We don’t have enough doctors and the backup plan is making it worse.
Over the past two years, a lot of physicians have retired or moved into hospital administration (talk about going over to the dark side!). There are lots of reasons, but the pace has certainly picked up.
Fewer medical students are choosing the cognitive specialties. This means we don’t have enough Primary Care Doctors (PCP’s), Neurologists, Endocrinologists, Infectious Disease Specialists, Rheumatologists and probably a bunch of other fields I’m forgetting. How bad is it? New appointments in all of these fields range from more than a month to more than six months.
Our Internal Medicine practice closed to new patients months ago. We are overwhelmed and regret not closing the door to new patients earlier. We are only human and cannot manage every patient in our region. Nonetheless, our incoming phone calls are mainly new patients looking for a doctor. The volume of these calls is astonishing.
Thanks to the specialty shortages, the challenge of being a PCP is getting worse. Patients are unhappy at referral delays and this creates some increased malpractice exposure.
Worse, the quality of Primary Care Doctors appears to be rapidly declining. If you are a medical student who is “cream of the crop,” why would you even think of Primary Care?
So, what is the backup plan?
Answer: Nurse Practitioners and Physicians Assistants. It makes sense, right? They take some of the workload off of the overwhelmed physicians in short supply. You send the easier patients to the PA’s and NP’s so you can focus your resources.
How’s that working out? HORRIBLE!!!
We are adding physician extenders at an amazing pace. Not just PCP’s are doing it. Neurologists, Endocrinologists, Rheumatologists, GI doctors and others are doing it. Yet, appointment waiting times are longer than ever. How can this be true?Ask the specialists and they will all tell you the same thing. They are getting clobbered with silly, stupid and time wasting referrals.
In the old days of primary care, the doctors did their best to handle and work up problems, saving the specialists for the tough and challenging cases. Even if you knew the patient needed a specialist, you took pride in laying the groundwork for an evaluation, “tying up the patient in a nice little package for the specialist,” speeding up the process. Now, Medical Care “providers” are little more than triage specialists. Nothing gets evaluated.
Have a bit of anemia? Hematology consult! Your toes are a bit tingly? Neurology consult! Your fasting sugar is 145? Endocrine consult! Do your knees hurt? Rheumatology evaluation! Memory a bit off? STAT Neurology evaluation! Trace protein on your diabetic screen? Nephrology!
The problem accelerates. The specialists now have to hire physician extenders to help their backlog of referrals. Yet, this only accelerates the trouble. The Cardiology PA sees someone with atypical chest pain who also makes a comment about something tingling and a Neurology Consult is added. For good measure, the chest pain seems like shoulder pain so a Rheumatology consult is added. Worse, when the patient takes an unexpected direction, perhaps slipping into congestive heart failure, the non-physician provider is befuddled and is unable to address the Cardiology problem.
Meanwhile, GI hires lots of physician extenders. The nice thing with GI is most new patients just need a procedure and the extender thing sort of works. Yet… Heaven help you if you have an actual challenging GI diagnosis like Crohn’s Disease, which really needs a physician with experience and training.
In other words, the number of medical visits is sky-rocketing, but the number of medical visits resulting in definitive plans is less. We are churning the patients through with more encounters and extra testing than ever but with little evidence of useful treatment.
Patients seen in a PCP office, almost always a PA or NP, may be referred to multiple specialists and even end up as a hospital inpatient, yet NEVER SEE A DOCTOR anytime in the process even while an inpatient!. Thirty years ago, my colleagues would have gasped in horror! But now? It has become the new normal.
We need more doctors. We need more training programs. We need to increase the pay of shortage specialties. This sounds like a lot of money, but step back and look at the disaster we have now. Tons of bad care with inconclusive evaluations are not cheap. More and more inadequate care simply costs lots of money.’
Education matters! Knowledge and experience matter!
Many on this blog warn of trouble in the future if we don’t act. But, it’s too late! It’s happening now!
Go ahead! Try to get a timely appointment with a PCP or any of the above specialists in less than a month. Now, request the appointment only with a doctor. See what happens.
I’m sorry, but there is NO PHYSICIAN SHORTAGE.
There is only a shortage of physicians willing to be screwed.
Ummmm quite simply full spectrum F.P. practice stinks in the modern era and I don’t blame students for forsaking it. I did it for over 33 years and it was fun before EHR came in. I’d dictate my progress notes so anyone besides myself could read them after transcription. I did that from day one.
Full spectrum means, office practice, hospital practice and hospital call. Doubt many F.P.’s do that anymore but it did lead to continuity of care. I retired a year and a half ago.
All’s I can say to students is bust your buns, specialize and you too can say to your patient who brings up a mundane problem, “Take that to your PRIMARY CARE doctor.” Family Practice is the worst specialty anyone can go into. Period!
