Advanced Practice Nurses to Fill the Gap in Primary Care

There’s a frightening scenario that looms ahead in the near future, one where there are not enough primary care physicians to provide care for those who need it. According to the American Association of Family Physicians, there will be 40,000 less primary care doctors less than necessary in ten years’ time. This is because there are not enough medical students choosing to enter primary care when other more lucrative specialties beckon, at least not enough to keep pace with the number of primary care providers who are retiring from active practice or leaving the field for other reasons. 

The jury is still out on whether advanced practice nurses (including DNPs and NPs) can efficiently fill this ever-widening gap in primary care, but with the US Department of Health and Human Services setting aside as much as $15 million to set up new clinics that will be completely run and managed by nurse practitioners, perhaps the future will see APNs taking a more active role in providing primary care to the citizens of our country. 

There are many advantages to this decision to allow APNs more autonomy in the way they practice medicine:

·        They are known to spend more time with patients, and they are already used to taking down patient history and providing follow up care. Patients feel more comfortable and satisfied when they perceive that their care provider is spending more time with them. 

·        Reimbursements for nurse practitioners and other advanced practice nurses in primary care is much less than that for primary care physicians, so it’s a win-win situation all round because NPs and DNPs are more in demand, physicians are free to carry on with other specialized tasks, patients spend less on healthcare, and the overall cost of healthcare comes down over a period of time.

·        With more people dedicated to providing primary care, diseases and illness come down with preventive care, chronic diseases become easier to manage, and general wellbeing and health improve with more people becoming aware of the importance of a good diet and regular exercise after spending quality time with their primary healthcare provider.

However, there is resistance to the idea of ANPs being allowed to run their own primary care show as opposed to being supervised by doctors – physicians insist that it’s not a case of protecting their turf but one of safety and patient concern; with physicians spending more than 150,000 hours of practice before they set out on their own and ANPs getting only 1500 hours of training, the difference is stark, according to the detractors of this idea.

But with over 24 states allowing NPs to set up their own clinics and practice without the supervision of a doctor, it seems that the future of primary care belongs to ANPs. And with the Institute of Medicine agreeing that to meet the increased demand for primary care, limits on nurses’ scope of practice should be removed; it’s a good time to consider becoming an ANP. 

By-line:

This guest post is contributed by Paula Dierkins, who writes on the topic of Online PhD Degree . Paula can be reached at her email id: paula.dierkins[@]gmail[.]com

Our Growing Primary Care Gap (#2)

Previously I wrote about our growing primary care gap. This gap is still growing and it begs the question:   "WTF...Why?"   I will speculate from the perspective of someone who recently completed eight weeks of Family/Ambulatory Medicine in South Central Los Angeles. 


1. The Art of Rushing
Preceptors and med school counselors herald primary care as "the next big thing." One common theme discussed in their motivational sessions are the proposed changes in compensation that are slated to take place across our country. These changes are aimed at increasing compensation for primary care specialties in an effort to increase the number of students pursuing careers in primary care. Still, there is prevailing cynicism in me; although I believe these changes are an important step in closing the primary care gap, there are considerable factors far more important than compensation which affect a student's decision to pursue primary care.

One of these factors includes the unavoidable time pressures faced when caring for so many patients and the burden of working with insufficient resources (e.g. uninsured/underinsured patients). This was far too common from my experience in outpatient clinics. I felt constantly rushed to see patients and to quickly write my notes. Whenever a referral needed to be made for specialty care, a long 1-3 month waiting period was implicated. This environment is not conducive to good health delivery, and as a result, it becomes increasingly difficult to advocate for patients. We should all strive to be expedient, resourceful, and professional but individual efforts ultimately succumb to systemic barriers and failures. Not only did this hamper my educational experience but it was a "turn-off" whenever I wondered how my future as an internist would unfold. How can clinicians feel satisfied in the quality of their work if something is constantly rushing you-- indirectly hindering your ability to provide the best care? As any student in any field, it's important to remain optimistic, make efforts to become part of the solution and change what needs to be changed. 


