Doctor Shortage-Who Should Fill the Gap?

You asked a question that seems to boggle many medical minds and I am not sure why. If Canada spends 50% of what we do on healthcare costs and has better outcomes; the only difference in our usage of funding seems to be on the emergent, and end of life issues. How about plenty of primary care and prevention for all, so that we don't spend the lion's share of healthcare dollars on fixing what should have been avoided.

As for critical thinking, the hardest push has been from specialists-gee, I wonder why that is? So maybe I shouldn't question critical thinking, just medical and moral ethics.

M

You asked a question that seems to boggle many medical minds and I am not sure why. If Canada spends 50% of what we do on healthcare costs and has better outcomes; the only difference in our usage of funding seems to be on the emergent, and end of life issues. How about plenty of primary care and prevention for all, so that we don't spend the lion's share of healthcare dollars on fixing what should have been avoided.

As for critical thinking, the hardest push has been from specialists-gee, I wonder why that is? So maybe I shouldn't question critical thinking, just medical and moral ethics.

M

I personally believe (I truly do) that NPs should be cut loose from the ties that bind them to physicians. No oversight, no nothing. Just purely independent practice in all 50 states. As you all have said, the patients like it, and the outcomes (at least those reported) are comparable in some settings.

With independence, though, should also come full responsibility for one's malpractice coverage. The rates now are often demonstrably reduced for the nurse, as the NP is "overseen" by a physician, who also shares in the liability.

I would also hope that NPs no longer are granted access to MDs/DOs for their clinical training preceptorships. NPs should be trained by other NPs only, so as not to confuse the practice of nursing with the practice of medicine. The two professions should become inextricably separated. Only then will the NP profession truly be allowed to flourish.

Not flaming or ranting-just stating facts based on the question that I read.

Again, I believe the savings portion touted has always been on a greater number of available primary spots=better primary care=less overall cost.

Not specific to NPs, PAs or MDs...just access to care can make all the difference.

MDs have abandoned basic care...someone must fill it...why not NPs?

While I'd love to do basic research for you right now....I can't as I am in the middle of several projects....HOWEVER, my comments have been primarily as an overall response. I have many concerns about proper programs, clinical hours and the types of nurses who will become NPs. I work with a variety of NPs, PAs and physicians in the ER-my scope of practice and our practices in the ER are very different from other types of nurses. I can only base my opinions on my type of nursing and think that any decent critical care RN would make an excellent candidate for Advance Practice Nursing.

I don't know any nurse that wants to be a physician, however I can tell you I am tired of the multiple strokes I see in the African American community due to lack of access, lack of medicine, lack of education and minimal time spent with these patients. As this has become my focus due to (20+) patients in my direct care who suffered a stroke 40-50s and the reason I want to provide adult primary care. Prevention is everything! These people may recover from their neuro deficits or not, but they and their families will never be the same! It has impacted my school work, my educational focus, and my feelings about US Healthcare. While this has been hard hitting (to my feelings about healthcare disparities) there are so many others that would benefit from the approach the nursing model makes at patient health.

As for the Canadian numbers-I'll be happy to email one of my politically active professors who has this info at her fingertips-as for Americans self-reporting-my pre-mentioned strokes all self reported good health before their strokes-they used to have hi bp and diabetes..hmmmm. Americans aren't given the true facts-only a pill to fix it all! Also, our fantastic system cuts loosed our mentally ill and makes it near impossible to treat depression or any other mental illness in those 5-20 visits allotted. In Canada, depression and other mental health issues are managed by primary care.

When was the last time your doctor sat down and spoke to you? I have one for the first time in 15 years who does, but he's young....I expect it won't last long.

As for the most comprehensive exam I every received-it came from an NP at my college. I couldn't believe it! The first time I'd ever seen someone actually do what they are supposed to do! Isn't that sad?

I work with a great healthcare team and want to continue to be part of a TEAM. No woman or man is an island, no one knows it all, no one is perfect, everyone is referred at one time or the other to a specialist-as it should be.