The electronification of medicine has totally destroyed the primary care specialties.
I spent most of my practice in the pre-computer age where I could dictate my notes like crazy. Life was well and I was satisfied with what I was compensated for though many many of my colleagues who really busted their butts made more money than I. I was o.k. with that.
Bring some stupid automaton computer in and wreck it for everyone. I wasn’t computer illiterate either as I was working and doing some basic programming in the Basic, Fortran and Linux computer languages back in the 90’s. I saw what the “proposed” practice computer programs et. al (Eclinicalworks was what killed us) was going to require more useless uncompensateable work. I thought it was taking a computer and instead of making a doc’s work easier, it was going to make it 5 times harder!!! I was freaking right. So glad I was able to retire comfortably after hanging on for 5 or so years.
Kurt Savegnago, M.D. (retired) so glad to be.
If these new doctors we are training have more concern over pronouns than patient care, we have an even bigger problem.
Well, Plan B isn’t working out so swell. I’ve been awaiting Plan C for a long time now.
American Healthcare is a National Security Issue.
It is so disorganized now, like the local town militias thrown together to rebel against the British. We need a Doctor George Washington to thrash these green troops together into a fighting unit. https://assets-cdn.rezserver.com/media/sale/departmentofdefense/logos/logo-public-health.jpg
¬Mandatory enlistment in the National Health Service uniformed corps upon admission to medical school. The NHS in turn will determine how many admissions are needed for doctors in a given year.
¬Residency and specialty assignment by the NHS. We can’t let all these places pick up doctors willy-nilly and direct them into saturated fields, when the high-needs fields go empty.
¬Practice location assignment. Of course the Officer-doctor and Officer-NP’s will have a say in where they request to go. But someone has to go to Fairbanks, Alaska.
I see the entirety of the Doctor Corps being filled in about 10 years, after the geezers (you) are grandfathered in and sifted out. You don’t have good standing for credentialing, privileging and call if you are not in the Corps, sorry.
A highly organized central command always brings chaos into order. Or from order. Or what ever. Shut up and Doctor.
Mandatory enlistment was done. Quebec could not find staff for certain Emergency Departments. The province tried to FORCE local physicians to cover the ED’s. I don’t mean “follow-up doctor”, I mean physically covering the Emergency Department.
https://www.cbc.ca/news/canada/quebec-government-to-force-doctors-to-work-in-emergency-rooms-1.344971
And they don’t learn. Same province, nearly 20 years later, tried again. MONTREAL – Premier François Legault is promising to identify and sanction all family doctors who don’t work hard enough for his liking.
https://montreal.ctvnews.ca/legault-threatens-sanctions-as-he-loses-patience-with-quebec-s-family-doctors-1.5640251
Let this cowardly, stupid nation empower its thugs to force me to work, and I will show them the true meaning of the word “lazy.”
The Hippocratic Oath does not obtain under compulsion.
Or your alternative is to go private.
There’s more of that in Canada than one might think.
Seems the doctors are 100% in, or 100% out. Kinda like Medicare here.
Quebec doctors are getting sick of being bashed by their government.
Private health insurance IS legal in Quebec, don’t know about the other provinces.
https://www.servicemedicalprive.com/
https://www.physimed.com/accueil-patients/private-medicine/?lang=en
https://montreal.ctvnews.ca/some-family-doctors-in-montreal-are-going-private-with-burnout-and-quebec-meddling-to-blame-1.5666443
We are also heading towards a basic nursing shortage. With every nurse graduate doing an online nurse practitioner program so they can make $100,000 a year, combined with retirements and boatloads of nursing administrators,we are going to be in a crisis of basic nursing. Already we have nurses going 50 miles to get paid traveling nurses wages and then the nurses from that region driving 50 miles to get traveling nurses wages here
It could be solved simply. Instead of worrying about student loans for people who decide to go to an expensive private school with a worthless major we should make nursing school at public universities free as long as they do basic nursing for at least 10 years.
Saw that with my own eyes, long ago.
Small town, hardly a garden spot to put it mildly. I laster about a year and a half there.
There was a CRNA. local girl.
She wanted a raise.
Hospital refused.
She quit, joined a locoms firm that gave her the wage she wanted. So let’s just say her expectation was not unreasonable.
Hospital can’t find anyone willing to work in shithole town. I fully understand, having been stupid enough to go there and lasting about a year and a half.
So, hospital goes to locums agency.
Locums agency assigns…….local girl that had just quit that hospital.
It’s been my experience, locums firms charge the hospital, about twice what they’re paying you. Let’s just say on a couple of occasions, the agencies over the years have accidentally sent me the contract for locum firm and HOSPITAL, instead of contract between locums firm and me.
So now the hospital pays far more than the nurse had asked.
But that’s the mentality of the hospital administrator.