US Health Care Strip-Mined for Profit: Primary Care Physicians Becoming Scarce, Poorly Trained Nurse Practitioners Run Wild

If you were to read the popular press, you’d come away with the impression that a shortage of primary care physicians was a looming issue, as opposed to an emerging crisis. As this post will explain soon, relying on IM Doc’s assessment, primary care doctors are increasingly being replaced by nurse practitioners, who simply don’t have the training or experience to perform the key job of a front-line doctor, that of diagnosis. Whether this shift to the inappropriate use of nurse practitioners is a bad adaptation to fewer doctors entering and staying in primary patient care or a MBA scheme to lower the costs of initial patient care, IM Doc also explains how nurse practitioners wind up overloading the system, increasing costs and degrading patient care.

A gander on search does clearly portray that the primary care physician shortage is acute. And even then, most of the coverage is in medical industry publications, as opposed to the mainstream media. From STAT in September:

According to a 2021 report by the National Academy of Sciences, Engineering, and Medicine, an increased supply of PCPs is associated with better population health and more equitable outcomes. With our country’s fraying healthcare system, it is essential to have a PCP who knows you, because it is almost impossible to access any type of coherent medical care without the coordination of a PCP.

The U.S. is running low on primary care physicians, with an estimated shortage of between 17,800 and 48,000 predicted by 2034. The dearth of doctors in this area has broad ramifications, ranging from more patients seeking care from specialty and emergency medicine to increased costs to the health care system and poorer public health outcomes.

Harvard Health in September 2022 provided anecdata, admittedly in a non-alarmist way, that it’s hard to find a primary care physician, and not just in rural America:

According to a 2021 report by the National Academy of Sciences, Engineering, and Medicine, an increased supply of PCPs is associated with better population health and more equitable outcomes…

The most common question I get asked as a doctor — by friends, acquaintances, relatives, families of patients, colleagues — is “Can you help me find a PCP?” I can’t. None of us can. Why is it so difficult to find a PCP nowadays?

While the COVID pandemic certainly pushed a large subset of already burned-out PCPs over the brink into semi- or full retirement, or into less stressful jobs, the current primary care crisis has been brewing for much longer. The US is expected to face a shortage of primary care physicians ranging from 21,000 to 55,000 by the year 2033.

Both patients and doctors are getting older. As patients age, they tend to need more care from their PCPs to address the proliferation of medical problems and medications that inevitably comes with aging. At the same time, the Association of American Medical Colleges reports more than 40% of active physicians in the United States will be 65 or older within the next decade..

Further, one-fifth of doctors say they will likely leave their current practice within the next two years, and one-third of doctors are intending to reduce their work hours within the next 12 months….

Primary care is getting hit harder than most specialties, due to having lower salaries, higher ratings of burnout, and a growing feeling that their job is generally impossible and thankless on all fronts.

The Harvard story acknowledged that medical systems are keen to replace primary care doctors with nurse practitioners (NPs) or physician’s assistants (PAs), and depicts that os OK for routine care but not anything complicated. As you’ll see below, IM Doc explains why that is false for everyone but the beancounters.

This tweet triggered IM Doc’s reaction:

For those not in the US, Brigham & Women’s is a top medical training institution. From Wikipedia:

Brigham and Women’s Hospital (BWH) is the second largest teaching hospital of Harvard Medical School and the largest hospital in the Longwood Medical Area in Boston, Massachusetts. Along with Massachusetts General Hospital, it is one of the two founding members of Mass General Brigham, the largest healthcare provider in Massachusetts. Robert Higgins, MD, MSHA serves as the hospital’s current president.[1]

Brigham and Women’s Hospital conducts the second largest (behind MGH) hospital-based research program in the world, with an annual research budget of more than $630 million.[2] Pioneering achievements at BWH have included the world’s first successful heart valve operation and the world’s first solid organ transplant.

Lambert snidely observed:

On the bright side, Brigham’s is one of the main driver’s in HICPAC’s drive to reduce PPE in hospitals and nursing homes to levels even lower than they were pre-pandemic. So some slots for new patients should open up soon….

Now to IM Doc:

I called the three largest groups of internists in the nearby mega city for an appt for [immediate family member]. An appt with a NP in September- that is the best they could do. The university there is accepting no new patients in their primary care right now. My PCP at that university resigned about two months ago. I have been unable to find anyone.

This is no longer just Medicare patients.

The crisis will soon be upon us.

Remember all the hoo-hoo in the past 15 years or so about our wonderful system?

About how the wait times in those “socialist” systems like Canada were just killing people right and left?

How is that working out for us now?

I have not heard that clap trap in some time. Wonder why?

We are grateful I guess for the appt next Sep. All of us maintain our health and have little need for the health care system. But I guarantee you there are many others who are not so fortunate. And mind you – her Sep visit is with an NP.

