With every indicator pointing towards a looming physician shortage and increased medical demand, there’s really only one thing for emergency physicians to do . . .
Hardly a day goes by that you don’t see some reference to the impending perfect storm of increased demand for healthcare, a shortage of providers and progressively less money to spend on it. Every forecast that I see indicates there will be a physician shortage in the not-so-distant future (if there isn’t one already for selected specialties). In the April 10, 2010 issue of the Wall Street Journal it was observed that “experts” warn that there will not be enough doctors to treat the millions of people newly insured under the new health care laws. According to the article, at current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, per the Association of American Medical Colleges.
The exact causes of this shortage – and the difficulties of increasing our health care workforce – are fodder for another essay. Today we will take this perfect storm for granted and move on to the next question: How can we increase our productivity in order to meet this looming demand? In short, how can we work smarter?
There are actually a lot of ways that physicians can work smarter. In general, it comes down to physicians being as unencumbered as possible of nonessential duties so that they can focus on the things that require their level of experience or training. Others should support their work as much as feasible since, fundamentally, physician productivity needs to be substantially increased.
One method of accomplishing this is through scribes, or personal assistants. These make a lot of sense in an environment where charting consumes a disproportionate amount of time, such as in the ED. Charting can easily consume at least 15-20 minutes of every hour – particularly where there is an emphasis on charting that meets Medicare requirements. This is particularly true in the ED setting where physicians may be seeing 2.5 patients per hour or more. Although I won’t go into the specifics of how scribes are used, essentially they assist the physician with charting, while also facilitating their work in a variety of other ways. They can, in the appropriate setting, chaperone or assist in the performance of exams, order lab tests, pull up computerized x-rays, make calls for physicians and generally facilitate their work. Their cost is modest and they easily increase productivity disproportionately.
Is physician order entry helping physicians increase their productivity? Despite the headlong plunge into CPOE, it’s hard to show that this increases physician productivity (and, frankly, I’m very concerned that the routine, knee-jerk use of order sets will substantially increase the costs of care). In fact, anything that requires a physician to sit down in front of a computer is almost assuredly not increasing his/her productivity. Does it improve safety? Hard to say. Does it improve quality? Hard to say. Does it slow physicians down – from the feedback I hear, unequivocally, particularly when compared with asking somebody to enter your orders while you move on to the next task. In fact, I know physicians who have hired scribes so that the scribes can enter their orders – a sad state of affairs. And don’t get me started on physician-generated computerized histories and physicals. Talk about a waste of precious time.
Extend Your Extenders
And what about nurse practitioners and PAs? Just think how productive a physician could be if a nurse practitioner saw the patients first, did the charting and the physician came in to tie up the essential parts of the visit. Could you see twice as many patients? At least. And here is something very radical: having nurse practitioners see patients independently. They would have to follow guidelines and protocols and have a physician accessible for consultation, but think of how this could improve your practice. There has been an ongoing battle between the AMA and the nurse practitioners trade organization (the American Academy of Nurse Practitioners) regarding the ability of nurse practitioners to set up independent practices without physician oversight. Honestly, there’s lots of literature that says, when within their scope of practice, nurse practitioners do just as well as physicians and are well received by patients.
I know that this is a difficult concept for many physicians to embrace; however, it is unequivocally true. And even if you don’t like it, you have to admit that the nurse practitioner-staffed retail clinics are increasing in number and popularity. The anesthesiologists went through this a long time ago when nurse anesthetists came along. They turned out to be a gift from the gods in that several anesthetists could be supervised by one anesthesiologist – substantially increasing their productivity.
A paper in the Annals of Family Medicine by Ahmed (8:117, March-April 2010) surveyed adults regarding their preference between going to a retail clinic (a la WalMart) or a physician’s office for symptoms of the flu or a UTI. If a patient could save an average of $31.42 they would choose an NP or PA over an MD. If they could get a visit on the same day vs. an appointment in one day or longer, they were willing to pay $82 dollars more (as would occur in a retail clinic vs. going to a doctor’s office with a delayed visit). So consumers place a larger premium on rapid service and less on who provides it. Without taking a position on the necessity for supervision or not regarding NPs, it seems clear that using these extenders would clearly increase physician productivity – and are a lot easier to produce than doctors.
And don’t be so sure that the quality of care is better for selected conditions when patients are seen by physicians vs. nurse practitioners. A study by Mehrotra, et al (Ann Intern Med 151 :321, September 1, 2009) using a large insurance database of paid claims found that visits for otitis media, pharyngitis and UTIs cost on average $110 in a retail clinic, $160 in an urgent care center or physician’s office, and $570 in an emergency department. When 14 measures of quality were assessed, there were no differences between the scores achieved in all of the settings – except for those visits to an ED – they were a little lower.
And what about group visits? Would it not be reasonable in the primary care setting to schedule patients with fundamentally the same medical conditions to come and be seen in a group setting where nurses specifically trained in the conditions could conduct educational sessions and address questions and facilitate patient care? And what about nurse-run CHF clinics that monitor patients weight over the phone and counsel patients regarding diet and avoid exacerbations of CHF that require costly admissions. And what about nurse-run smoking cessation programs, ctc, etc. etc. Nurses could be taught in a relatively short time (weeks) to be able to provide excellent care for very many conditions disproportionately consuming physician time in the primary care setting.
So, there is a perfect storm coming, particularly if we are unwilling to try ways to value physician skills by having their work appropriately supported by others. Physicians should actively resist the trend of becoming progressively more encumbered with non-essential duties. Efforts to maintain or improve quality while improving productivity must be addressed and the entire health care team needs to critically evaluate meaningful ways to change practice.