Nurses: The future in the provision of basic health care?
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- Newly qualified physicians are continuing to turn away from primary care.
A young primary care physician stares at a computer screen while the adjacent waiting room becomes increasingly congested with patients. This image is becoming a frequent occurrence in rural clinics across the US as the demand for the provision of basic healthcare rises almost concurrently with the number of administrative duties doctors are expected to complete.
Demographic changes and the Affordable Care Act, which will see millions of Americans gain health insurance for the first time, are augmenting the strain on an already ailing system. Unfortunately, poorly structured graduate training schemes and low salaries comparative to the specialty areas are continuing to turn doctors away from primary care. Research by Stephen Petterson at the Robert Graham Center estimates there will be a shortfall of 52,000 physicians in primary care by 20251.
After years of stress, study and exams, one may finally put the letters M.D. after their name. Though in order to obtain a license to practice, a further year of training in a hospital is required. The Graduate Medical Education System (GME) accredits further training or "residency' programs. Unlike medical school, which is funded by the individual, the GME survives on federal funding to the tune of $13 billion2. Currently, the amount of funding received by a program is not dependent on where their graduates choose to work. A snapshot study of 759 programs found close to half of all primary care physicians came from just 20 programs. These programs combined received $292 million in GME funding. Stomach churning findings considering another 20 programs that produced just 6.3% of all primary care physicians and yet received $842 million3. A more structured approach to GME funding with allocations linked to the number of primary care physicians produced would counterbalance the skewed distribution of physicians towards the specialties.
Changes in the structure of funding may be helpful but do not address the overriding problem facing new doctors. In 2012 86% of medical school graduates had upwards of $166,000 in debt from their undergraduate training, a notable point given the massive discrepancy in salaries between specialty areas and primary care4. A dermatologist in San Francisco can earn twice as much as their colleague in a rural clinic in Jackson, California. Federal policy makers should look to countries such as Australia and Norway, which also struggle to deploy doctors to their sparsely populated areas but utilize tax breaks or higher salaries as incentive5,6. Equally, Canada's Return-For-Service scheme, which incorporates loan forgiveness, has seen some success7.
Physician lobby groups continue to fight to maintain the status quo but the shift from traditional doctor -- patient care is eminent. Advanced practice registered nurses (APRNs) are frequently appearing as the first line of call in basic care. The extra training done by APRNs prepares them to work with an extended scope of practice so that they can assess, diagnose and manage patient problems. Research suggests the level of care provided by APRNs is comparable to that of physicians. The corporate world has also seen cost saving opportunities as pharmacy chains such as Walgreens have started opening retail clinics. These clinics open early and close late with many patients being treated solely by a nurse. Unfortunately only 19 states recognize APRNs. Draconian regulations in the remaining states need to be revised. This, in conjunction with increased clerical support for administrative duties, will free physicians to focus on more complex cases and improve accessibility to healthcare.
Time is ticking for policy makers to ditch the sleeping pills and address the primary care shortage. Several avenues are available to them, now all they need to do is choose one. In the meanwhile, eat an apple a day as the doctor is away.