Another factor often forgotten but important to consider is how the doctor-patient relationship is strained when a patient's visit feels rushed.  One memorable case, which to this day I regret having experienced, was not being able to fully address issues of depression among several of my patients that came for non-psychiatric care. At the end of the day, it seemed like I short-changed them. Still despite all this, I remain optimistic that primary care medicine in our country will assume its deserved place...


2. Paperwork.
Though I actually enjoy writing thorough H&P's,  far too much of the paperwork required to complete during visits are meant to "cover you ass." Its important to understand how and why clinicians chart in specific ways -- this necessity stems partly from the current state of litigation and tort reform in our country, but this becomes far more taxing in primary care when many patients need to be seen in one day. Doing detailed and comprehensive charting is good medicine, but i'm still not sure how i feel about practicing defensive medicine where the focus is not the health of the patient but rather to safeguard against possible malpractice liability.


On a different note, I'm a writer at heart and I don't mind pen and paper, but still... the hell with paper...dare I say... bring forth electronic health records.

 3. Debt
The mean debt for the average medial student in the U.S is an outrageous $156,456. Add to this number the debt that many student accrue during undergraduate education, and then you have an even larger debt. To add insult to injury, then consider a resident's modest fixed salary while his/her debt accrues significant interest for 3-7 years during post-graduate training. Many of us have chosen a career in medicine because we genuinely desire to help people, but believing that income/debt are not essential aspects of career satisfaction or that they are unimportant motives in career choices, is very naive and unrealistic.


4. Our Health Delivery System
IMHO, our health care model is the underlying reason why our country has one of the worst health outcome measures despite being the one country in the world who spends more of its GDP on health care. These poor health outcomes are not a result of poor quality of care rendered (i feel), rather by the lack of access to preventive care services coupled with the high costs of obtaining care.  What is most baffling to me, however, are the patient dissatisfaction ratings that seem to be rising despite having one of the most technologically advanced health systems in the world. Simply put, our system is an epic fail.  



'Tis against my inclination to bitch and moan, but 'tis simply a reality check.

The Growing Primary Care Gap

There was a recent study published in the Journal of the American Medical Association and mentioned throughout the media. The study involved surveying medical students to asses what percentage of them were interested in pursuing careers in primary care medicine. Primary care generally refers to family medicine, pediatrics, or internal medicine. Out of 1,200 medical students surveyed, only 2% were planning in pursuing a career in primary care and are instead hoping on becoming specialists.

Briefly, the main reasons cited by students for not wanting to pursue primary care included:

• Having to deal with too much “paperwork”
• The increasing demands that will ensue when caring for the growing elderly population
• The need to bring work into the home
• The salary gap that exists between PCP’s and specialists
• The increasing amount of debt upon graduation
• Time pressures when caring for so many patients with inadequate resources

Essentially, the study suggests that student are deterred by three factors - salary, autonomy, and insurance bureaucracy. It is no surprise why students would rather pursue more lucrative specialties. However, it will be interesting to see how many of the survey participants will actually match into the specialty of their choice (apparently, non-primary care). Many of them will face the harsh reality that without high USMLE scores and polished CV’s that include research, their competition for those highly sought non-primary-care specialties will be fierce. For those who have their sights on Dermatology, Ophthalmology, ENT or Ortho, lets hope they do not feel slapped in the face when they open their white envelopes on match day. There are limited slots each year for each specialty, and its unfortunate that many of the U.S. medical graduates are leaving most primary care residency slots unfilled, such that even international medical graduates (IMGs) cannot satisfy all the needed vacancies. No offense to IMGs, but this reality is disheartening. As future health professionals, we are supposed to herald disease prevention as the first line of defense against disease. We are well aware (I hope…) how research has established primary care medicine as the most effective approach to health promotion. Alternatively, health policy experts also tend to agree that primary care should be the emphasis of attention in the solution to our healthcare crisis revolving around access, quality, and cost. So why are 98 out 100 medical students undermining the solution? Are we part of the problem, or is it the delivery system itself ?

