physicians are just not enough. But we are now grossly out of balance, with a truly inadequate number of primary care physicians to take care our our growing needs, and appropriate use of midlevels could be a solution to the problem.

1 comment:

Ohana Street said...

I enjoyed reading your solution-driven blogpost, plus your comments about sheep throughout your blog :-)

Very interesting insight re: the use of MLPs to drive down healthcare costs. They are, in fact, Physician Extenders, to begin with...why not take it to the next level as mentioned in your post?

Just like your other post about the subcutaneous flu shots and now this post re: procedures commanding more $, your proposed solution would indeed be unpopular. Nonetheless, your writing is inspirational. Your recommendations may not make big leaps immediately due to $ and politics at the macro level, but I'm sure it will attract attention soon due to rising healthcare costs. Perhaps it would even start a movement of some sort at the micro level, especially with increased awareness.

We need more primary care physicians like you.

Your blog made me re-think primary care. I am considering going to med school and leaving the "comfortable confines" of our great nation, the USA, so as to obtain a multinational approach to medical education. While a US medical education is undeniably great, I think there is value in gaining firsthand insights and gleaning heaps of "lessons learned" (and even best practices) from other countries and how they practice medicine. I have read your other posts re: how janitors learn how to do procedures in developing countries - true, indeed.

My thoughts on obtaining a multinational medical education seem to be unpopular at the moment--still, I refuse to be a sheep. I refuse to go into medicine for the mere opportunity to learn medicine; my objective is beyond that (otherwise, I should just stay in Corporate America to secure my comfortable lifestyle). Perhaps it is safe to assume that you did not go into Primary Care for the sake of becoming an MD. After all, you have a penchant for perpetual learning--I am inspired by your enthusiasm to learn from others based on what you shared in your other blog posts.

Anyway, keep up the good work. I am still deciding on my preferred specialties after med school, and after reading your blog, I have decided to place primary care among my top choices.

Mahalo and Aloha!