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When All You Have Is A Hammer: The Problem With Outsourcing Primary Care To Non Physicians

May 19th, 2013 by Dr. Val Jones in Opinion
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Image Credit: Dan Page, Boston Globe

What is the US going to do about our current and future primary care physician shortage? Many believe that the solution is to expand the scope of nursing practice, and license non-physicians (such as naturopaths) to practice medicine. In the face of scarcity, 17 states have licensed naturopaths to provide primary care and nurse-led, in-store pharmacy clinics are gaining popularity.

Studies have shown that nurse practitioners are as capable as physicians at treating common primary care complaints such as strep throat and headache. What studies have NOT shown is that nurse practitioners recognize and diagnose less common diseases with similar symptoms. What if the strep throat were throat cancer? What if the headache were meningitis? Substituting practitioners with half the training and experience of an MD comes at a price. And that price may include missed diagnoses, delay of appropriate treatment, and life threatening consequences.

But the lure of cost savings cannot be ignored. Nurses are paid less to practice primary care, so in theory we could save untold millions each year by having patients see nurses instead of doctors. That sounds good, but now nurse practitioners are lobbying to receive the same salary as MDs for their time. After all, they’re doing the same work, right? Never mind that everyone they treat must be squeezed into a limited set of diagnosis codes – when all you have is a hammer, then everything starts looking like a nail. “Poof” goes the savings, while care quality standards are permanently reduced by forced limitations on differential diagnoses.

A better solution would be to find ways to extend physician reach and expertise with telemedicine platforms, longer patient visit times, and by reducing their non-clinical practice burden. Nurses and ancillary providers are valued members of the clinical team who are dearly loved by patients and doctors alike, but they simply do not have enough training to be ruling out tens of thousands of rare diseases and conditions. This is why we need physicians at the helm of the clinical team – to  make sure that patients are on the right treatment pathway.

Some nurses cry “prejudice” when physicians suggest that MDs provide better primary care. But we all know that knowledge and experience are a critical asset when lives are at stake. As the research results begin to roll in regarding better patient outcomes under the care of physicians versus nurse practitioners, common sense tells us that outsourcing primary care to the less qualified will have undesirable consequences for some. And if you choose to get your primary care from a naturopath or nurse, you’ d better hope that headache isn’t anything serious. Because a little savings now could cost you your life.

Is It More Important To Make Patients Happy Or To Heal Them?

June 27th, 2012 by Dr. Val Jones in Health Tips, Opinion, Research
1 Comment »

One would think that happiness and healing are inextricably linked in healthcare, but the Happy Hospitalist (HH) raises an interesting question: is modern medicine’s emphasis on patient satisfaction (and shared decision-making) sacrificing our quality of care? A recent study found that patients who preferred their physicians to take the lead in their medical decision-making had shorter, less costly hospital stays.

HH argues that if physicians are expected to perform like airline pilots, reliably choosing/performing the best course of action for those depending on them, then patients should behave like passengers. In other words, passengers don’t tell the pilot how to fly the plane, nor should patients override a physician’s clinical judgment with personal preferences.

I think this analogy misses the mark because patients are rarely interested in making decisions about how a physician accomplishes her task, but rather which tasks she undertakes. Flight passengers aren’t interested in quibbling about the timing of landing gear, they are interested in the selection of their destination city. And so they should be.

While there may be a correlation between physician-led decision-making and shorter hospital stays, I’m not convinced that this translates to improved care quality. For the study subjects, discharge could have been delayed because the “empowered” patients insisted on ensuring that a home care plan was in place before they left the hospital. Or perhaps they wanted to get their prescriptions filled before going home (knowing that they couldn’t get to their home pharmacy over the weekend)? The study did not assess whether or not the discharge delays reduced readmission rates, nor did it seek to determine the cause of prolonged stays. This study alone is insufficient to draw any conclusions about the relative value of the patient empowerment movement on health outcomes.

While I certainly empathize with HH about the excessive focus on patient satisfaction surveys over true quality care, I strongly believe that an educated, participatory patient is our best ally in the practice of good medicine. There are simply too many cogs and wheels turning at once in the healthcare system to be able to ensure that the right care is provided at the right time, every time. We need all the help we can get to monitor our care plans in order to avoid medical errors, compliance problems and missed opportunities.

If you see something, say something. That principle applies to healthcare as much as it does to flight safety.