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Nurses May Not Fill The Primary Care Shortage: “We’re Not Suckers”

There is a critical shortage of primary care providers in the United States. The public’s perception is that there is no shortage, and politicians have spent very little time talking about how to address the shortage. The American Academy of Family Physicians has been carefully studying this issue and strongly recommends incentives for physicians who would consider primary care: increased reimbursement for non-procedural work, and medical school debt-forgiveness are two of many.

The universal coverage system in Massachusetts immediately unmasked the problem of the primary care shortage. Newly insured citizens have been astonished to discover that they cannot find a primary care physician even though they want one. Wait times often exceed 6 months, and very few physicians are accepting new patients.

I have had the privilege of listening in to various healthcare reform discussions among politicians and advocacy groups here in Washington. Every time I raise the issue of “what will you do about the primary care shortage?” they offer the same tepid response: all providers will need to “work together” to provide primary care services, and innovative programs like retail clinics and nurse-driven care models will help to fill the gap in physicians.

My friend and fellow blogger, Dr. Rich Fogoros recently wrote an amusing (and cynical) post about how physicians should simply “hand over” primary care to nurses. (The same argument that many politicians seem to be making). The only problem with this reasoning is that nurses may not be willing to provide primary care services for the same reasons that physicians aren’t too keen on it: the pay is low, the workload is grueling, and there are other career options that offer better lifestyle and salary benefits.

I spoke with a group of nurses on a recent podcast about this very issue and their view was that, “we’re not suckers” – primary care is not as appealing as ICU work, for example.

Gina (Code Blog): Not every nurse wants to go back to school for additional years and shell out a lot of money to become a nurse practitioner and then not make a whole lot more than we’re making now. I’ve worked with nurse practitioners who have come back to work in the ICU because they can’t make enough money in primary care to support their families.

Strong One (MyStrongMedicine): We don’t have enough educators to teach nursing at our nursing schools. Nurse educators are paid about a quarter of what they’d make at the bedside. There are long waits to get into nursing school because we don’t have enough instructors to handle the influx. Until that problem is solved we aren’t going to see in increase in nurses entering the market.

Terri Polick (Nurse Ratched’s Place): I have a friend who’s a nurse practitioner and she had to borrow over $100,000 for her education. I’m a three-year diploma nurse so technically I don’t even have a college degree – but I’m making a lot more than nurse practitioners and I don’t have all that debt. Politicians need to know that nurse practitioners can’t just “pick up the slack” from physicians. Nursing and medicine are two different specialties and we’re trained to do different things.

So for those of you out there who may have shrugged at the primary care shortage and figured that when the docs are gone, someone else will just pick up the slack – think again. Any national universal coverage system will simply unmask what many physicians have known all along: equal access to nothing is nothing. Without making primary care a more attractive career option for providers of all stripes, don’t expect an influx of any sort into the field.

Long wait times for basic healthcare will probably become the norm in America.


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7 Responses to “Nurses May Not Fill The Primary Care Shortage: “We’re Not Suckers””

  1. Katie Brewer says:

    It’s kind of like saying we’ll just fix the nursing shortage by bringing in more foreign-educated nurses. It reminds me of eliminating national debt by just printing more money – you know? You’re not fixing the fundamental problems – pay, work quality, appreciation, advancement – that’s what drives both physicians and nurses out of practice…

  2. Dan says:

    So, You Want To Be A Doctor…..

    Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular- both now and in the speculated future. Typically, the main reason believed and speculated by others for this decline of this health care profession specialty that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training, as the annual salary of a PCP is around 130 thousand a year on average, others have concluded may be the national average and factors in payers both of a private and public nature.

    Yet considering the additional attention of shortages of students in some medical schools as well, as conceived by others, one could posit hat this professional vocation that has been one viewed in the not so distant past in the U.S .

