A Win-Win for Doctors and Vets / #Save GME

https://www.youtube.com/watch?v=VZvNDuP1xlY

Most of the solutions I have described to eliminate the Residency Shortage will take time to enact.  They involve legislative changes at both the National and State levels (I have already talked about how long and hard those changes can be).  I have also described what has been passed in several States.  What most concerns me are the unmatched doctor grads TODAY.  What can we do to “preserve” them before they are forced to leave Medicine permanently?

Perhaps you recall a “mini uproar” that came out in the Washington Post in May 2016.  The article titled, “VA:  Let nurses Treat Vets”, related how “The Department of Veterans Affairs would dramatically expand the authority of nurses to treat patients…”(1)  This plan was intended to reduce long waits for medical appointments and “to ensure the VA has the authority to address staffing shortages in the future”, according to VA Undersecretary for Health Dr. David Shulkin.

 I wrote to Dr. Shulkin at that time to propose a “win-win” for both doctors and vets.  I suggested hiring the unmatched doctor grads through the VA to see patients under the supervision of the current VA medical staff (much as with the supervision provided in a residency program).  The unmatched doctors would be given meaningful work as well as further medical experience and training.  The Vets would receive timely care with reduced appointment wait times due to the increased staffing.  The doctors would apply again for residency as the number of residency slots increased.  The supply of doctors would increase to alleviate doctor staffing shortages for the VA in the future as well.

Ironically, these doctors would be “distributed” all across the US, as are the Veteran Hospitals.  This would be a quick fix to two currently existing problems, the Residency Shortage and the long appointment wait times for Vets.

I received a response from Dr. Shulkin stating that the VA does NOT have its own residency programs (although residency programs actually DO staff VA hospitals).  I responded again to Dr. Shulkin that I was aware of that fact, but was instead suggesting a temporary use of these unmatched doctors until the deficit was eliminated.  Dr. Shulkin replied, “Oh, now I understand”, but nothing more was said.  I suppose this is where the politics come in to play.  I am assuming the “greater plan” was to reduce healthcare costs for Vets by allowing nurses to provide more cost effective care (I discussed the pros/cons of nurse vs. doctor provided care in a prior blog). 

So this is one proposal I am suggesting to “preserve” the unmatched doctors in a timely fashion before it is too late, and their educations would have been for naught.  The VA could more easily create a system much like Missouri did (Assistant Physician license), because the VA system is Federally operated.  It would require only “one” new license which would apply nationwide.  The usual hurdles of individual state licensure for these “unlicensed” doctors would not be an issue.  It would save the costly and tedious process of changing each state’s licensure laws to accommodate this National “emergency”.  These doctors could work to provide quality, yet supervised care to our veterans, while under the supervision of current VA doctors.

(1)

https://www.washingtonpost.com/news/powerpost/wp/2016/05/27/to-cut-wait-times-va-wants-nurses-to-act-like-doctors-doctors-say-veterans-will-be-harmed/?utm_term=.52493662cce7

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Second-Half Summary/ Residency Shortage

Second- half Summary/Residency Shortage

https://www.youtube.com/watch?v=LT2xcjL-eNo

Here is the second half of the “story”:

• What is the AMA doing?
• The Nation has broken the “Social Contract”
• 25% international medical graduates do not match, yet ECFMG has been monitoring and making recommendations to them for 60 years!
• We want to think US Medical Schools are “better”, yet individual learning and passing of the “Criterion Task” have leveled the field.  Only fully qualified applicants are eligible to participate in the NRMP in the first place!
• ACGME is not in favor of Missouri’s plan for Assistant Physician License, yet has not taken the lead in finding a solution
• AMA and ACGME, two of the most influential agencies in Medical Education, are not leading in timely fashion to prevent an utter waste of human talent
• The impending doctor shortage will be more than 90,000 doctors short in the next decade
• Some question the legitimacy of the “Doc Shortage”.  Either the demographics are correct, or they are not!  Baby Boomers are ageing and will require even more medical care.  Is this really politics trying to use lesser trained medical professionals to provide patient care at lower costs, using physician assistants and nurse practitioners?
• Are P.A.s and N.P.s as qualified as MDs?
• A number of states are approaching this problem but tend to favor their own residents
• Need a “tsunami” of outrage to solve this
• Need action by each person concerned about this solution

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Slam Dunk? / Politics / Residency

Slam Dunk?/ Politics/Residency
https://www.youtube.com/watch?v=DZt3xeV_n00&t=2s

   Too many medical students, yet not enough residency slots.  Impending doctor shortage, yet “discarding” fully educated doctor grads.  Why isn’t the solution to this dilemma a “slam dunk”?  Because nothing is ever that simple.  There are the “politics” involved that complicate the solution to this deficit. 

