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What Happens if We Run Out of Doctors?

SMG’s Davidson studies shortage of primary care physicians

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A doctor deficit plagues the country, and persuading more medical students to become old-fashioned general practice family docs requires three measures: more public subsidies for medical education, more primary care provided by nurses and foreign doctors, and a stomach for alphabet-soup abbreviations.

Those conclusions spring from two studies now being conducted by Stephen Davidson, a School of Management professor of markets, public policy, and law. Aided by students in the Undergraduate Research Opportunities Program, which offers BU undergrads the opportunity to participate in research projects with a faculty mentor, Davidson is seeking a solution for a problem that the American College of Physicians has issued a dire warning about: “Primary care, the backbone of the nation’s health care system, is at grave risk of collapse.”

One of Davidson’s projects looks at existing public subsidies for medical education, to relieve the debt crushing many students who might become primary care physicians (PCPs)—here’s where the abbreviations start. The second project asks whether advanced practice nurses (APNs) and international medical graduates (IMGs), or doctors trained at foreign medical schools, can provide some care in the absence of more homegrown docs. APNs are nurse practitioners and other types of nurses trained in certain care that was once done by doctors alone.

How big a problem is the lack of primary care docs? The New England Journal of Medicine notes that “a growing proportion of patients report that they cannot schedule timely appointments with their physician.” Davidson cites another barometer: only a third of American doctors are in primary care, compared with half or more docs in other developed nations. With 30 million uninsured Americans scheduled to get insurance in 2014, says Davidson, “that shortage is going to become even more acute.”

In part, fewer medical students choose primary care because specialties pay more (on average last year, roughly $203,000 versus $356,900, says the Medical Group Management Association). “It’s not that primary care physicians don’t get paid well compared to other professions,” says Ashwini Kerkar (SAR’13, MED’17), who is assisting with the subsidy study. “It’s just that they don’t get paid as well as an orthopedic surgeon.” Reimbursements based mostly on the quantity of medical services forces PCPs onto an exhausting conveyor belt that rushes patients in and out, and that workload is strained further by an aging, overweight patient population.

Primary Care Physicians PCP research, Stephen Davidson, Boston University School of Management SMG

“That’s a hard sell,” says Davidson of whether the United States should import physicians from countries with greater shortages than we have. Photo by Cydney Scott

Uncle Sam does offer scholarships and loans to students who go into primary care and agree to serve in doctor-starved regions for a few years after graduation, through the National Health Service Corps and the Public Health Service Act. Those programs have had some success, says Davidson, whose research likely will recommend increasing funding.

But even if more medical students opted for primary care, there are constraints on how many PCPs we can churn out. “Med schools can only expand so much,” Kerkar says, and can’t keep up with demand for family doctors. “Only people with heart problems need cardiologists. Everyone needs a primary care physician.”

Importing foreign-trained docs might help, but that poses the ethical problem of a brain drain from countries that desperately need medical care, too. “Should it be U.S. policy to import physicians from countries that have an even greater shortage than we do?” asks Davidson. “That’s a hard sell.”

Hence the idea of growing primary care services, as opposed to primary care doctors, by allowing APNs to do more such care “largely on their own,” he says. Legal restrictions, which vary state to state, sometimes curtail how much subbing for doctors nurses may do, and APNs study fewer years than doctors, says Davidson, who suggests researching the advantages of lengthening the training for APNs.

There’s another impediment: “I actually talked to a doctor, and he doesn’t agree with the idea that an APN can do as much” as a physician, Kerkar says. “And that’s understandable. Because he went through that many years of medical school. Why would you think someone can do the same thing with three years of training? It’s like devaluing your own service.” Her response: empowering APNs would ease doctors’ workload, giving them more time to do the things only they can do.

Budding doctor Kerkar found an economics-oriented research project intriguing. “I personally don’t like working in labs,” she says, “and this interested me because I’d always looked at just the science behind the entire medical field, and never as to how it was managed.”

Davidson expects to have written papers summarizing the research results by spring. It’s a longtime research interest for the SMG professor, who last year wrote Still Broken: Understanding the U.S. Health Care System, which catalogues the health reform to-do list lingering after passage of Obamacare.

15 Comments
Rich Barlow

Rich Barlow can be reached at barlowr@bu.edu.

15 Comments on What Happens if We Run Out of Doctors?

  • Tiyang on 12.09.2011 at 9:19 am

    yes, just import some doctors from China, they are always talking about the low payment

    • Student on 12.10.2011 at 4:12 am

      The “doctors” in China aren’t really doctors

  • Elizabeth Shannon on 12.09.2011 at 11:25 am

    you are NEEDED!!!!!!!!

  • Obs on 12.09.2011 at 11:50 am

    Medicine is under assault from all fronts including it appears the good Dr. Davidson who feels Dr. Nurse can replace a primary care physician. And one wonders why people don’t go into primary care?

  • observer on 12.10.2011 at 5:08 pm

    I think a good question to ask ourselves is this: Is MD training necessary to complete the role of a primary care provider? If advanced care nurses or PAs (pending changes in state practice acts) know what is within their scope and when to refer to a specialist, what is wrong with that? I have often wondered if MDs are over-trained for being Primary Care Providers. To substantiate these thoughts, we would need to look at a lot of data (i.e. what are the primary diagnoses seen in the primary care environment, are there differences between referral patterns between NPs and MDs, are there tx differences between MDs and NPs, etc). What do other people think? Do you know if any such studies exist?

