We’ve all seen the data projecting a shortage of physicians in the United States, expected to reach a shortfall of more than 90,000 by 2020. The lack of nurses is equally well documented. These trends raise concern for all medical specialties, but especially for primary care.
More and more Americans are expected to need these services in the coming years, at a time when fewer and fewer students are committing to careers in primary care – either because the field is perceived to be less prestigious, the hours expected to be unmanageable, or the pay viewed as too low. Amidst the statistics are streams of reports from professional societies, suggesting that their particular profession is best equipped to lead the health care team into the future and provide the primary care services the nation so clearly needs.
The reality is one health profession cannot provide the proverbial magic bullet. It is going to take a spectrum of medical talent – doctors, nurses, physician assistants and others – to ensure adequate delivery of high-quality primary care to all who need it. Rather than jockey for hierarchy within the medical team, we should focus on the concerns we share, particularly insufficient numbers of educators and clinical training sites to teach and guide the next generation of health care professionals. One of the reasons we have too few primary care providers flowing into the workforce is that this clinical training bottleneck prevents or delays many students from practicing, and it limits the expansion of primary care.
Consider the facts. In 2011, more than 75,000 qualified applicants were turned away from nursing programs because schools did not have adequate faculty, clinical sites, classroom space and clinical educators to teach additional students. For physician assistants, one of the fastest growing professions in America, colleges and universities with physician assistant programs cannot keep up with the demand. The majority of physician assistant programs are at capacity for first-year slots and most schools don’t have sufficient public or private funding for expansion. Too few clinical training sites is a major obstacle to expanding the pool of physician assistants ready to work in primary care. And while billions are spent on residency programs for doctors, funding for residency slots has been frozen since 1997, even as medical schools have increased enrollment. Something has to give – and there are some sensible ways to approach the problem.
If we want to have a 21st century, patient-centered health care system where health professionals work as a coordinated team, we need to first reevaluate how everyone on the team is trained and educated before they work together as graduates. While each profession has its respective licenses and certification, and our roles and responsibilities to the patient can vary, we hang our hat under the same medical principles and ethics. Together we are called to ensure the welfare of the patient is primary; and in practice, the team-based approach is key to optimizing the delivery of quality care. For optimum patient care, we must embrace interprofessional education and start to train together. Today, there are so few preceptors and so few sites available to train students, the professions are all scrambling for the same slots and bumping each other out of them. We can be much more efficient and effective in using the slots we have if we apply the principles of interprofessional education.
The first step is for medical, nursing and physician assistant schools to collaborate and develop curricula models that maximize use of existing clinical sites and educators. The next step is to develop and test more innovative ways of training, including the use of high-fidelity simulations that do not rely on the current model of in-person interactions and still maintain quality. The facts are plain: we do not have enough facilities for clinical training, nor do we have enough willing preceptors to oversee the training. This is not a PA problem, or a nursing problem, or a physician problem. It’s a health system problem, and it’s particularly acute in primary care – where we can least afford another roadblock.
Developing a more interprofessional model of education for our professions will also help us more effectively advocate for necessary and impending reforms on the policy level. As the regulation and financing of graduate medical education for doctors is currently being reexamined, policy makers at all levels should also consider supporting the training and educating of physician assistants as part of the health care team. Additionally, we need to ensure that training in primary care, especially in rural and medically underserved parts of the country, is emphasized in proposals for additional funding of medical education for all of our professions.
As we embrace new models for a more coordinated and patient-centered health care system, we need to ensure that the next generation of health care professionals can meet patient demand. Our challenge will be for our schools to address the educational infrastructure and resource issues hindering the deployment of more highly trained nurses, physicians and physicians assistants to help fill the primary care shortage. Until we solve this critical pipeline issue of insufficient clinical education sites, all members of the patient-centered medical team will be unable to realize their full potential in helping to reduce the shortage of primary care providers.
Anthony Brenneman is President, Physician Assistant Education Association.
