Doctor shortage could derail reform

Doctor shortage could derail reform

Summary: Recognize and empower chiropractors? Give prescriptive power to nurses? Enable treatment by people who never saw the inside of a medical school? Yes, we must.


Norman Rockwell, “The Family Doctor,” as a postage stampEveryone knows there is an enormous, and growing shortage of primary care physicians.

But health reform programs all mandate that everyone see one.

This is a contradiction that must be solved or health care reform is impossible.

What primary care doctors want most is to practice medicine without the burden of paperwork, as in this example from Seattle, describing a group practice whose rules let doctors spent a half hour on each patient visit.

The problem lies deep in the story, a quote from the company's medical director. "This is truly the way to save primary care."

Sorry, but no.

This system is great for the doctor, but if there aren't enough doctors already. If the numbers are due to decline, and if the need for them is about to grow exponentially, you are not offering a solution.

The answer is obvious, but it requires an enormous leap of faith from the medical profession.

Doctors can't be the only gatekeepers into the medical system.

Ways must be found to empower nurses, nurse practitioners, alternative medicine folks, and others to become primary points of contact on family health.

This means a lot of what primary care doctors do must be routinized, demystified, and turned into a checklist that anyone can follow.

Primary care physicians must become the top of a health pyramid, not the bottom of a care pyramid. They need to be backstops, not line workers.

It would take over a decade to train enough primary care physicians so that each American can see one, regularly. Reform does not have that kind of time available to it.

This will be an enormous leap for everyone, not just policymakers but interest groups, patients, and insurance companies as well.

Recognize and empower chiropractors? Give prescriptive power to nurses? Enable treatment by people who never saw the inside of a medical school?

Yes, we must. The numbers are inescapable. They don't lie. The sooner we recognize that fact and act accordingly the faster we move toward real health reform, in which everyone has someone to turn to for health.

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  • Are you nuts?

    Chiropractors may be fine for a sore back but they also think allergies can be treated by spinal manipulation. Nurses do not have the training to prescribe the correct antibiotic for the patient's condition, the correct dose of insulin, the best antihypertensive. Sorry, one doesn't fix this problem by placing para-professionals in positions for which they don't have the knowledge or training.
    • Nurse Practioners can...

      prescribe medication...and are trained to do so. Pharmacists as well. Doctors do not hold some sacred talent for being able to figure out the best antibiotic for a patient's condition. This isn't magic. Hell, you could write a good software application that, given a set of conditions (symptoms, patient info including weight, general health, allergies, etc....same things a doctor would look at) would then spit out recommendations for medication. But doctors won't give up that monopoly, especially in the States, where prescribing a certain brand of medication nets them kickbacks from pharmaceutical companies.
      • State laws differ...

        ...on the power of nurses and others to prescribe.
        Here in Georgia we have an annual fight about it.

        Georgia also made it illegal for pharmacists to give
        flu shots without prescriptions.
    • Anyone can follow a checklist

      I'm not talking about unlimited power, but
      circumscribed power to advise, to coach, and to help

      There's no way out of this.
  • Self-created problem

    The current Doctor shortage results from a misguess about the number of Doctors required in an era of managed care. Medical schools are now being expanded to make up for the problem, though time will be required.

    The near-term solution for family care is, I think, an expansion of responsibility and authority of nurses, for instance, working with the oversight of a Doctor.

    For ordinary maintenace care, for instance, 5 nurses might deal with the patient, while the Doctor sees each when results are available.

    In other words, what many MD's are doing now.
    Anton Philidor
    • Not enough, and not fast enough

      Half of our GPs are going to be retiring within three
      years. The rest are (rightfully) demanding better pay
      and working conditions.

      I think we can improve the situation by moving some
      specialists into general practice, but it still won't
      make the numbers work.

      Think of what a doctor needs to earn. Any doctor.
      Think of how much time a single patient requires in a
      gatekeeper visit. Now divide.

      Won't work.
      • Are you certain?

        5 nurses x 8 patients x 200 days = 8,000.

        At $50 per examination = $400,000.

        And that's just base revenue, without much of the Doctor's time.

