A recent New York Times story (“Doctor Shortage Likely to Worsen with Health Law“, July 28, 2012), reported a severe shortage of physicians in the US, not just in primary care, but in every specialty, except for plastic surgeons and dermatologists. The story included predictions from the Association of American Medical Colleges (AAMC), who estimate within 10 years there will be more than 91,000 fewer physicians than we need, approximately 45,000 primary care physicians and 46,000 surgeons and other specialists. http://www.ama-assn.org/amednews/2010/10/11/prsb1011.htm
What’s concerning is the following patterns that we see continuing for quite some time:
The number of graduates going into medicine continues to shrink.
Thousands of doctors are retiring.
The Affordable Care Act reforms are bringing millions of new patients into the health care system.
The baby boomers continue to age and require more services.
Many of these patients will not be able to find a doctor in a location or at the time they need care. As a result they will seek care options outside the conventional doctor’s office including: retail clinics and pharmacies,work site clinics, home based care and the emergency room. One in ten patient care visits for non-emergency concerns currently take place in the emergency room and in settings outside the doctor’s office and that trend is not changing any time soon.
The Times article pointed out that patients get care, but, the process is often slow and difficult, with people driving long distances and experiencing long waits to see a doctor. They also overuse emergency departments of hospitals for routine matters. Patients are also delaying care,resulting in more serious conditions that require more complex treatment.
New patient care initiatives by the private sector are evolving to address this problem including: the proliferation of retail and work site clinics, the expansion of home-based care, the increasing use of telemedicine to address physician shortages in remote areas, and more home and virtual physician visits. Additionally, time-pressed primary care practices are using interdisciplinary teams to serve their patient populations.
The model of care has shifted from a physician at the center of care to the patient at the center of care surrounded by a new cadre of providers including nurse practitioners, physician assistants, health educators, nutritionists, and social workers, who handle basic care and collaborate with the physician when there are more complex issues.
According to the California Heath Foundation, a quarter to a third of all large employers (those with a workforce of 1,000 workers, or more) have on-site clinics in their workplace. These clinics tend to provide basic health services and wellness and prevention programs for employees. They spur early diagnosis that will prevent complications and lower the cost of care by offering screenings, immunizations, treatment of workplace injuries and chronic disease management.
Retail clinics are also spreading, to serve patients who have an income and are not candidates for federally subsidized health clinics. The retail clinics offer a viable alternative to the long wait and inconvenient hours of primary care physicians. Nurse practitioners provide the care at the majority of these clinics and when they function correctly, all findings and notes are sent on to the patient’s primary care doctor to ensure continuity of care. Wal-Mart, CVS and Walgreen dominate the retail clinic markets. They are well positioned to offer the basic health services needed by this population and approved by employers and health plans.
The California Healthcare Foundation study also found that more health consumers are assuming increased clinical and financial responsibility for their care by engaging in self-care, seeking health information online, and relying on home remedies and over the counter drugs. This model includes physicians house calls and e-visits. The adoption of broadband and wireless communication technologies enable the movement of clinical data, and images and make it easier for patients to find care in non-traditional ways that do not include a personal visit to the physician’s office.
Efforts to resolve physician shortages include the opening of new medical schools and expanded class sizes in existing schools, and the establishment of more residency positions to train doctors, funded by grants from the Department of Health and Human Services. All of these programs help, but are too little, too late. The bottom line is that we are going to be hard pressed to serve our vast population in the United States without a complete restructuring of the system. This will require lots of work by e-patients who understand that there is much to be gained for themselves and their families when they consider all care delivery options available to them, beyond the physician/patient standard of care that has been the model up to now.