Who Will Be Your Health Care Provider? (We don't have enough medical professionals to meet demands)

Although the dust is still settling since the passage of ObamaCare, it's not too early to start thinking about who will be providing your health care a few years from now. More specifically, who will be the practitioners who actually provide your health care services?

A recent AT article described the difficulty associated with training a physician. Similar difficulties exist for the training of dentists, pharmacists, nurses, and other health care professionals. Physicians may be at the top of the medical food chain, but they don't function in a vacuum. Health care is incredibly complex, and the various disciplines and sub-disciplines are inextricably interconnected. As demand for physician services increases, the demand for the services of all associated health care practitioners increases accordingly.

The recently passed health care legislation will, among other things, expand the rolls of Medicaid by 16 million eligible recipients and force another 15 million without health insurance to purchase health insurance. This will undoubtedly increase demand for the services provided by physicians, dentists, nurses, pharmacists, and other professionals. There are currently shortages of physicians, dentists, nurses, and pharmacists in most states. How do we address a shortage exacerbated by dumping tens of millions of newly entitled patients into the system? One might be tempted to look at the associated federalization of student loans and suggest that we should simply decree that more physicians, dentists, nurses, and pharmacists shall be trained to meet this demand. Voilà! Problem solved.

Unfortunately, this is not as easy as printing money. Health professionals are more like gold: You must mine them and refine them. One of the critical rate-limiting steps in training health care professionals is the availability clinical training sites. In the late 1990s, all accredited schools of pharmacy decided that the entry-level degree for the practice of pharmacy would be the Doctor of Pharmacy degree (Pharm.D.) by the year 2000. The Pharm.D. degree had existed for decades, but it was generally a post-graduate degree earned by those who specialized in the practice of clinical pharmacy. Many schools never offered a doctoral curriculum, some were only just starting one, and some had transitioned to an all-Pharm.D. curriculum years ago. The result was that many schools found it very difficult to find an adequate number of clinical instructors and training sites to meet the mandates for experiential training.

Virtually all pharmacists who graduated after 2000 are "Doctors of Pharmacy." This additional training may be a net benefit to your typical retail pharmacy, but the rigor of the old post-grad, clinically focused Pharm.D. programs had to be watered down to get an entire class through. To meet the demands of hospital-based clinical pharmacy services, the number of post-grad residency programs increased.

Did these Pharm D. requirements do any good? Not really. Pharmacy schools got richer because they kept students in school longer. Those who earned the older, more scholastically and experientially demanding Pharm.D. degree saw their academic credentials cheapened. Younger pharmacists paid much more for their education. Pharmacists' salaries increased markedly -- not because of the new entry level degree, but because of a scarcity of licensed pharmacists. In most cases, the degree (B.S.Pha. vs. Pharm.D.) makes little difference in the salary a pharmacist earns; years of experience have a much greater influence. The license to practice is the most valuable commodity.

It is virtually impossible for government to approach medical schools with a big pile of money and tell them to increase their output of (the same quality) physicians by 20% in the next five years. This is not to say that the schools wouldn't agree and take the money -- they almost certainly would. The problem is that they wouldn't succeed. Academia is, after all, a business. Money can't buy all the resources necessary for training professionals. Their entry requirements would be relaxed, the didactic requirements would be diluted, and their experiential training sites would be stretched to the breaking point. The result would be a graduate with less training. Then the schools would have to consider the increased demand for additional residency slots (these are not developed or funded quickly). One can extrapolate this problem to the training of dentists, pharmacists, nurses, or any other health professionals. So what do we do?

The first and most obvious solution would probably be to import more health care professionals from other countries. Foreign medical graduates (FMG) are required to go through testing to assure that they meet minimum requirements for licensure in the United States. One has to consider that every physician or nurse trained in another country and working in the U.S. is one less physician or nurse practicing in his or her native country. Is this moral? Many FMGs have taken residencies in the U.S. and have gone on to become excellent practitioners. At the same time, many will always remain on the left-hand side of the competence bell curve. Although the U.K. is aggressively employing the importing option to meet their needs for medical professionals, it is ultimately unsustainable. But there are other options.