        Of course, accumulating 1,600 patients isn't easy, probably require a combined practice. But the office expenses will be covered before the Doctor's own time is billed.

        This is a business whose product is time, and so long as the Doctor has enough patients he can make a substantial profit.
        Anton Philidor
  • RE: Doctor shortage could derail reform

    I agree, let the chiropractors take over, they have an
    additional four years of education after undergrad. They're
    prepared to deal with wellness. At least they don't claim to
    cure anything(they don't claim to cure allergies, but they
    do go away sometimes after an adjustment), they remove
    nerve interference so the body can build up the immune
    system to fight off illness and disease.
    Medical doctors...hmmm, we are not any healthier by all
    the drugs being pushed. Cancer is at its highest, drug
    resistant illnesses. They are great for emergencies!
    If we all understood which doctor to visit when appropriate
    I think this conversation wouldn't be happening right now.
    • Sorry...

      So what does that four years of "education" after undergrad mean? Chiropractors have an alternative sense of how the body works that doesn't square with known scientific principles and research. Go to one for back pain, if you want, spend hundreds of dollars for spine x-rays and "adjustments" if that's your choice, but don't be so foolish as to think chiropractic has anything to offer allergies, asthma, hypertension, heart disease, hypertension, etc.
  • RE: Doctor shortage could derail reform

    We do not have shortness of primary care physicians. We have over supply of insurance company clerks that's setting road block to prevent legitamate doctors being paid. MOst of the physicians that I know have spend 30% to 50 % of their time dealing with paperwork and insurance companies various requests. There are layers and layers of people that are getting paid for standing in between the patients and their physicians. I also see a lot of patients that have lost their insurance but continue to come in to see me for their care. Their cost of treatment is a fraction of what they pay for their insurance. There is a recent study showed that medical cost are inflated by 40% due to layers of insurance structures and administration cost. If we wants to have affordable and improved health care system in the 21th Century, The current structure must be changed. The vast amount of money that have been taken out of the system by the middleman and administrations must be reduced. There is no shortage physicians. THere is a shortage of willingness to pay the physicians that this system need. I am willing to take a 15% pay cut just to get the insurance off my back. I can see 20% more patients just by diverting my time and attention from batteling insurance companies to batteling patients' illness. I will be still happier and make more money. We don't have to spend a lot of time and money to train more primary care physicians. We need to spend more time to change insurance system and it's monsterous cost to this country and it's people.
    • I wish it were that simple

      Yes, it would be nice if you were right. And you are
      right about insurance companies and the time drain on
      physicians from dealing with them.

      But if general practitioners spent all their time with
      patients, they still could not deal with the expected
      load from the coming wellness boom.
  • No

    What doctors want to do most is practice medicine without having to pay $100,000 a year in insurance premiums because of John Edwards types.
    • Sorry. Not true.

      It is simply not true that malpractice claims explain
      the problem. Where malpractice has been reduced by law
      (leaving many suffering patients without recourse)
      rates did not go down. They went up.
  • RE: Doctor shortage could derail reform

    Look at this article about hyperension and chiropractic
    from web md.

    Also here is a chart about comparing medical vs
    chiropractic education (this is what chiropractors do in 4
    years after undergrad---they earn their doctorate)

    Degree Requirements

    These basic educational requirements for graduates of
    both chiropractic and medical schools show that although
    each has its own specialties, the hours of classroom
    instruction are about the same. (The class hours for basic
    science comparisons were compiled and averaged
    following a review of curricula of 18 chiropractic colleges
    and 22 medical schools.)

    Minimum Required Hours

    Chiropractic College Medical School
    456 Anatomy/Embryology. 215
    243 Physiology 174
    296 Pathology 507
    161 Chemistry/Biochemistry 100
    145 Microbiology 145
    408 Diagnosis 113
    149 Neurology 171
    56 Psychology/Psychiatry 323
    66 Obstetrics & Gynecology 284
    271 X-ray 13
    168 Orthopedics 2
    2,419 Total Hours for Degree 2,047
  • RE: Doctor shortage could derail reform

    My wife is in her final year of resedency and going to be doing primary care. I shared this article with her and this is her reply:
    "Enable treatment by people who never saw the inside of a medical school?"