I don’t presume to know the answer, but it is reasonable to suggest that as students who were raised and trained in a capitalistic nation, we are likely to view our education as a long-term investment that should yield the maximum product for our venture. The product herein being job satisfaction and the investment being the 12+ years of training one must undergo before even being eligible for Board Certification. Regardless of our reasons, if we continue at this rate, the primary care gap will worsen.

On another note, we should be wondering what measures are being proposed to address this concern. According to the article, congress is being called to create a “permanent regulatory commission to encourage training for needed specialties.” I guess we could really use some “encouragement”- whatever that means…

A Criticism of Managed Care

Managed Health Care has become the dominant system for health care delivery and financing in our country. Under this system, health care professionals and hospitals form structured networks in order to manage the expenses, quality and access to health care. Managed Care Organizations (MCO’s) account for the coverage of millions of health care consumers, yet they have not resolved the prevailing crisis of high cost and low access to health care. If the health care crisis is to be resolved, careful attention should be given to the history of MCO’s, their approach to health care administration and their consequent repercussions to consumer interest and physician autonomy, moreover, to their stand-point towards health as either a basic right or as a commodity.

MCO’s promote a unique approach to health care delivery and financing that differs from the common fee-for-service system. Traditional fee-for-service plans involve an insurance company that covers most medical fees, and allows patients to freely choose their providers (Birenbaum, 455). Since the third party payer (in the fee-for-service system) will ultimately cover the medical fees, such coverage has two additional effects:

1) It increases doctor-patient contact,

2) and creates opportunities for doctors to perform additional diagnostic tests for their financial gain and benefit to their patients (Birenbaum, 464).

In contrast to fee-for-service plans, MCO’s provide health care coverage based on capitation (a fixed fee per person), and exercise different forms of control over providers and consumers alike. These controls comprise of a fixed salary for physicians based on capitation, and stipulate patient restrictions on which doctors they can request for treatment. In the last few decades, managed care has become more popular among health care consumers and employers because capitation fees are typically lower than most common indemnification insurances (Birenbaum, 456). Yet, recent trends suggest significant increase in coverage fees, which has led to consumer dissatisfaction with managed care and the desire for health care reform.

Since its introduction, managed care was marked by strong support from the fiscal government due to their reasonable fees based on capitation and their emphasis on reaching high levels of cost-effectiveness. In fact, three decades ago, Congress enacted The HMO act of 1973, which required employers to offer their employees HMO’s as part of their health coverage, and granted millions of dollars to promote the establishment of HMO’s (Light, 492). In addition, Medicare and Medicaid, which are forms of managed care, were also ratified by US governments. Today, HMO’s have prevailed in the health care industry and their membership has grown significantly (Birenbaum, 458). Nonetheless, today most forms of managed care have been criticized for their policies on health coverage.

MCO’s have invested interests in cost-effectiveness and profit making; that distinguishes them as businesses seekers who compete and promote health care delivery under an industrial framework. MCO’s pursuit of financial gains leads them to complete annual “utilization reviews,” allowing them to evaluate doctors, patients or practices that are financially unattractive to their organization (Weitz, 230). This review helps them root out problems involving excessive spending, and openly establishes their system of check and balances on health care providers. Initially, health maintenance organizations were non-profit; today most are profit-seeking organization (Birenbaum, 461). Consequently, Birenbaum states that HMO’s function according to “standard business practices” and parallels the popular philosophy of American manufacturing in which managers “exhibit autocratic behavior in the workplace” (Birenbaum, 462). Managed care has become a business enterprise that has turned health care into a purchasable commodity; a fact that is associated with popular notions of U.S health care as an industry rather than a cause.

