We all know there is a shortage of primary care physicians in America. At least that's the convention that's been spread by the AMA and politicians over the last several years. So it was kind of surprising to read an editorial in KevinMD about how all this handwringing may be exaggerated. Dr. Peter Ubel, a physician and Professor of Marketing and Public Policy from Duke University, says that there may be a shortage of PCP's in this country, but that doesn't necessarily mean there is a lack of caregivers here.
He explains that PCP's should follow the example of anesthesiologists. We clever anesthesiologists have learned to increase our efficiency by caring for multiple patients simultaneously. What is the secret to our magic? Many of us have hired work extenders to enable our tentacles to reach into different operating rooms without having to actually be there. They are called CRNA's. According to Dr. Ubel, CRNA's are able to deal with the usually routine cases, needing only the anesthesiologist during critical or difficult parts, and we doctors get to enjoy the monetary bonus of our uncanny ability to treat more than one patient at a time.
Dr. Ubel's proposal is that PCP's should welcome nurse practitioners, physicians assistants, and registered nurses into their practices. The extenders can treat the routine coughs and sniffles while the doctors will be responsible for the complex, positive review of systems patients that are beyond the capabilities of such lesser educated caregivers. Thus the shortage of professionals able to see patients will be alleviated.
I had to scoff when I read his idea. I'm not sure if he is serious about opening up this Pandora's box. We anesthesiologists have been battling the encroachment of nurse anesthetists for decades. Many of us do not see their presence as a panacea. Dr. Ubel should take a closer look at the battles that are working their way through the courts and legislative capitols as the CRNA's aggressively expand their scope of practice. First they won the right to practice free from physician supervision. Now they are bidding to take on procedures such as pain management that even an anesthesiologist requires at least a year of extra training to perform but a nurse thinks she can learn to do in some hotel resort over the course of a weekend.
His description of the interaction between a CRNA and the anesthesiologist in the operating room is especially indicative that he doesn't have a clue. He writes about how the anesthesiologist will be present for the more difficult parts of the operation or if the patient becomes unstable while the CRNA can handle all the other mundane parts of the procedure. That is beyond laughable. If only some of our CRNA's were astute enough to realize that they are in over their heads. Many have a militant attitude that practically demands we MD's should butt out of "their" cases. They only want our signatures on their records in case something goes wrong and they can say they had nothing to do with making any medical decisions. Is this really how Dr. Ubel envisions the future of primary care? Before you know it, NP's and PA's will demand that they have the freedom to work independent of physician supervision and start taking over smaller medical offices. Soon, primary docs will be ghettoized into large city hospitals that only treat difficult medical cases. People will soon see that PCP's aren't necessary at all since these complex cases will most likely be seen by a battery of medical subspecialties and the field of primary care will whither and die. That is one way to alleve the shortage of PCP's.
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