When is the doctor not needed? And who should take their place?

A lengthy editorial in the New York Times, December 16, 2012, "When the doctor is not needed”, discusses how a variety of other health professionals can help to meet the health care needs of the American people when there are not enough physicians. The editorial names, specifically, pharmacists, nurse practitioners, retail clinics (mostly staffed by nurse practitioners), “trusted community aides”, and self-care. It is very good that the Times recognizes the shortage of doctors (and, here, primary care doctors) and the fact that the planned fixes in the Affordable Care Act are not likely to solve the problem, issues that I have often addressed, recently in Health reform, ACA, and Primary Care: Is there still a conundrum? (November 24, 2012). It is also good that the Times recognizes the important contributions that can be made by health professionals other than physicians, by “trusted community aides” and very importantly, by self-care.

As the editorial points out, both pharmacists and nurse practitioners (and physician’s assistants) have a significant knowledge base, and can (depending on state law) practice independently. In our clinic, we work closely with both, and even have a real interdisciplinary educational clinic in which medical students, nursing students, and pharmacy students see actual patients together, under the supervision of faculty from all three disciplines. We have long had nurse practitioner faculty seeing patients with us, and an NP is the medical director of our clinic. Pharmacists work collaboratively with us, particularly in the hospital, and can manage not just drug refills but dosage adjustments and alternative drug regimens in the outpatient setting as well. As the Times editorial and my earlier posts make clear, the promise of ACA to produce sufficient numbers of primary care physicians is likely to take a long time, if it comes at all, as a result of the combination of adverse reimbursement and the long pipeline to produce doctors. If we are to have any hope of having adequate primary care for our population, everyone – doctors, nurses, nurse practitioners, pharmacists, physician’s assistant, et alia, will have to work “at the top of their license” so that doctors are not expected to “do it all”, and the others have the opportunity to really demonstrate their skills.

Unfortunately, however, it will not solve the problem. I don’t say this because I am a doctor (I am) or a primary care doctor (I am), or because most of the statements about the effectiveness of pharmacists and nurse practitioners cited by the Times come from pharmacists and nurse practitioners. I say it because the biggest problems in access to health care are economic and geographic, about people in rural areas and poorer parts of urban areas not being able to access health care because there are no providers there. This is not going to change if we have more pharmacists or nurse practitioners; they want to stay in the cities and suburbs from which they come just like the doctors. They do not “diffuse” into underserved areas. The retail clinics at which many work, often actually based in chain pharmacies, may provide a significant service (see my previous post, Retail clinics: power to the patient, June 28, 2012), but they are also located in cities and suburbs, and serve basically the same population that more traditional medical practices do.

In addition, there is the issue of money / health insurance. Many people, particularly the working poor, whether in cities or rural communities, do not have health insurance. And while some may have the cash to go to a retail clinic, if one is available,  most are unlikely to have enough to cover a big ER or hospital bill. Maybe ACA will help, but its primary method of expanding coverage will be through expansion of Medicaid, and this looks as if it will not happen in many states, which have said they will not participate or (like mine, Kansas) have not yet said. Plus, even if Medicaid is expanded, this does not mean that people will be able to access care. Maybe through a retail clinic, maybe via a nurse practitioner or primary care doctor. But specialist care is becoming increasingly unavailable to Medicaid (and, of course, uninsured) patients, as noted in this recent article by Anna Gorman in the Los Angeles Times, “Health care crisis: not enough specialists for the poor”, December 15, 2012. Health policy expert and retired family physician Don McCanne commented on this in his “Quote of the Day” (December 17, 2012), noting that from the beginning of Medicaid (Medi-Cal in California) this has been a problem.

Dr. McCanne says that there have been enough specialists for Medicare, but I fear even this may be changing; our hospital notes that Medicare is its worst payer and that it loses money on Medicare patients. And, as physician practices continue to be acquired by hospitals (which I discussed on December 1, 2012, in Gaming the system: Integration of healthcare services can just raise costs, not quality), the cost of care is increasing (as noted by the Charlotte Observer, in “As doctors flock to hospitals, bills spike for patients”, December 17, 2012). And pharmacists and nurse practitioners are even more likely than physicians to be employed by big hospitals or health system or other corporations (such as the chain pharmacies in which most pharmacists work and which host most retail clinics).

Now “trusted community aides”, as the NY Times editorial calls them, are something different. While that editorial refers to two pediatric practices, in Houston and Harrisonburg, VA, where patients pay about $17 a visit, this concept is in much wider use – and should be used even more. Sometimes called community health workers or (from the Spanish) promotoras (health promoters), these are lay people, not doctors or nurses or pharmacists, who have been trained to do basic health assessments, recommend treatment (usually in consultation with a nurse or doctor by phone) and help patients do a better job of taking care of their own health. They are most effective when they are from the community and culture of the patients they care for (see the discussion of community health workers in Camden and you: the cost of health care to communities, February 18, 2012). Why do I believe that they have more promise? Because they are recruited from the communities that they will serve, and in which they have roots and ties, they are going to continue to serve those communities. This model has worked for dental care in Alaskan Native communities, and in urban inner city communities like Camden. In the case of rural communities, the concept can also be used to increase the skills of nurses. Enhancing and expanding the training of a nurse in a rural community, someone who has family there, or training community health workers who live there, will improve access in those areas in a way that simply will not happen by producing more doctors and nurse practitioners who come from and train in major urban centers.

And self care? Sure, for the right things. These things include most of the diagnoses (notably excluding immunizations) that retail clinics provide care for. For colds, for minor injuries, people have should be able to care for themselves. Where it gets tricky is when the “self” has multiple chronic diseases (say diabetes, hypertension, congestive heart failure, chronic lung disease, arthritis, low thyroid, and high cholesterol – a very common combination in any primary care practice). These people can provide more of their own care, but need the guidance of a skilled health professional, most often a primary care physician. The NY Times article provides some examples of the use of self-care and it has great potential, particularly when coupled with “trusted health aides” who can help, and teach.

All of these ideas have merit, but the issue of geographic and socioeconomic diffusion is largely ignored by most of those who tout their profession as the solution. Of course, as Dr. McCanne concludes his comments on specialists not seeing poor people, “I'll say it once again. If we had an improved Medicare single payer system that treated everyone equitably, we would not have this problem.”

Yes, certainly there would still be problems, but that would be a great start.