In comparison to the fee-for-service systems, MCO’s competitive moderate fees allow them to exercise significant control over consumers. They emphasize primary care treatment first, and then apply a referral system for patients who require medical specialists or expensive treatments. These referrals require the approval of the organization, and promotes the “gatekeeping” role of primary care physicians to high cost care (Birenbum, 455). These physicians, working under corporate influence, are encouraged to avoid unnecessary resource utilization and are often rewarded financially when they adhere to such practice (Birenbum, 457). Patients may desire special care or treatment from a specific specialist, but the standard coverage of managed care may impede such privilege. The gate-keeping role of the physician implies that only he can order, arrange and provide the patient’s overall health care. MCO’s may also place restrictions on out-of-state coverage (Weitz, 252) and affect the quality of care by limiting particular aspects of health coverage. To consumers, Managed Care raises issues of emergency coverage, restriction of services, specialized care options, overall quality of care and other central matters that affect consumer satisfaction with overall health care coverage.

MCO’s are also marked by their unique level of control over physicians. Their influence on physician autonomy is an important issue to analyze because it imminently affects the quality of health care provided. If you recall, MCO’s pay physicians on a capitation basis, and they also scrutinize their practice through a systematic review (aka, utilization review) that analyzes their performance on cost effectiveness to the organization – hence, a physician may request an expensive diagnostic test, at the risk of being investigated by the organization and perhaps censured for his utilization of resources. Physicians owning their personal diagnostic equipment are more likely to perform tests than those who do not own their equipment (Birenbaum, 465). This may be attributed to the fact that doctors practicing under MCO’s experience considerable, subjective restrictions. Birenbaum states that primary care providers “are encouraged to see the patients with as little frequency as possible, to limit testing, and to make as few referrals to specialists as they can” (Birenbaum, 461). The effect of Managed Care and physician autonomy is an aspect of the system that is often associated with consumer complaints and criticism. Here is one heartbreaking example:

Among all the industrialized nations in the world, the US is the only country that does not offer universal health care coverage to its citizens (Weitz, 253); this leads to fundamental concerns regarding MCO’s and their role in citizen’s health rights. The facts indicate that health care in the U.S is a commodity rather than a basic right. For example, today more than 40 million Americans are uninsured, underinsured or precariously insured (Weitz, 241). Although the US is the nation that applies a higher portion of its GDP into health among the 119 countries in the World Health Organization, it ranks thirty-seventh in quality of care (Weitz, 283). Managed Care is perhaps the most central element of the large and complex US health care system, thus playing a pivotal role in the crisis; although managed care aims at providing superior care at low cost, the present crisis suggest that MCO’s may actually contribute to the problem of reduced access and elevated costs of health care. Although MCO’s aim at achieving a cost effective system with equitable distribution of health care services, they are obviously not achieving the desired objective. Effective reform requires awareness of the principal elements, which characterize MCO's and their approach to health care delivery and financing. Understanding these effects that providers and consumers encounter in such system is also crucial for suitable health care legislation. By focusing our attention on MCO's and their role in the current crisis the nation may prevent futile reform efforts and create a system that embodies the desired effects of cost-effectiveness, equitable distribution of services, and high quality of care.

-Michael Garcia

Mo' Power to Patients

To the AMA and their know-it-alls:

Patient activism has become essential in attempting to change the attitudes of the biomedical community towards consumer demands. Fundamentally, the movement has produced radical changes in the paternalistic role of medical professionals in relation to patients, creating a more equitable association between the two groups. Two powerful examples of patient activism are the Women’s Health Movement (WHM), and the popular AIDS activism that took place in the 1980’s. Herein, I hope to jut on the importance of patient activism to consumer health, and I also wish to portray these two movements as pivotal events that have contributed to the changing facets of health care.