M

But outcomes aren't really better in Canada compared to the US though:

"Medical care in the United States is derided as miserable compared to health care systems in the rest of the developed world. Economists, government officials, insurers, and academics beat the drum for a far larger government role in health care. Much of the public assumes that their arguments are sound because the calls for change are so ubiquitous and the topic so complex. Before we turn to government as the solution, however, we should consider some unheralded facts about America’s health care system.


1. Americans have better survival rates than Europeans for common cancers. Breast cancer mortality is 52 percent higher in Germany than in the United States and 88 percent higher in the United Kingdom. Prostate cancer mortality is 604 percent higher in the United Kingdom and 457 percent higher in Norway. The mortality rate for colorectal cancer among British men and women is about 40 percent higher.


2. Americans have lower cancer mortality rates than Canadians. Breast cancer mortality in Canada is 9 percent higher than in the United States, prostate cancer is 184 percent higher, and colon cancer among men is about 10 percent higher.


3. Americans have better access to treatment for chronic diseases than patients in other developed countries. Some 56 percent of Americans who could benefit from statin drugs, which reduce cholesterol and protect against heart disease, are taking them. By comparison, of those patients who could benefit from these drugs, only 36 percent of the Dutch, 29 percent of the Swiss, 26 percent of Germans, 23 percent of Britons, and 17 percent of Italians receive them.


4. Americans have better access to preventive cancer screening than Canadians. Take the proportion of the appropriate-age population groups who have received recommended tests for breast, cervical, prostate, and colon cancer:

• Nine out of ten middle-aged American women (89 percent) have had a mammogram, compared to fewer than three-fourths of Canadians (72 percent).
• Nearly all American women (96 percent) have had a Pap smear, compared to fewer than 90 percent of Canadians.
• More than half of American men (54 percent) have had a prostatespecific antigen (PSA) test, compared to fewer than one in six Canadians (16 percent).
• Nearly one-third of Americans (30 percent) have had a colonoscopy, compared with fewer than one in twenty Canadians (5 percent).

5. Lower-income Americans are in better health than comparable Canadians. Twice as many American seniors with below-median incomes self-report “excellent” health (11.7 percent) compared to Canadian seniors (5.8 percent). Conversely, white, young Canadian adults with below-median incomes are 20 percent more likely than lower-income Americans to describe their health as “fair or poor.”


6. Americans spend less time waiting for care than patients in Canada and the United Kingdom. Canadian and British patients wait about twice as long—sometimes more than a year—to see a specialist, have elective surgery such as hip replacements, or get radiation treatment for cancer. All told, 827,429 people are waiting for some type of procedure in Canada. In Britain, nearly 1.8 million people are waiting for a hospital admission or outpatient treatment.


7. People in countries with more government control of health care are highly dissatisfied and believe reform is needed. More than 70 percent of German, Canadian, Australian, New Zealand, and British adults say their health system needs either “fundamental change” or “complete rebuilding.”


8. Americans are more satisfied with the care they receive than Canadians. When asked about their own health care instead of the “health care system,” more than half of Americans (51.3 percent) are very satisfied with their health care services, compared with only 41.5 percent of Canadians; a lower proportion of Americans are dissatisfied (6.8 percent) than Canadians (8.5 percent).


9. Americans have better access to important new technologies such as medical imaging than do patients in Canada or Britain. An overwhelming majority of leading American physicians identify computerized tomography (CT) and magnetic resonance imaging (MRI) as the most important medical innovations for improving patient care during the previous decade—even as economists and policy makers unfamiliar with actual medical practice decry these techniques as wasteful. The United States has thirty-four CT scanners per million Americans, compared to twelve in Canada and eight in Britain. The United States has almost twenty-seven MRI machines per million people compared to about six per million in Canada and Britain.


10. Americans are responsible for the vast majority of all health care innovations. The top five U.S. hospitals conduct more clinical trials than all the hospitals in any other developed country. Since the mid- 1970s, the Nobel Prize in medicine or physiology has gone to U.S. residents more often than recipients from all other countries combined. In only five of the past thirty-four years did a scientist living in the United States not win or share in the prize. Most important recent medical innovations were developed in the United States.