    Viewed as one with great esteem and respect may not be desired as a vocation by many, that demands commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of their lifespan. Such reasons for this paradigm shift may include:

    Primary Care Doctors perhaps more than other physician specialties seem to be choosing to practice medicine under the direction and financial security of one of the many and newly created health care systems These regional and nationally created systems are typically composed of numerous hospitals and clinics under combined ownership- frequently of a private nature that is not dependent upon their beliefs as it is perhaps on their profit motives and intentions. Yet their approach and etiology of their views regarding the restoration of the health of others are usually similar with such mergers of multiple medical facilities, which are presently preferred to save costs, it has been said, and therefore these systems have not been protested by a largely uninformed public.

    Conversely and in addition, this system of increasing popularity is not necessarily a desired method to practice medicine as a primary care physician, often stated by them as members of their employer that has the power to limit and dictate how they practice medicine. This is because, among other reasons, such doctors have largely unexpected and unanticipated limitations regarding their patients’ heath provided by them. This is further aggravated by possible and unreasonable expectations of their employer, such as mandating that doctors they employ are required to see as many patients as theycan in a day, and there have been cases of physicians being fired by a health care system- along with financial rewards for seeing more patients a day than what is determined as average visits by others. Such requirements likely and potentially affect or alter the clinical judgment determined by physicians employed in what may be viewed as authoritarian employers, which would limit the medical care they provide to their patients, as well as the quality of this care. Also, such health care systems may have their own managed health care system that may be determined by factors not in the best interest of the patients of doctors employed by the health care system.

    The primary etiology and stimulus for a doctor to practice medicine in this way is due to their frequent inability to provide and employ ancillary staff, combined with the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently.

    Malpractice laws and premiums, which is determined in large part on a state level, are an issue with those required to have this adverse aspect of their professions. Also, these premiums become more expensive for doctors, depending on the perceived risk of their chosen specialty. For example, the premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps. Plaintiffs win about 25 percent of the time on average a half a million dollars. 95 percent of these cases are settled out of court.

    In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine, which basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. Because if a doctor practices medicine in such a way, it typically involves what may be considered as unnecessary diagnostic testing for their patients to rule out what may be unlikely disease states of their patients’ medical conditions. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients.

    Such restrictions and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility on a societal level. It seems that this perception and vocation that now is greatly misperceived due possibly to being deformed by others who may have profit as their motive for the health care they may dictate to doctors they may employ in some way, which often and likely is in conflict with their motives as doctors and how they wish to deliver needed health care to others. This may be why this medical profession may no longer be viewed as distinct from other vocations, in large part, as it seems that presently the profession of a doctor has been reduced to one dependent on the financial stability and growth of its employer, which may alter how the doctors perceive what is expected of them as well, which may affect the importance of how they view their profession, as it has been said that overall, doctors are somewhat understandably more cynical and demoralized, which may be replacing the pride they historically have viewed their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.

    Further complicating and vexing to these restrictions is the usual financial state of the individual physician, as they normally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed, it has been estimated, along with this debt amount presently is about 5 times higher than it was only a few decades ago.

    Conversely, there are some who believe that doctors in the U.S. are over-paid and are compared with some corporate monster, who behaves based upon the premise of greed. In spite of how they are judged, physicians are likely not absent of financial concerns- which may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations. Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a physician, as others are more dependent on their judgment.

    It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable it is also and potentially unfortunate for the health of the public in the future, and the nature normally associated with the medical profession which could deter ideal medical care for others

    There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession.

    Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.

    Then again, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession in relation to how their vocation is viewed by others and based on limited judgment and analysis. Yet citizens overall should determine what sort of health care they desire, and it seems that often they fail to voice this right as a citizen.

    For perhaps Primary Care Physicians in particular, the medical profession and those who provide medical care clearly needed by others to some degree appears to be absent as a desired path of today’s careerist. The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet need to be active more in assuring this necessity is more aseptic.

    “In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero

    Dan Abshear
    Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.