I played out in my mid all kinds of routes for the demise starting about 15 years ago when anyone with a brain back then could see what was coming. Never in a million years did I see the NP thing coming. I love RNs – but their training is not even close to what we do as physicians. I would never dream of usurping an RN on the wards – their entire world view and work is vastly different. But the NP thing is really quite frightening. They get their RN – and then the vast majority of them nowadays get into NP school usually within the first year. Virtually zero actual independent clinical experience. The vast majority of them then end up in a 16 month or so correspondence school and are then unleashed upon the world as “providers”.

The tragedies I have had to deal with from this arrangement are just too numerous to discuss here. But there are very simple and tangible ways this too is absolutely cratering the system. Because they are so poorly clinically trained in diagnosis – they make many mistakes. But they also send almost every patient to all kinds of consults with specialists that would be unneeded with a properly trained PCP. Therefore, the specialists offices are now drowning in way more consults than they can handle for the most ridiculous of things.

What does that mean for everyone else? – Well, I now have two very sick patients that need urgent subspecialty attention – one rheum and one endo. The nearest rheum visit is in APRIL of next year – the nearest ENDO is is July. I do my best to take care of people as a general internist – and have been trained to do so from an intense program and career in the inner city where there were no specialists – but even I need help with very complicated patients. I am holding them together with bailing wire right now and calling weekly to beg for help. Never in my wildest dreams. And this is now chronic and across many subspecialties.

Furthermore, there is a myth out there that the NPs will be doing primary care. What a laugh. The ones that do get involved in primary care get burned out within a year just like the rest of us from the overwork and miserable pay. They often leave primary care – and then end up as an NP in GI or cardiology or Pulmonary or ortho or what have you. Why not? If I just had a 16 month correspondence zero clinic training – why would I not go for a more cush life and higher pay. It really is an intelligence test. What would happen if I, as a general internist, tried to pass myself off as a GI “provider”. I would probably end up in jail.

The outpatient general internists and family practice docs are the lynchpin of our entire health care system. The emotional and spiritual duress is now becoming unmanageable. They are leaving in droves. I found out this past week, my very first intern as an attending was a very successful general internist in Florida. She is 53 years old. She left her practice of 2000 patients and is now teaching school at a local private high school. She reports to us all – “Life is so much better – I can breathe.”

IM Doc then pointed to a related, recent story from The Hill: 1 in 4 US medical students consider quitting, most don’t plan to treat patients: report. Key sections:

The report “Clinician of the Future: Education Edition,” which was released by the health science and journal publisher Elsevier, surveyed 2,212 students from 91 countries between April and May of this year…

Among the surveyed medical students, 60 percent said they were concerned about their mental health, 69 percent said they were concerned about their income, 63 percent expressed concerns about experiencing burnout and 60 percent were worried about how clinician shortages would affect them.

Overall, 12 percent of medical students around the world said they were considering quitting their studies. Among U.S. students, this percentage more than doubled to 25 percent.
More than half of medical and nursing students — 58 percent — said they viewed their current studies as a stepping stone to careers in health care that don’t involve treating patients.

IM Doc’s comments:

Ten or more years ago, I would have considered this type of report an LSD trip. 58% have no intention of ever seeing patients? 25% of medical students want out before graduating? Really?

Five years or more ago, I would have said that I could see it but they have really overestimated the numbers.

Now, today, I think this is right in line.

I have a parade of students every month from all over the country, but mostly from the elite medical schools of the coasts.

I have been told by more than half of them over the past year that they have absolutely no intention of ever laying hands on a patient in any way after they are done with their residency. Patient care is now considered “dirty work” by many of the students in our elite schools. The action is now in Big Pharma, Big Hospital, and Big Insurance. They will have huge incomes and never have to bother themselves caring for a soul.

I can scarcely believe it, but it is absolutely true. Our taxpayers are paying a fortune for the education of these people and they have zero intention of ever seeing a patient their entire careers. And this in the jaws of the worst physician shortage in our history.

This is especially true in the more elite schools. Therefore, it is unsurprising that a place like Boston would be the epicenter of having no PCP options.

When I discuss this with these students, it is very unfortunate but very clear that many of them have the unspoke attitude – “I am elite, I have worked hard for this career, why would I want to waste my precious brain on any kind of interaction with the hoi-polloi? These people refused to be vaccinated and have questions — why am I going to waste my time?” That kind of thinking was unknown in my youth, and if it had been exhibited would have been beaten out of that person with great fury.

And you just thought the Hillary Clinton “deplorable” schtick was just an offhand remark……

The humiliation of my entire profession, and indeed the country, is at hand.

I have said the US is on track to suffer the sort of social disintegration that Russia suffered in the 1990s. It probably won’t be as cataclysmic or complete, but we do seem to be setting up the level of lifespan reduction Russia suffered, with the slow-motion collapse of many components of health care, and started from a base line of life expectancy reduction out of line with advanced economy peers and even much poorer societies:

Thailand has higher life expectancy at birth than the US, despite a GDP per capita of $7,300 versus $64,200 for the US. Looting has even bigger costs than you might have thought.

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