There is no acceptable substitute for the skill of a well-trained surgeon or the diagnostic acumen of a board-certified internist. A dental hygienist or assistant cannot perform the same procedures as a dentist (essentially a very specialized surgeon) can. A nurse assistant does not possess the same clinical judgment as a nurse. A pharmacy technician cannot make the same professional and clinical decisions as a pharmacist.

There are, however, workable solutions to allow these professionals to practice more efficiently. Dentists employ hygienists and assistants that allow them to treat more patients than they possibly could if they performed all the tasks themselves. Nurses (at least in hospital and clinic environments) have assistants to perform routine tasks so that they may serve more patients. In most cases, pharmacists have (often registered) pharmacy technicians making computer entries and preparing prescriptions so that they can devote more time and attention to evaluation of treatment and patient counseling. Many physicians employ physician assistants to see patients for routine checkups and management of treatment. Some states go even farther in allowing such assistants to treat patients.

Another solution to our impending predicament would be to expand utilization of "midlevel practitioners." Midlevel practitioners include Physician Assistants (P.A.), Nurse Practitioners (N.P.), optometrists (O.D.) trained and certified to prescribe, clinical psychologists (Ph.D. or Psy.D.) trained and certified to prescribe, and clinical pharmacists licensed to prescribe. The extent to which any of these practitioners may practice, and the conditions under which they may practice, vary widely from state to state and usually constitute a politically contentious issue.

New Mexico licenses all the midlevel practitioners listed above. A Physician Assistant has prescriptive authority but ostensibly practices under the direct supervision of a physician. In practice, this is laughable, as the physician isn't even necessarily on-site when the patient is seen. The supervising physician is required to review the charts of the P.A. after the fact and sign off on them. Nurse Practitioners are essentially R.N.s with a master's degree and specialized training. They have independent practice and prescriptive authority in NM. They can legally hang out a shingle and go into independent practice (and many do). The optometrists have prescriptive authority limited to their scope of practice (e.g., dilate pupils, treat glaucoma, eye infections, and "chronic dry eye").

This is also the case with clinical psychologists. Their prescriptive authority is limited to their narrow scope of practice. Usually this is limited to the treatment of ADHD, depression, and anxiety. Most cases of profound schizophrenia are generally referred to psychiatrists.

The pharmacists (pharmacist clinicians or Ph.C.) receive an additional year of training. Their prescriptive authority is the same as that of P.A.s. It is specifically and narrowly defined by protocol and must be "supervised" by a physician. Some serve in the role of primary care providers, but most specialize in managing anticoagulation in warfarin clinics. Their utility in community health clinics is limited because of their prescriptive authority. A clinic can hire two P.A.s for the salary of a single pharmacist. There are both advantages and disadvantages with all of these practice types.

The problem is defining what a midlevel practitioner can and should be allowed to do and what only a physician should be allowed to do. A tremendous number of physician office visits (and even E.R. visits) could be shifted to midlevel practitioners. Many chronic disease states require periodic monitoring and perhaps adjustment to the prescribed medication regimen. This does not require the attention of a physician each and every time. Many minor, acute situations do not necessarily require physician evaluation. At the same time, physicians sometimes make other diagnoses when patients show up for routine visits.

The opportunity for significant savings and increased patient accessibility to health care providers exists only if the roles for midlevel practitioners are expanded and more clearly defined. The problem is that there are fifty states with multiple regulatory boards that will fight these changes tooth and nail. In the end, it might not matter. If the need becomes acute enough, the changes may be willed into being by legislative fiat.

The fact is that we as a nation can neither produce nor import enough medical professionals to meet the demands soon to be placed on our medical system. Many physicians will choose to retire, and fewer of the best and brightest will choose to enter the field. All the while, more and more demands will be placed on all health care professionals. In the end, something's got to give. Unless this is stopped, in five years' time, "health care" will be delivered by a whole new group of practitioners. In many cases, it may be "adequate"...and in many other cases, it may not.

