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Docs Shouldn’t Have to Do Everything

The existing structure of preparing the healthcare workforce of the future is attracting increasing attention. Recently, in his MedPage Today “Revolution and Revelation” blog, Milton Packer deconstructed the traditional academic medical center as a failing concept. I submit that his critique needs to be complemented by a reflection on the role of the future physician on the care team and how to re-engineer our professional training accordingly.

The pertinent debate is driven by concerns about access. Getting a timely appointment with a primary care physician is difficult: In 2009 the average wait time was reported as 19.5 days. Getting in to see a specialist is often worse. Overall, the situation has undoubtedly grown more dire in the past decade with millions of individuals having been added to the pool of the insured, a situation that will continue to be a challenge as the nation aims for universal insurance coverage.

As the word “provider” has often replaced the term “physician,” the traditional concept of “The Doctor” has been eroding. The revered healer in the white coat has become an endangered species.

Today’s physician is a worker in the healthcare service industry, functioning either as an independent vendor of a defined service or as an employee of a service company. He or she is one of many in a fairly large pool of members of the care team: People wearing scrubs or lab coats or some other uniform who are addressed as “doctor” in clinic and hospital settings include a wide swath of professionals, such as pharmacists, podiatrists, MDs, DOs, nurse practitioners (DNPs or doctors of nursing practice), psychologists, etc.

In other words, physicians fit into a continuum of service providers. The family practitioner, for instance, is closer to a family nurse practitioner or a physician assistant (PA) than to, say, a pediatric neurosurgeon in skill set, expertise, and professional-fee structure.

I submit that we have built too much redundancy into our medical school training. We see it as perfectly reasonable that dentists get trained from the start as tooth-and-gum specialists who do not need to be knowledgeable about the details of renal histopathology, for example.

By contrast, much of doctors’ training is aimed at producing the well-rounded generalist who is acquainted with all organ systems and tissues in the body before he or she moves on to get in-depth training in the area of work actually performed. A future pediatrician is required to learn all about Alzheimer’s disease before being awarded the licensure-critical MD degree, and an obstetrician must study the innervation of the inner ear. A future pathologist spends all his or her clinical years (now often 30 months) learning how to interact with patients even though the pathologist will only deal with tissue samples and dead bodies.

The debate about access to healthcare is, plausibly enough, often framed in terms of physician supply. The Association of American Medical Colleges, for instance, projects a physician shortage of 40,800 to 104,900 by 2030. I propose that these alarming projections are too much predicated on the old model of a physician-centric workforce. Primary care, encompassing preventive interventions, lifestyle medicine, physical examinations, and triage to specialists as indicated can be handled by professionals who have gone through the training programs for PAs or nurse practitioners.

This large corps of frontline clinicians (primary care providers or PCPs) must be complemented by a cadre of technical specialists who can perform the diagnostic and therapeutic functions beyond the skill set of the PCP. It is unclear that the proficiency of a gastroenterologist who performs ERCPs (endoscopic retrograde cholangiopancreatographies) or a urologist extracting a kidney stone is superior to that of a well-trained non-MD technician.

Technical specialists have better outcomes the more often they perform the task they are trained to do. Thus, within a future surgical center, there might be procedure-specific service lines such as “hernia repair” or “thyroid surgery,” just as in dentistry today there are specialists who do nothing but root canals. So, in the future we may have a heart transplantation surgeon, a stent implanter, and a valve replacement specialist replacing cardiac surgeons and interventional cardiologists.

If we are serious about meeting market needs, we will have to let ultimate labor demands influence the design of professional training programs. Using fully trained obstetricians and fetal-maternal health experts to deliver babies in low-risk situations is indefensible if midwives can provide the same service. Expanding this concept to all medical specialties would dramatically change the physician shortage calculus.

But to fully take advantage of the inherent efficiencies, our clinical training paradigms have to shift quite radically. Such a shift, in turn, presupposes a flexibility about the definition of healthcare worker roles that is currently in short supply among the physicians in this country.

Ole J. Thienhaus, MD, MBA, is a psychiatrist who received his medical training at the Free University of Berlin in Germany and completed residency training in psychiatry at the University of Cincinnati. He currently serves as professor and chair of the Department of Psychiatry at the University of Arizona College of Medicine in Tucson.


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