Posts Tagged DO

Training Doctors — choked by tradition

towerGrand poobahs, long robes, ivory palaces, exulted wise men — is it the Arabian Nights?  — no, it’s graduate medical education in the US.  Finally, a voice of reason — coming from the Institute of Medicine (IOM).  The surprising report released 7/29/14 says doctor training is not meeting the needs of the country.

The problems:  $18 billion per year going to academic medical centers without adequate accountability.  Money lavished on the Northeast fails to trickle down to community training programs elsewhere.  Self-serving training of an academic workforce but not main-street primary care.

The US has never had a coherent plan to train doctors — academic medical centers have been making decisions that should have been made by ordinary people, people who don’t like waiting lists.  A huge manpower shortfall has been expected for a long time.   The IOM expert committee is calling for big changes to the system.  The hope of the country, West of Harvard, is that Congress will follow the recommendations — the report is not asking for more money (which would be a stake in the heart) just a rational use of funds to meet obvious needs.

A primary care doctor does not need to go to Harvard to be a very good doctor and the US does not need to support super specialty programs at the expense of towns lacking a doctor.  The cost savings by diverting  funds to community training programs could be huge, possibly training 2 or 3 physicians instead of one in Boston.

Funding of training needs to be tied to providing service where service is needed.  What better way to train doctors for Iowa (or other areas needing doctors) — train young people in the communities where they live.

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The Rise of the Midlevel Provider

Several recent articles have commented on the shortage of physicians.  In particular, the Atlanta Journal-Constitution reported “The number of physicians in the U.S. grew from 737,764 in 1996 to 954,224 in 2008, a 29 percent increase, according to a 2011 American Medical Association report. But the number of physician assistants went from 29,161 to 73,893 and the number of nurse practitioners from 70,993 to 158,348 in the same period. That’s an increase of 153 percent and 123 percent, respectively.”

The US healthcare system is adjusting to the difficult and expensive problem of training new physicians (MD and DO) by training midlevel providers (nurse practitioners or physician assistants).  The midlevel providers must go to college and then have 2-3 years of additional training as opposed to the additional 7-10 years for physicians.

The midlevel providers are a welcome addition to the health care workforce.  They fit an interesting gap not well filled by physicians.  They provide more face to face time with patients, they provide excellent health care education for patients, they tend to follow evidence based guidelines more closely than physicians and they excell at routine type patient interactions.(see examples below).  Physicians will always have the advantage in diagnosis of illness and complex problem solving due to the nature and duration of their training (some claim this advantage fades as midlevel providers gain  experience in their area of practice over several years)

So, how should patients take advantage of the growing number of midlevel providers?  Seek providers (MD and DO) that are part of organizations that include midlevel providers in a ratio of about 1 – 2 midlevels to 1 MD or DO.  Look for a team approach to patient care where the midlevel providers do a lot of the routine visits but the MD and DO providers are on the front line for acute or new problems.  This type of a setting helps to improve access to care — better access hopefully means longer visits, better education and higher satisfaction.  If a patient calls a primary care provider’s office for an appointment with a new problem it should be with the MD or DO.  In the course of a routine visit if a problem clearly needs a specialist the midlevel should be able to make the referral just like an MD or DO.


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