“Who will be your health care provider”

As P.J. O’rourke said the man behind the DMV counter. Who will want to go into medicine just to become a goverment hack?

Welcome to the dark ages of ‘medicine’ in America.

I have heard Dick Morris make this argument for the last year.

But I don't get it.

Those people already have doctors. This bill only changes who pays the doctor.

I don't see how this bill is going to create more demand for doctors. It is only going to change who pays the bill.

They’ve already thought of this and are cranking-up a program to produce crash-trained “doctors” on the 36 week plan.

They will have medical diplomas on the wall. But they won’t really be doctors. They’ll just play one in the Obama health care plan.

Most people avoid going to the Dr. unless they are really sick because of the cost. When you make people buy insurance they are going to use it and some will use it a lot. That is where some of the Dr. Shortage will come from, some. Then you have the Drs. dropping medicare coverage, then you have Drs. not accepting new patients (we already have that). This thing is going to be a disaster....

“Hello I am Dr. Abu”

When I lived in Rhode Island 3 of my 4 Drs were from India. The 4th was from Romania.

Oncologist...India
Gastro.......India
Generalist...India
Pathologist..Romania

I agree with you in part.

We have a $5000 deductible. If forced to purchase a new low deductible plan for several hundred more dollars per month, we would definitely make sure we use it more to get our money out of it.

But I don’t think that 30 million are in this same boat. Many of the uninsured simple have not applied for medicaid.

Millions of young and healthy people are likely to keep paying and never use it.

In the US- I think that foreign graduates have to go through a residency program in the states ( I could be wrong). I also think that if western countries started poaching physicians from poorer countries, those countries would stop the exodus by making that practice illegal.

In teaching hospitals, the physicians teaching the residents are usually private practice physicians. You would need a lot more teacher physicians to handle more students. I don’t see that happening, as a lot of physicians are baby boomers nearing retirement.A lot of the teaching is one on one, especially in the surgical specialties.

The physicians who are going to take the hit are the family practice doctors. They can be replaced by nurse practitioners and PA’s. I really do not have much sympathy for family practice/primary care physicians. For years, they have been screaming about wanting socialized health care. For years they have been screaming about the income disparities between the surgeons/specialist and PCP. Except, surgeons/specialist spend more years in training than the PCP. Most PCPs do not even see their patients in the hospital- hospitals now hire hospitalists ( a hospital specialist) to perform that function. A PCP once told me that in an average day- 90 % of his patients are the “worried well”- nothing wrong with them. The other 10% get referred to a specialist because they have something wrong with them that the PCP does not have the specialized training to treat.

http://www.freerepublic.com/focus/f-news/2485666/posts

Of course, SEC. 430, Establishing a Ready Reserve Corps. lists in detail the commissioned Regular Corps and Ready Reserve Corps that will be trained up, fired up, lined up and controlled by Obama himself. Naturally the purpose for this army is to stand by in case they are needed at short notice for a national health emergency or emergency response missions. The health bill talks specifically about their routine training, appointment by the President with the advice and consent of the Senate, and other details of service

“Join the service,we forgive your loans”

No most of those people do not have doctors. They go to the ER for primary cre, now they will have to find a docotor to do that. With the amount of doctors planning to retire and the government in the Healthcare bill being able to tell you who you are allowed to see finding a doctor if you don’t already have one or your’s retires might be a tad difficult.

When one of my colleagues was hospitalized, I visited him and found a male nurse attending to him who everybody respectfully called — doctor.

I was quite intrigued as he was obviously a nurse, not a doctor. Upon conversing with him, I found out that he was a doctor in the Philippines who worked at a government hospital. He actually took the nurses exam for the USA and easily passed it. So here he is, a doctor practicing nursing in the USA. He’s making more money here than he would have had he stayed in the Philippines too.

Expect a lot of cases like this in future.

Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.