The Growth of the Health Sector: Bigger Doesn't Always Mean Smarter
As the jobs data spill into the political pot, job growth in the health sector is portrayed as the pony in the manure pile. In fact, to the contrary, the projected expansion seeks to embrace but another policy corrosive to the quality of American medicine.
To be sure, there is a shortage of physicians relative to population and specific to primary care. Paradoxically, however, the Patient Protection and Affordable Care Act actually limits the size of medical school classes (back to 1997 numbers) and the amount of federal money allocated for uncompensated care that teaching hospitals have used for medical trainee education.
If the number of doctors will not be increasing, who will be delivering patient care?
"Reform," in this case, means a redefined primary care system with non-physicians displacing the doctors' responsibility for determining diagnosis and treatment. This administration believes that any health professional can provide quality if guided by enough checklists and clinical cookbook recipes written by far-removed health care regulators. This is not reform, but retreat.
To the public, the idea of adding non-physicians to do primary care may seem an enlightened accommodation to the problems of cost, distribution, and access to care. A common justification for going "physician lite" is an expanding patient demand. From 1996 to 2006, there was a 26% increase in physician visits to 1.1 billion. This averages to about four visits per year, with 7.6 annual visits for those 65 and older. More, however, is certainly not merrier.
In 2006-7, there were 427 million mental health drug prescriptions written in the United States. Primary care accounted for over 60% of scripts for anti-depressants and over 50% for stimulants. In 2010, the most prescribed drug in the United States was the narcotic hydrocodone, at 131 million scripts, leading the second drug, one for high cholesterol, by 40 million. These statistics infer why many people visit doctors and suggest that part of the growth in primary care reflects the paucity of more appropriate resources for mental health and substance abuse.
A second reason why some welcome the non-physician is a perception that technology (CAT scans, for example) or blood testing really makes the diagnosis, so it does not matter who orders them. Yet technology does not find the answer unless directed by the right clinical question. The harshest test of quality is the amount of time it takes to arrive at the correct diagnosis. The best financial outcome and the lowest human cost occur when the problem is understood at the first innocuous symptom rather than when a disease is more obvious and severe.
Physician "extenders" are serious people who train rigorously. The issue is where their skills best belong in the medical process. Nursing schools increasingly argue for autonomy from the doctor, but few studies compare diagnostic acumen between nurse practitioners and physicians. There is evidence for similar patient outcomes in the management of stable chronic disorders, but that is vastly different from seeing clearly through what is often the fog of disease.
Until this bar is met, there will be clinical roulette, with patients hoping to be in sync with the level of expertise that engages them.
The medical profession has to forcefully advocate that physicians must retain professional independence and appropriate authority. They are already the most licensed, certified, and re-certified of the professions. This alone does not always translate into a loyal or comforted patient -- studies of nurse clinician primary care tellingly show that patients often perceived more concern and human attention from nurses than they did from their physicians. For most people, going to the doctor is scary, and kindness can easily trump knowledge.
Non-physician care extenders have a valuable role to play in concert with, rather than separated from, the physician. Medical practices should develop innovative and cooperative relationships between many types of health professionals. Nonetheless, illness is unforgiving, and medical school and years of residency make a difference. A Viennese reflection said it all: "The physician sees only what the physician knows."
If we continue to simplify how we react to what diseases demand of us, we will rue the day when we let soft policies replace hard realities.
Joel B. Levine, M.D. is a professor of medicine and the founding director of the Colon Cancer Prevention Program, University of Connecticut Health Center.