  3. Ed Stevenson says:

    In relative terms physicians assistants and nurse practitioner are still the best set up to fill primary care needs. Yes its hard for someone to go back to school for a couple years and pay tuition of $100,000. But compare that to physician who are accumulating $350,000 of medical school debt and take 8 years to train to to the same job. Most doctors have little to no work experience and often have 4-5 years of undergraduate debt and living expenses. Where NPs often have several years work experience earning good money and may have savings to pay for NP training. Physicians may also be bearing additional $10-100k debt in the form of small business loans for office equipment and practice overhead before they start to earn any real money. PA/NPs are most often salaried out school and bear little to no administrative burden. Bottom line, when you look at the larger financial picture it can take decades for a doctor to reach the same wealth level as a NP/PA for the same work. PA/NP do have a relative financial advantage for them to assume the primary care role.

  4. Strong One says:

    “equal access to nothing is nothing” ~
    It’s a hard pill to swallow and we still are trying to fix something from the outside-in.
    How are we supposed to entrust the ‘fixing’ to individuals who do not walk in our ‘collective’ shoes?
    This problem is only going to exponentiate in the coming decade. We are struggling to keep our head above water in these trying times, how well will we all be swimming in the future?
    Something has to change, and if we all sit around waiting for the change to happen.. the only thing that WILL change… is you.
    And the beat goes on..

  5. I agree with some of what Edward said about having a slight advantage over MDs when starting out in a nurse practitioner position. We don’t have the overhead (at least in the non-independent practice states) as the MDs but we do have just about the same debt level. I worked full time through my program because I had to being the only providing parent (my husband is disabled). I ended up with 7 years of schooling with 83,000 dollars in student loans. I’m not sure why 8 years would cost a MD 350,000 dollars unless they didn’t work at all during all 8 years. If it takes decades to pay back student loans, it would keep anyone front wanting to go into the medical profession regardless of what type. I don’t plan on taking that long. I supplement my income by blogging (ads, paid advertising space, guest blog posts and such). I’m glad to see that you agree that NPs/PAs are strong enough to handle primary care. It’s what we’ve been doing for years with great patient outcomes.

  6. I wholeheartedly agree with the nurses you have quoted. Nurses have begun to recognize their potential away from the bedside as well. We are tired of the physical stress and strain on our bodies, the lack of respect often found at the bedside, and are seeking other avenues for income, appreciation, and challenge. Providing primary care is not one of those.

    More and more nurses are using their education and the critical thinking model known as the nursing process to create their own businesses. The nursing process is an excellent model for business entrepreneurs.

    Nurses are becoming educators (outside of nursing education), legal consultants, case managers, agency owners, etc. and are willing to put in the time and effort when the work directly benefits our own bottom line. Why would we take on tens of thousands in debt (or more) if we don’t see the benefit (if any) for years and years to come? By the time we leave the bedside we are usually older and don’t want to be saddled with the education debt into retirement.

  7. Sharon says:

    to NPs save lives: Medical school is not like nursing school. It is simply impossible to work enough to make any significant amount of money. Remember that med students, as opposed to nurses, often can’t get jobs where they can work a 12-hour shift a few times a month and make a decent amount of money for it (not that that would be enough to live on, but it would be something). The first two years it might be possible to work a very part-time job if you found one with flexible hours, as long as you did nothing but study and work. However, during the 3rd and 4th year one is frequently in the hospital for 100+ hours a week. I don’t know how it’s possible to work on top of that. Med students are expected to be able to show up at any time with little advance notice, and to stay as late as is necessary to get the job done, not to mention overnight shifts. Med school can’t be done part-time either. I think that’s why people in a lot of other professions don’t understand our debt load. Admission to med school is competitive. Usually you apply to 10-20 schools and you go to whichever one you are accepted to, whether it’s on the other side of the country or near your family. Most med students also are not married, which means they don’t have someone else to help pay the bills while they’re in school. So most of us had to borrow for living expenses. So if tuition and fees are about 40K a year, and you’re borrowing 15-20K for living expenses yearly, it’s quite easy to owe over 200K.

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