    • Lisa Philpotts on 01.30.2012 at 9:16 am

      Great question. There was a Cochrane Review along touched on those subjects called “Substitution of Doctors by Nurses in Primary Care,” but at the time it was done only 25 studies out of 4253 met the inclusion criteria to be included in the review. Thus, the authors’ conclusion was, “In primary care, it appears that appropriately trained nurses can produce as high quality care and achieve as good health outcomes for patients as doctors. However, the research available is quite limited.”

      Citation: Substitution of doctors by nurses in primary care, Miranda Laurant, David Reeves, Rosella Hermens, Jose Braspenning, Richard Grol and Bonnie Sibbald. DOI: 10.1002/14651858.CD001271.pub2

      Objectives of review: “Our aim was to evaluate the impact of doctor-nurse substitution in primary care on patient outcomes, process of care, and resource utilisation including cost. Patient outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Process of care outcomes included: practitioner adherence to clinical guidelines; standards or quality of care; and practitioner health care activity (e.g. provision of advice). Resource utilisation was assessed by: frequency and length of consultations; return visits; prescriptions; tests and investigations; referral to other services; and direct or indirect costs.”

  • SJ on 12.11.2011 at 1:18 am

    Well, a few things will need be changed before this problem is solved.

    1. Policies in medicine need to be streamlined and the fear of malpractice and over-complexity coupled with under-payment needs to be eased. As a med student, I fear going into family practice because there are 10 ways to solve each problem but 5 ways are not effective, 2 ways are very risky, 1 way is very expensive and the last way isn’t really documented/supported by regulations or insurance.

    2. Compensation needs to be inline with what other specialities make. As a radiologist, if I can make 4x the salary with other benefits, why should I go into family medicine.

    3. Better support of existing family residents or newly trained docs. These people undertook the same loans and had the same opportunity cost as their peers who chose to go into surgery or rads or another field and are driving better cars, living in better places and can spend $$$ on luxuries that these people cannot afford. Does this sound like social justice?

    It’s easy to import doctors because their opportunity costs is different, often much less, and they really don’t care/understand the complexity. But there is no free cake here – you will have to deal with shortages tomorrow, or day after, until the underlying problem is solved.

  • Peter J DeLuca on 12.12.2011 at 12:28 pm

    automation – skype exam with robotic triage. direct KNOWN insured-member diagnosis depending on severity of problem intervention moves to next level [possible human interaction. 80 percent of the health care is routine and almost predictable by CDC.

  • Beatrice on 12.14.2011 at 11:25 pm

    “Only people with heart problems need cardiologists. Everyone needs a primary care physician.”
    So you would think that PCPs might make more. Interesting…

    • Crystal on 01.27.2012 at 11:48 am

      Well, I can see how you would think that. But if PCPs are getting more patients, they can (and do) charge less per visit. Whereas a cardiologist, being a specialist, is only getting a handful of patients who have heart problems, and are providing more in depth diagnoses than a PCP would. So each visit costs a lot more, hence their increased salary.

  • greenlife on 01.09.2012 at 7:48 pm

    Respond to Student’s comment: I disagree with you. Doctors from China are just as competent as U.S. doctors because no matter what, med students still have to passed certain classes and exams. Also, I feel that Chinese students study way harder than Americans.

  • Catherine Caldwell-Harris on 01.26.2012 at 1:01 pm

    I like the idea of nurse practitioners becoming primary care doctors. Whenever I have had the chance to interaction with RNs I’ve been impressed with their capabilities, e.g., during pregnancy. This is a win for everyone, form nurses, to doctors, to all who use primary care.

  • Just Saying on 02.06.2012 at 3:40 pm

    If you want more US jobs, give those jobs to Americans ho want to be Primary Care Doctors,that is what is wrong with us, we always want to strenghten another country with all our knowledge so they can benifit.

    Next time you go to your Primary Care doctor , don’t complain why he or she is taking so long to see you while you sit waiting 45-60 minutes on top exam table,
    they are doing 50 different things all at once.
    they are looking at your chart , while typing another patience medications,answering questions, stopped by other doctors, nurses and what ever else that is front of them.
    You can help by studying be to be a Primary Care doctor to help with the high demand.
    Don’t let Technology comsume your life so much that you might depend on those doctors for care.
    Ask the Haitian Earhquake suvivers how many doctors where there to help them through tough times during Earthquake in their country?

  • Patanjali on 10.02.2012 at 12:28 pm

    The problem also exists in the French countryside. To overcome this, municipalities rely Romanian doctors.

  • NO Residency on 01.07.2014 at 9:47 pm

    There is a shortage of doctors but there is also a shortage of residencies too. I passed my step 3 but didn’t get single interview this year, applied only in family medicine, why? because I am a international graduate, program directors are so obssesed with scores that they don’t care if you are a US citizen or Resident. Another thing I don’t get it that why they have 75% as passing score, why don’t they have 85% as passing score as no body care about 75% . These egoist, stupid program directors are giving a way to nurse to take control over the doctors.

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