It’s Just A Flesh Wound

Why do we rely so much on doctors? A good friend of mine is currently in med school up here in D.C. (hi there, Travis), and we frequently get into fights enthusiastic discussions about whether or not the U.S. health care system could be improved by expanding the practice areas of health care providers who are not MDs. My view: Of course we should. It doesn’t take seven years of schooling to diagnose simple ailments or put in stitches. His view: Having procedures be performed by non-doctors will result in subpar quality of care and therefore is not ultimately more efficient.

And to some extent we’re obviously both right. Non-doctors — such as nurse practitioners and physicians’ assistants — are cheaper to train and are more than adequate for most common health complaints that turn up in primary care. But in some patients, health problems that appear on the surface to be routine will in fact turn out to be more complicated issues, and having a doctor involved from the start would result in a better outcome. But I still think that for a lot primary care and urgent care situations — and particularly for the uninsured — being forced to see a doctor when a nurse would do just as adequately is a waste of resources. And while a good majority of doctors appear to be against the idea of allowing greater involvement by NP’s, I do wonder how much of this is due to a protectionist sentiment at play.

There is empirical evidence supporting the idea that the quality of care provided by both nurses and doctors is equivalent. Studies have found that “[i]n an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients’ outcomes were comparable”, as well as that “[p]atients are more satisfied with care from a nurse practitioner than from a doctor, with no difference in health outcomes”. I’d caution that this doesn’t necessarily translate to cheaper in all cases; some studies find that even though patients experience increased satisfaction with their results when they receive care from mid-levels, they might not gain an additional benefit in the form of reduced costs, as “Even though using nurses may save salary costs, nurses may order more tests and use other services which may decrease the cost savings of using nurses instead of doctors.”

But even if mid-level health-care providers offered slightly lower quality of care, why are they banned from providing it all together? For those who are confident they have only a minor health issue, why not let them choose to pay less and go see a nurse rather than a doctor? It’s both a little paternalistic and a little suggestive of anti-competitive business practices for doctors to continue to lobby the government to set a floor on the supply of health care services in this way.

Still, even if we allow non-MDs to oversee more patients with routine problems or in need of only primary care services, this may do little to counteract the growing shortage of primary care physicians:

Mid-level [practitioners] are not immune to the vast incentives favoring practicing in a specialty environment. As Val Jones reported, when nurses were asked why more are not entering generalist practice, the reply was blunt: “We’re not suckers.”

Already, 42 percent of mid-level providers practice in specialty fields, and I fully expect this number to rise if the primary care environment continues to deteriorate, especially when contrasted to the salary and lifestyle offered to specialists.

Suggestions that we fill the primary care practitioner shortage with foreign medical graduates are equally lacking — many foreign doctors act as general practitioners in rural areas to fulfill visa requirements, and then switch to more lucrative positions as specialists in urban areas.

One small step towards increasing the number of GP’s might be a
re-branding effort
:

By the way, I hate the term primary care. It makes it sound cheap. It makes it sound dumb. It makes it sound so superficial. What we do as internists, pediatricians and family medicine doctors is far more than the connotation of primary screening and evaluation. We manage many complicated patients with mulitorgan failure. And many doctors in rural America do it all alone. With no help at all. Some of the best doctors in the world are rural primary care physicians who must treat highly complex medical issues by themselves. Not because they want to but because they have to.

The name primary care has got to go. Perception is 4/5th of the equation.

Another blogger used the word comprehensive care once. I think that is perfect. And I use it often in my blogging.

-Susan

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