As a primary care doctor, my days are busy. Seeing patient after patient, I try to provide the most patient-centric, evidence based care that I can. But if I read anything about healthcare reform, it will tell me that 80-85% of the patients I see can be seen by a nurse practitioner or a physician’s assistant. So why did I train for an extra 3-4 years as a doctor, incur several hundred thousand dollars in debt, and go through years of residency training to do the same work as someone who has done a fraction of this?
With this as a background, is it any surprise that an article in the December 5th edition of the Journal of the American Medical Association reported that among internal medicine residents, those with career plans in general internal medicine were markedly less common than those with subspecialty career plans?
The term “general internal medicine” may not mean much to those not in healthcare, but these are the doctors who comprise many of this nation’s hospital-based general medicine doctors and primary care doctors. Hospitalist medicine has been at the very forefront medical industry growth for the past several years; primary care, also made up of pediatricians and family physicians, has not. It is not a stretch of the imagination, then, to assume that most of the residents going into general internal medicine will not go into primary care. Study after study supports this.
There are still physicians that go into general internal medicine and choose primary care though. I am one of them. But there are days where I wonder if I would make that choice again. Here’s a big reason why that has not received much attention: I don’t really know if I am needed.
What? A primary care doctor not needed? Whatever do you mean? Let me explain: the Affordable Care Act is already changing medicine – patient centered medical homes, team based care, care coordination, and value based purchasing are becoming the norm. And all of this is great. It will likely improve care, and may even improve primary care provider satisfaction. So where is the general internal medicine physician in all this? The same place we are now.
If nurse practitioners and physician assistants can see 80-85% of the patients I see, and require only 4 or 5 years of post-graduate training – and not the 7 or 8 that most primary care physicians receive – then we need to develop systems that select the 15-20% of patients that need a physician. As one organization, the American Academy of Family Physicians, which has a huge percentage of its doctors serving in primary care roles, has recently reported, the educational and training differences among these groups of providers profound: nurse practitioners complete 2,300 – 5,350 hours of education and clinical training during five to seven years, compared to physicians’ standardized path of 21,700 hours over 11-12 years.
There are several validated methods that have been used to classify patients as “medically complex” based on diagnoses and combinations of conditions, such as the one using “adjusted clinical groups” developed at Johns Hopkins. These systems should be more broadly employed to preferentially siphon the more complex to those providers with increased training. It would have the potential to provide more efficient care and also provide a more thoughtful, appropriate distribution of limited resources.
I work with several nurse practitioners and physician assistants, and they all do a great job, but in no other industry would three groups with very different levels of training and expertise be asked to provide the same level or service and adhere to the same professional standards. There are some areas in the country where there are no choices, and NPs and PAs must work independently. And I realize that we as physicians do not get fairly reimbursed for providing complex versus non-complex care. But this does not mean the whole situation is appropriate.
In places where there is a mix of PAs, NPs and MDs, their job responsibilities, descriptions and levels of care should reflect the 6, 7 and 11 or more years of training they have had. Not doing this is a systems failure with broad implications for patient and provider satisfaction, healthcare spending, access to care, and healthcare reform. It also just doesn’t make much common sense.
Doug Olson is a primary care physician. He can be reached on Twitter @doctorolson.
