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.

We have seen that there is a physician shortage, but it is confined to primary care–the number of specialists relative to the population has expanded.

In addition, there is a geographical factor that is beyond the scope of this blog: are the physicians, primary care and others, distributed to provide coverage of those in need, or are they concentrated geographically so that they are adequate in numbers but inadequate in dispersion? Huang and Finegold believe 44 million Americans will be living in places where the demand for physicians exceeds supply by more than 5 percent, 7 million where the deficit will exceed 10 percent.

The American Association of Medical Colleges (AAMC) advocates lifting the cap on Medicare-financed medical residencies imposed by the Balanced Budget Act of 1997. Senator Charles Schumer (D-NY) has introduced the Resident Physician Shortage Act to increase the number of residencies by 15,000 over the next several years. He is particularly concerned about the absence of physicians in the more rural–and colder–upstate New York. His argument is that the shortage is driven by retirements. Aside: New York appears to have more medical schools (12) than any other state (7 next highest).

However, if the problem is really primary care, will simply increasing residencies address the problem? The following chart from the Washington Post is cause for optimism or pessimism, depending upon how you look at it. The number of residents choosing family practice residencies has declined precipitously since 1998, followed by an upturn, which may be brief or long-lived.

Consequently, the AAMC, as does Schumer, stresses that retirement will affect specialties as well as primary care.

The question of adequate numbers of medical residencies is actually a separate, though indirectly related, question than the adequacy of the physician supply. According to Peter Ubel, who supplies the following graph from Karen Sliff of the Washington Post. The source of the data is the AAMC, which is why it is so difficult to get at the truth of an issue in Washington: the providers of information have an interest in actions taken on that information.

So, let us grant that it is probably reasonable, although not necessarily essential, to increase the number of financed medical residencies; however, it is fair that those residents take responsibility for part of the cost to us of providing them, and that such obligation be forgiven if they are willing to serve rural populations for 5 years? My support for increasing residencies is conditional on them going where the need is, not where specialists find the big bucks.

Next time, we will finish this series by looking at other approaches of providing care to a growing population.