    Sorry, not the answer. I am in my final year of residency and have chosen to go into primary care. I will make much less than some of my colleagues but still have the same amount of med school debt, in my case about 125000 dollars. One solution to this problem could be reducing med school debt. Other graduate students are sponsored by their universities, why not medical students?

    To address the issues of chiropracters and nurse practitioners: Nurse practitioners are trained specifically to work in tandem with a doctor. This model might help address the primary care crisis, but their training is not sufficient to stand on their own.

    Chiropracters recieve little or no training in many common medical conditions (diabetes, hypertension etc, and I'm sure none in many uncommon conditions. I have seen examples of holistic providers do more harm than good; prescribing sodium bicarb tablets to a patient with heart failure...because they do not have the training to understand disease processes.

    While they do go to school for 4 years, medical students are required to do a residency after school, where they are supervised with the care of thousands of patients.

    Chiropracters have a role in the treatment of a limited number of conditions( back pain), but in no way is their training sufficient to function as a primary provider.
    • RE: Doctor shortage could derail reform

      this is why I will always look at both sides of the story....

      I feel pretty safe when the facts state that chiropractors
      have an additional 400 credits to graduate with their
      doctorate, have an externship with supervised patient care
      and produce research that beats out the leading
      hypertension drugs.

      Holistic providers that prescribe are not chiropractors so
      lets take that off the table. They do not want to prescribe,
      nor is it in their scope of practice. They often feel that
      drugs do more harm than good. Their paradigm is
      completely different than medical.

      It would do us all good to be open to many possibilities of
      health and wellness. Let's look at the countries that lead in
      healthcare instead of only through the lens of the medical
      society in America.
      • that's anti-American

        Ac McCain said, there is no place in USA for socialized medicine. We should not import bad and expensive ideeas from France, UK or Canada in this land.
        Here people care about real things like tax cuts, gun rights and moral values not some socialist concepts like free healthcare for all.
        The founding fathers din not mention healthcare in the constitution and we should stay the course as so many generation have done before us!
        Linux Geek
        • Sorry, you're wrong...

          First off, I acknowlege your sarcasm.

          Second, I have to take issue with your use of the term "free healthcare." Only the most naive person would believe that socialized medical care would be FREE. [i]Someone[/i] has to pay for it, and inevitably it will be those who work for a living paying the tab for those who don't.

          Socialists love to think that money for their Santa Claus-style programs rains down from Heaven. Or, more likely -- since most leftists don't [i]believe[/i] in a heaven -- they prefer to think that their programs will be funded by taxes on the "greedy rich."

          News flash: the rich have, and always will, find loopholes and shelters to shield their money from taxes ... and I say more power to them. However, that leaves the working middle class to pick up the tab for the largely unemployed lower class.

          I'm all for a safety net for those who fall on hard times in our society. I wouldn't begrudge people assistance and health care [i]while they look for new work[/i]. Nor would I heartlessly cut off care for those who are unable to work. Aside from these people, however, too many able-bodied and mentally capable people use the welfare "safety net" as a hammock.

          The thought of piling anything-but-FREE medical care onto the shoulders of the already overburdened middle class is worthy of a taxpayers' revolt.
          • sarcasm???

            Praising the founding fathers and the US Constitution is no sarcasm.
            You are trying to twist and obfuscate the founding principles of the USA same way as today crazy liberals call themselves 'progressive democrats'.
            We don't need no stinking 'progress'!
            We need to stick with the conservative values as enumerated in the constitution!
            Linux Geek
          • Apologies

            Sorry if you were being sincere and I misread you, Linux. I would agree the Constitution spells it out almost perfectly; sadly there are too many in power who view it as a "living document." (Read: irrelevant when it doesn't suit their aims.)

            There's a reason that the amending the Constitution is so difficult; unfortunately the legistlature and activist judges find their way around the Constitution all the time.

            How am I trying to "twist and obfuscate" the founding principles of the USA? I'm arguing FOR the individual initiative and personal responsibility that made this country what it is ... or at least what it WAS before the recent sickening lean leftward.