The Changing Relevance of the American Physician

July 8, 2012

According to the Association of American Medical Colleges, if training and graduation rates don’t change, the United States could be short 130,000 doctors by 2025.  And this is before the Affordable Care Act (ACA) adds some 32 million lives to our panels.

While the pundits have grappled over the merits of ACA, little to no attention has been drawn to those charged with providing the services detailed by this new law.  There’s no practical way that this physician shortfall can be met without significant change to our medical education infrastructure.

I suspect that over the coming generation, patient care will fall increasingly on the shoulders of non-physician clinical providers.  And with the sudden demand for basic health care services, the scope of practice of professionals such as nurse practitioners will increase.  I suspect that in this changing environment patients will play an increasing role in monitoring themselves.  AI and ambient monitoring will likely play an emerging role in patient care.

Health care is a right, not a privilege.  Consequently, patients deserve a system conceived and designed in a way that meets their needs.  While doctors aren’t the only folks who can meet a patient’s needs, considering their role should probably be on the government’s short list when planning health policy.  Providing insurance for 32 million is very different from providing for 32 million.

All of this reflects the changing relevance of the American physician.


{ 7 comments }

Nick Dawson July 8, 2012 at 7:12 pm

Great post Bryan – you succulently point out a big challenge facing the industry. I worry it may be endemic in how we’ve come to view physicians.

In Congress’s PPACA summary doc they sum up Title V **Healthcare Workforce** as follows:

>Innovations in the Health Care Workforce: The Patient Protection and Affordable >Care Act establishes a national commission to review health care workforce and >projected workforce needs and to provide comprehensive information to Congress >and the Administration to align workforce resources with national needs. It will also >establish competitive grants to enable state partnerships to complete comprehensive >workforce planning and to create health care workforce development strategies.

>Enhancing Health Care Workforce Education and Training: New support for >workforce training programs is established in these areas:
> * Family medicine, general internal medicine, general pediatrics, and physician assistantship.
> * Direct care workers providing long-term care services and supports.
> * General, pediatric, and public health dentistry.

I take some solace in those ideas. But, in general, I see a trent of treating physicians as highly trained, highly paid contrators. Think airline pilots.

I had a conversation with a prominent [healthcare economist](http://healthfutures.tumblr.com/) who attributes this shift to the employed physician model – health systems are buying physicians at an historically high rate and treating them like 1) sources of market share and 2) production workers.

From a strictly operational perspective, both reasons may make sense on a spreadsheet. But they fail to take into account the human aspect of the work physicians do. Nevertheless, the end result is a new culture were physicians are just something which produce a unit of work. Even Congress’s summary above hints at that. *Lets grow the workforce* is often code for hiring, as you suggest, mid-level providers (which I think may also be a pejorative term).

The AAMC study is pretty scary. I get reassured by ideas like those you suggest – we’ll start using technology and patient engagement to help reduce the stress on the system.

There’s a theory about environmentalism (which I dont really subscribe to) which suggests we don’t have to worry about using up all the oil because by the time it runs out, we’ll have new technology. Ergo it won’t be a problem.

While I’m fairly sure that’s not a valid argument against conservation and ecology, it may, in fact, be true for medicine. I like a vision of the future where physicians are liberated by technology and patient empowerment. It’s a vision that doesn’t include hours of charting at the end of the day. It’s one where the burden of monitoring and reporting is offloaded on devices and services. That means providers can spend time treating people…with all the double entendre one can conjure for the word treat. That’s cool stuff!

Nick Dawson July 8, 2012 at 7:13 pm

also realizing markup doesnt work with wordpress comments – sorry for the strange formatting.

Heidi Roman July 8, 2012 at 9:55 pm

Great post, Dr. V.
Working in a county clinic, I’m afraid that I don’t yet see much consideration of our role as physicians (as it pertains to expected shortage) or that of non-physician clinical providers in any meaningful way. Thus far, we are encouraged to see and do more, instead of doing better. I am hopeful that there are smart people out there thinking about how to restructure the clinic day and how to incorporate NPs and PAs in a way that makes sense. I am concerned, though, that the same primary care shortages exist in training of non-physician clinical providers as with physicians. We may not even have NPs and PAs in the numbers needed to provide basic care. Appreciate you bringing this issue some attention. Right on target, as usual.

Sam Girgis July 9, 2012 at 9:09 am

As the baby boomer generation becomes older and enters into retirement, the medical care that they will need will become greater. In addition, the ACA will add to the growing need for physician care. Increasing the number of primary care physicians will be needed to solve the projected physician shortage. Our current medical eduction system pushes medical students into subspecialties so that they are able to pay back the enormous student loans that they have taken on. In order to provide appropriate medical care in the future, we need to increase the number of primary care physicians. There needs to be a financial incentive to drive medical students into the primary care fields. CMS is realizing this and has proposed increased reimbursements for primary care physicians and general internists in the coming year.

Howard Luks July 14, 2012 at 8:54 pm

The issues in healthcare and its relative ineffectiveness at providing timely, accurate, affordable, safe, and patient centric care can be broken down into at least three broad categories… access, quality and cost. Seems quite bizarre to me that we would want to place 32 million plus into a system that can not afford it, nor actually offer quality care to the newly insured in a cost effective timely manner. When considering the three broad categories (I know, there are far more) it seems misguided to start with access… Here we go…

Howard Luks July 14, 2012 at 8:57 pm

Should have added… now more than ever — Technology is not about replacing physicians … instead, we must remember, change brings opportunity — and we must use these troubled times to to scale great physician thought leaders!

Individual Health Insurance July 26, 2012 at 3:50 pm

Wonderful post Bryan, you precisely pointed out a big challenge the industry is facing.

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