Short on Physicians, Long on Adverse Effects

The United States faces a shortage of 100,000 physicians in the next decade. Why? The patient population is aging and battling multiple chronic conditions. Millions of newly insured persons are entering the health care system. And the work force is experiencing attrition as many physicians move into retirement.

In addition, fewer aspiring physicians are opting for primary care-only one-third of U S physicians are choosing primary care compared with about half of physicians in other developed nations. You know the reasons: lower payments, frustrating practice models, and long hours of clerical work that doesn’t use your medical training to full advantage.

These and other factors also contribute to a high burnout rate among physicians. You and your colleagues work an average of 10 hours more per week than the general population and are nearly twice as likely to be dissatisfied with your work-life balance. In one survey, close to half of physicians reported experiencing at least 1 symptom of serious burnout, such as emotional exhaustion. And the suicide rate among physicians is 2 to 4 times higher than in the general population.

A high burnout rate translates into even more physicians leaving practice, thus adding to an already critical shortage.

That a shortage of primary care physicians poses a threat to the quality of patient care is not subject to debate. The big question is what to do about it.

Many of the issues were addressed recently by the not-for-profit Association of American Medical Colleges. The AAMC submitted a statement, “Successful Primary Care Programs: Creating the Workforce We Need,” to a hearing of the Subcommittee on Primary Health and Aging to the Committee on Health, Education, Labor, and Pensions-appropriately acronymed “HELP.”

Medical schools already have taken the first critical step in addressing increased demand for primary care physicians, with the goal of enrolling 30% more students by 2016 than in 2002, the AAMC noted. But several medical graduates have expressed concern about their level of interest in primary care careers. And despite medical schools’ best efforts, the AAMC added, such action will have a negligible effect on reversing physician shortages unless Congress permits a proportionate increase in federal support for graduate medical education training positions at teaching hospitals.

At the forefront of the physician shortage discussion lies the potential role of nurse practitioners in meeting increased demand for primary care services. In a recent study in the New England Journal in Medicine, researchers questioned close to 1000 physicians and nurse practitioners in primary care practice about scope of work, practice characteristics, and attitudes about nurse practitioners’ expanding role.

Physicians and nurse practitioners did not agree about a number of things. Consider the following:

• “Nurse practitioners should be able to practice to the full extent of their education and training”-95.6% of nurse practitioners agreed to this statement vs only 76.3% of physicians.

• “Nurse practitioners should lead medical homes”- 82.2% of nurse practitioners agreed vs only 17.2% of physicians.

• “Nurse practitioners should be paid equally for providing the same services”- 64.3% of nurse practitioners agreed vs only 3.8% of physicians.

• On the question of whether physicians provide a higher-quality examination and consultation than do nurse practitioners during the same type of primary care visit, 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed.

The authors concluded that both physicians and nurse practitioners will be needed to address the growing primary care workforce challenge but suggested that current policy recommendations remain controversial. In other words, many primary care physicians are unlikely to embrace an expanded role for nurse practitioners.

Data from the National Ambulatory Medical Care Survey support the use of physician assistant and nurse practitioner services as a strategy to ease the shortage. Findings suggested that some division of labor exists among providers that could contribute to improved organizational efficiency in ambulatory  systems.

A new practice model, direct primary care, is another potential solution, one that has gained support from the American Academy of Family Physicians. Practices charge patients a monthly fee in exchange for access to a broad range of primary care services. Physicians do not take insurance but encourage patients to carry major medical health insurance to cover hospitalization and other high-cost care.

Family physicians who adopted the model were described as priding themselves on “having found a way to cut the red tape that has some physicians looking for the exit door” because “providing quality health care at a lower cost and at a relaxed and reasonable pace makes every day at the office a good one.”

Still another remedy, a movement from a physician-centric model of work distribution to a shared-care model, comes from a group of physician-authors. They attempted to identify the challenges that primary care practices face and innovations that might increase physicians’ work-life satisfaction, attract future physicians to the field, and improve the quality of patient care. Their main recommendation, the shared-care model, is designed to produce higher levels of clinical support of physicians and frequent forums for communication that can result in high-functioning teams.

There may be little agreement on the best solution, but everyone agrees that the potential consequences are worrisome. Dr Atul Grover, chief public policy officer at the AAMC, summed up the problem very nicely: “We are very concerned that we’re going to hand insurance cards to 30 million people and we won’t have the doctors to treat them.”