There was a man with tongue of wood

We showed it exists. We show that one proposed solution probably won’t help without extensive micro-managing: conditioning receipt of new residencies on service in under-served areas, e.g. service in the National Health Service Corps.

What else can be done?

First, we can make alterations in the practice of primary care by physicians in the United States.

Peter Ubel makes this argument, suggesting that primary care physicians adopt the model of anesthesiologists supervising nurse anesthetists. He argues that the advantages of having more non-physicians offering care under the supervision of a physician are:

1. More non-physicians doing routine primary care frees physicians from routine.
2. Such a practice could see more patients per hour, improving physician compensation in primary care
3. The model would improve primary care, as it is not physicians but primary care that is in shortage.

A recent article in Health Affairs adds the element of telemedicine to changes in primary care, long distance diagnosis and supervision of non-physicians through the use of technology.

Second, we can move more of primary care to non-physicians.

The second proposal takes the first one step further: allow nurse practitioners and physician assistants to practice independently of physicians. Peter Ubel is a physician, so his proposal in part reflects his background.

Consider this: we allow paramedics operating in a moving vehicle to make life-saving decisions but do not permit nurse practitioners to prescribe or refuse to prescribe an antibiotic with a supervising physician.

Paramedics and emergency medical technicians have a scope of practice that they know. There is no reason for nurse practitioners and physician assistants not to have a similar scope of practice clearly defined for when they are operating independently of a physician–such a scope might be slightly different than when a physician is involved.

The scope of practice of health care professionals is at the state level. In Texas bills are under consideration to make it easier for nurse practitioners to locate supervising physicians. In Connecticut bills have proposed permitting nurse practitioners to operate independently.

Third, we can make it easier for foreign physicians to practice primary care in this country.

A study at the University of Virginia is skeptical of the additional residency requirements for foreign-trained physicians.

All physicians must pass the three sections of the US Medical Licensing exam. It is a good test: there are no statistical differences in patient outcomes or complaints to medical boards between foreign and domestic-trained physicians. The proposal is to permit those passing the exam to compete for residencies on an equal footing, regardless of the location of their medical school.

If the problem is as dire as the AAMC and US Senators have suggested, then we should use all of these approaches to be sure the problem is addressed. At the worst we will have too many primary care providers, improving our health and lowering costs through an abundance of supply.