The Women’s Health Movement was historically important because it questioned the nature of medical knowledge, critiqued medical professionals for conceptualizing their bodies as naturally predisposed to illness ([1], Zimmerman 387), and eventually led to the creation of Self-HelpPolitical Action Organizations (Zimmerman 389). Gradually, women became aware of the gender-specific views that existed in health care; these included notions that illnesses among women were innately connected to their reproductive system, and that male-centered thinking dominated medical information (Zimmerman, 386). As they recognized the lack of control they held over their own bodies, they organized and established self-help groups and political action organization to create awareness and mobilize resources for health care improvements. Their standpoint was centered in the belief that if women shared control in health decision making and “brought female-oriented perspectives to balance male views,” health care would be improved (Zimmermna, 385). Today, these groups are effective promoters of health awareness [2]. 

Likewise, the AIDS movement of the 1980’s confronted and effectively challenged AIDS health officials by questioning the organization and pace of research on AIDS treatments. They united to voice their opinions, and profoundly impacted the biomedical community. AIDS activism led to a number of activists becoming members of powerful “institutional review boards” that evaluated “the methods and ethics of clinical trials of AIDS” (Epstein, 609). They “sat as regular voting members on the committees of the AIDS Clinical Trials Group (ACTG) [3],” and worked in conjunction with academic experts in the field (Epstein, 609). Their activism influenced the course of action that was taken in research treatment regiments, and regulations on research protocols. Most importantly, like the women’s health movement, it created awareness of important health issues affecting consumers of health care.

The WHM and AIDS movement are manifested in various forms of patient self-empowerment that involve cyberspace communities. As Goldstein states, 

The internet provides a means by which individuals suffering from unexplained symptoms, or recognized conditions, can reach out and become part of a virtual community of suffering, exchanging information on symptoms, diagnoses, illness experiences, treatment, and research with other individuals scattered across the globe (Goldstein, 121).

Although it’s difficult to evaluate and control the flow of information in these sites (Goldstein 122), they provide an excellent space to convey subjective experiences among sufferers and provide anonymity for patients to freely express their concerns. As oppose to the objectivity that biomedicine stresses, these groups place high value on subjective experiences (Goldstein, 128). Consequently, knowledgeable sufferers (known as “lay experts”), can share their experiences with others and create the kind of practical awareness that biomedicine often does not provide. In essence, participants of these cyberspace communities exercise power by sharing and gaining relevant, practical advice that biomedical experts do not present.

Other forms in which patient activism has been visibly manifested is through self help groups. The sudden increase of self-help groups has become a good indicator of the increasing role and participation of ill patients in health issues. Participants of self-help groups gain the support and encouragement they often can not find with their health care providers. In general these support networks create emotional, financial and informational support, promote research and public awareness, confirm and validate illnesses and provide a space where patients can voice their opinions. Their popularity has increased, and has resulted in greater awareness among sufferers. So, if one of you, is ever diagnosed with Leukemia today, tomorrow you could probably find a Leukemia support group that will positively impact your experience with the illness.

It is also important to recognize that patient activism has made significant impact at the institutional levels of health care and government. For example, California’s Coalition for the Medical Rights of Women (CCMRW), founded in 1974, successfully pressured California’s state government to impose stricter standards for the labeling of drugs and medical devices (Zimmerman, 383). Furthermore, the resilient efforts of women’s political action organizations led to the establishment of the National Women’s Health Network (NWHN), which today “closely monitors Congress and government agencies [and] functions primarily as an information clearinghouse” at Washington DC (Zimmerman, 390). In the AIDS arena, many AIDS activists now work as “representatives to FDA [Federal Drug Administration] advisory committees charged with evaluating new drugs” (Epstein, 616). The direct involvement of activists in federal institutions, are affecting the outcome of new drugs and treatments being proposed.

The strong efforts made by AIDS activists, to push for effective, unbiased AIDS research, led to the unprecedented cooperation of patients, advocates and clinical investigators (Epstein, 616)). This was an important feat because it led to the increased accessibility of drugs still in the experimental phase, according to the FDA. Although they experienced resistance from biomedical researchers, the New England Journal of Medicine published an article stating that ineffective trials should be stopped, and that current research should be done in a manner that facilitated subject adherence (Epstein 616). The efforts led to what is referred as a “parallel track,” which helped keep clinical trials pure by providing another outlet for patients wanting drugs. This “parallel track,” pushed to allow the pharmaceutical industry to provide free medications that are still on research trials.