                                                            (Bloom's Taxonomy) 

    Is there really going to be a physician shortage, or are the VA, The Affordable Care Act, and some states planning to utilize less expensive physician assistants and nurse practitioners to administer healthcare?   Josanne Page of the Cleveland Clinic said, “P.A.s generally make about half a physician salary or less, depending on specialty (an ER doctor makes an average $270,000, an emergency-room P.A. $112,000).” (1)

 “ And several states, such as Arizona, Maine, Maryland, Nevada, Vermont, and Washington have liberalized laws to enable nurse practitioners and PAs to perform some treatment normally done by doctors.” (2)  The Affordable Care Act has allowed millions more insured patients, with a shortfall of sufficient doctors to treat them.  Compared to other countries, the US has 2.5 practicing physicians per 1,000 people vs. 3.2 physicians per 1,000 for an average of 34 other countries. (3)

 Is a PA or NP qualified to see patients as effectively as a doctor?  A PA curriculum typically requires 1 year of classroom learning and 1 year clinical work.  A NP requires a 1-3 year program post graduate after obtaining a nursing degree.  Doctor training requires a minimum of 7 years after college.  The 3 doctors in my family had 7 years, 10 years, and 11 years of post college training.  The further depths of knowledge and medical experience afford a doctor a level of synthesis not attainable with lesser years of study. 

 A dermatologist I know recommended that a patient obtain a consult regarding a skin ailment, sometimes associated with pancreatic cancer( The patient returned to thank the doctor for the early diagnosis of pancreatic cancer which might have been missed under normal circumstances.)  Would a PA have known that correlation? 

  An OB/GYN doctor told a patient to obtain further diagnostics for continued lactation after cessation of breast feeding.  There is an association with pituitary tumors with uncharacteristic lactation.  The patient did end up having a pituitary tumor.  Would this have been noticed by a PA?  Often, a doctor never enters the room when a PA is seeing a patient.

     Ironically, PAs who by “definition” are “supervised” by a doctor, are allowed to work immediately after graduation.  A doctor with 4 years of medical school cannot work at all, until obtaining a license upon completion of a residency.  They can’t even work as a PA due to the stringent PA licensure rules!

(1) http://www.nytimes.com/2014/08/03/education/edlife/the-physician-assistant-will-see-you.html?_r=0

(2) http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/08/11/to-address-doctor-shortages-some-states-focus-on-residencies

(3)http://www.epi.umn.edu/mch/wp-content/uploads/2013/09/ACA-Overview.pdf

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Doctor Shortage / Waste

Doctor Shortage/Waste

https://www.youtube.com/watch?v=DZt3xeV_n00&t=2s

 

   Let’s talk about the upcoming doctor shortage.  Here are some statistics and projections:

• 27.6% of the current physician workforce are age 60+ years old and likely to retire in the next 10 years (1)
• 32.6% of practicing physicians are women
• 46.1% of residents are women
• “Historically women have worked fewer hours than men-a trend that continues today” (2)
• 24% of current US physician workforce are IMG (International Medical Graduates)
• 25.9% of US “ resident” workforce are IMG
• “By year 2025 the United States will face a shortage of between 61,700-94,700 physicians”. (3)
• “Thousands of baby boomers are turning 65….seniors are the population with the greatest healthcare needs”. (4)
• “The Association of American Medical Colleges (AAMC) projects there will be a shortage of between 12,500-31,100 primary care physicians in the next 10 years…equally troubling is the shortage of between 28,200-63.700 specialists.”(4)
• More than 40,000 fully qualified doctors have not matched into a residency over the last 5 years and cannot practice Medicine without residency training.
• 8,640 doctors did not match on March 17, 2016, what are they doing now?
• “With medical school and residency combined, it takes a minimum of seven years to train a doctor.” (4)

What are we thinking?!!!  In view of the upcoming doctor shortages over the next decade, we are simply “discarding” our fully educated doctors!  This just does not make sense!