The activism which the WHM and AIDS activism created in the biomedical field imminently affected the doctor-patient relationship. Patients have assumed a more active role in the treatment and progression of their illnesses. In using Szasz’s three models of doctor-patient relationships[1], I would argue that the traditional guidance-cooperation relationship model which formerly characterized most doctor-patient interaction, is now shifting to the mutual participation relationship. Regardless of race, gender or economic status, patient activism has shifted the relational power towards the patient. 

For this important reason, providers need to acknowledge and empathize with the so called “lay experts” of certain illnesses, who posses valuable insight as to the progression of particular disorders. Even though, activism may be seen as a threat to medical authority and autonomy, physicians should respond to these changes with respect and sensitivity because patients have rights, and a choice to become involved in the treatment of their illness.


-Michael garcia

Access to Healthcare among Hispanics

Minority groups lack insurance coverage at higher rates than whites [1]; 7.6 million (20.5 percent) of African-Americans, and 15.3 million (34.1 percent) of Hispanics in the U.S are uninsured compared to 10.8% of Whites [1]. In our managed care health system, the uninsured are thus denied medical care*. As a result, these groups lack a regular source of care in the form of preventive care. Bearing in mind that preventive care has been linked to better health status, these individuals are inclined to seek care in local Emergency Departments where the nature of their illness may be in advanced form [Rodriguez Et al., Annals of Emergency Medicine, Volume 26, Issue 5, Pages 615-620. ]. This lack of a regular source of care is a major point that needs to be addressed if large positive impact is to be made in these patients. A classic example where preventive care, as a regular source of care, can effectively counteract health disparities is in the aspect of vaccinations. A pneumonia vaccination provided at a preventive care clinic can avert a highly detrimental illness, avoid excessive healthcare cost, and improve health status. The reality is that better measures need to be implemented to address the lack of regular source of care due to lack of insurance.

An issue specific to the U.S Latino population and disparities in access to health care is legal status. In 2006, out of the 11.5 to 12 million illegal immigrants living in the U.S, approximately 57% came from Mexico, and 24% from Central or South America [2, 3]. Despite the fact that most Hospitals do not require patients to show proof of legal residence, illegal immigrants may still feel hesitant to seek healthcare because of fear of deportation. Furthermore, a majority of these individuals are employed in low paying jobs (i.e. agriculture) and meet low income standards to qualify for MedicAid, however current policy prohibits the allocation of state funded health insurance to illegal immigrants. As a result, legal status can adversely affect specific subsets of the population.

In order to access healthcare resources, some patient must overcome existing structural barriers. These structural barriers include inadequate transportation, an inability to arrange appointments quickly or during convenient hours, or excessive time spent in waiting rooms, all of which affect a person's ability and readiness to obtain needed care. These structural barriers in the access to healthcare are most evident in rural underserved areas throughout our country, which happen to consist largely of minority groups [4]. In analyzing the changing demographic profile of rural American, Kirschner et al found that “rural places are generally declining in their proportions of non-Hispanic whites and increasingly are Latino, Asian, American Indian or African American [4].” A direct consequence of these barriers is the marginalization of these patients when it comes to access to medical technologies located usually in large non-rural cities. Many patients have to travel or be transported long distances to get the care they need, specially trauma and critically ill patients [Davis, R 2008, Feb 26. Shortages of Surgeons Pinches U.S hospitals. USA Today, pp.A1-A2]. To address this crucial issue, various medical schools and academic medical centers have implemented programs aimed at training future medical professionals to serve in rural areas and to counteract the structural barriers that discourage patients from seeking and obtaining healthcare. The University of California Irvine has upheld this mission by funding training programs for medical students to become medical leaders in the Hispanic community [5].

-Michael Garcia

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* Exceptions include those insured by MedicAid programs aimed at insuring select individuals below the poverty line, defined as < $10,210/year per individual.