(1)   page 12

https://www.aamc.org/download/452922/data/thenationsphysicianworkforceandfuturechallenges.pdf

(2)   page 13

https://www.aamc.org/download/452922/data/thenationsphysicianworkforceandfuturechallenges.pdf

(3)

https://news.aamc.org/for-the-media/article/gme-funding-doctor-shortage/

(4 )page 1

https://www.aamc.org/download/386378/data/07252014.pdf

(3)   page 2

https://www.aamc.org/download/386378/data/07252014.pdf

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Residency Shortage = Doctor Shortage

  
https://www.youtube.com/watch?v=P3a03rDfyKg

Many people cannot relate to the current situation with the residency shortage.  My local congressman asked why the unmatched doctors could not just go and apply elsewhere for a job.  The rigid system in place for educating a doctor is very unforgiving.  Without a US residency, a doctor cannot obtain a medical license in the US, period.  One thing we can all relate to however, is the results of a doctor shortage.  That is when it will really mean something to which everyone can relate.

Updating a previous blog about the “Ramifications of a Doctor Shortage”, I wanted to talk more specifically about what this doctor shortage could entail.  The AAMC (Association of American Medical Colleges) now predicts that, “By 2030 the US population under age 18 is projected to grow by only 5%, while the population aged 65 and over is projected to grow by 55%.  Because seniors have a much higher per capita consumption of health care, the demand for physicians- especially specialty physicians- is projected to increase.”(1)  Additionally, on a scale of 1-5, the US currently has a per capita number of doctors of 2.6 compared to Austria at 5.0 (2)  Sweden, Switzerland, and Germany all have about 4 doctors per capita (2).  The US even falls behind the number of doctors per capita of a 3.4 average for other developed countries.  So the US already lags behind per capita in current number of physicians, and this scenario is predicted to get even worse up to the year 2030.  The US is predicted to have a 105,000 doctor shortage. 

Let’s talk about one of the most critical areas of the projected shortage.  “A shortfall of between 33,500 and 61,800 non-primary care physicians is projected by the AAMC (includes surgical and other specialists).”  Think about the average person’s use of doctors.  For females between 0-21, we would assume girls initially go to a primary care doctor and then change to an OB-GYN doctor in the teen years.  Perhaps they would go to the doctor once/year, and sometimes even less.  As I watched my own Mother as she aged she utilized the following physicians:  Primary Care, OB-GYN, orthopedist, Otolaryngologist, Cardiologist, Dermatologist, Audiologist, Ophthalmologist, Gastroenterologist, and Pulmonologist.  I am counting at least 10 specialists, and some on a frequent basis each year.  Going to a doctor has become part of the weekly ritual for many seniors.  Just imagine the difficulty that will be forthcoming in the next decade in receiving quality care from medical specialists.  Personally, I have called the office of a gastroenterologist each day for 3 days, have never talked to a human, left messages, and still have not received a call back.  The office message says to expect delays due to the high volume of calls (and I live in a city, not a rural area). 

 Now back to the current travesty of the residency shortage.  We can see how the non-medical person can relate to the upcoming doctor shortage.  But this doctor shortage directly correlates with the current medical residency shortage.  We as a Nation have been “discarding” fully educated and qualified doctors at the rate of 10,000 unmatched doctors per year.  The AAMC keeps writing about the need to increase the number of residency slots to prevent the loss of thousands of doctors, but to no avail.  No “one” person seems to be taking this impending crisis seriously.  It takes a minimum of 7, and up to 10 or more years, to educate and train a doctor, especially a surgeon or medical specialist.  By the time the doctor shortage is fully realized, the “solution” will take that amount of time and more to catch up with the deficit.  We need to act now to correct the residency shortage to prevent an impending doctor shortage in the future!

(1)   https://aamcblack.global.ssl.fastly.net/production/media/filer_public/73/32/7332e443-2302-4daa-a56e-6937a43646ea/2017_workforce_projections_key_findings.pdf

(2)   https://www.healthsystemtracker.org/dashboard/#access-affordability

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