Despite serious challenges, such as escalating costs and care for the uninsured, the U.S. health care system compares favorably to those in other developed countries."

This article is from the Stanford University's Hoover Institution: http://www.hoover.org/publications/digest/49525427.html

And regarding your statement that a big chunk of complaining is coming from specialists, well, duh? What do you expect when you slash down reimbursements, effectively cutting down take-home pay? I'd think that anyone in any profession would complain about pay cuts, not just in medicine. Doctors aren't gods; I don't see why they should not be allowed to complain about pay cuts.

"Medical care in the United States is derided as miserable compared to health care systems in the rest of the developed world. Economists, government officials, insurers, and academics beat the drum for a far larger government role in health care. Much of the public assumes that their arguments are sound because the calls for change are so ubiquitous and the topic so complex. Before we turn to government as the solution, however, we should consider some unheralded facts about America’s health care system.


1. Americans have better survival rates than Europeans for common cancers. Breast cancer mortality is 52 percent higher in Germany than in the United States and 88 percent higher in the United Kingdom. Prostate cancer mortality is 604 percent higher in the United Kingdom and 457 percent higher in Norway. The mortality rate for colorectal cancer among British men and women is about 40 percent higher.


These are likely relative rates, not absolute differences.
Older data but read:
http://caonline.amcancersoc.org/cgi/reprint/49/3/138.pdf

Deaths per 100k

US 20.7
Canada 20.9
Germany 22.1
UK 25.1

Would be interesting to see if things have dramtically changed in the past 10 -15 yrs.


Prostate
http://www.nationmaster.com/graph/mor_mal_neo_of_pro_percap-malignant-neoplasm-prostate-per-capita

Deaths per mill

US 105
Norway 225
UK 12.8

Colon

Interestingly,

Converging patterns of colorectal cancer mortality in Europe.
http://www.ncbi.nlm.nih.gov/pubmed/15691644

Granted,

Survival differences between European and US patients with colorectal cancer: role of stage at diagnosis and surgery
http://gut.bmj.com/cgi/content/abstract/54/2/268
“US-Europe survival differences in colorectal cancer are large but seem to be mostly attributable to differences in stage at diagnosis. There are wide variations in diagnostic and surgical practice between Europe and the USA.”



2. Americans have lower cancer mortality rates than Canadians. Breast cancer mortality in Canada is 9 percent higher than in the United States, prostate cancer is 184 percent higher, and colon cancer among men is about 10 percent higher.

Above.

3. Americans have better access to treatment for chronic diseases than patients in other developed countries. Some 56 percent of Americans who could benefit from statin drugs, which reduce cholesterol and protect against heart disease, are taking them. By comparison, of those patients who could benefit from these drugs, only 36 percent of the Dutch, 29 percent of the Swiss, 26 percent of Germans, 23 percent of Britons, and 17 percent of Italians receive them.


Correction, Americans with insurance. The flaw in these surveys is that it excludes Americans not under care, underestimating the number who would benefit from treatment.

4. Americans have better access to preventive cancer screening than Canadians. Take the proportion of the appropriate-age population groups who have received recommended tests for breast, cervical, prostate, and colon cancer:
· Nine out of ten middle-aged American women (89 percent) have had a mammogram, compared to fewer than three-fourths of Canadians (72 percent).
· Nearly all American women (96 percent) have had a Pap smear, compared to fewer than 90 percent of Canadians.
· More than half of American men (54 percent) have had a prostatespecific antigen (PSA) test, compared to fewer than one in six Canadians (16 percent).
· Nearly one-third of Americans (30 percent) have had a colonoscopy, compared with fewer than one in twenty Canadians (5 percent).

I call complete BS on the PAP stat. Additionally the PSA is highly debatable regarding its relation to prostate CA outcomes.
5. Lower-income Americans are in better health than comparable Canadians. Twice as many American seniors with below-median incomes self-report “excellent” health (11.7 percent) compared to Canadian seniors (5.8 percent). Conversely, white, young Canadian adults with below-median incomes are 20 percent more likely than lower-income Americans to describe their health as “fair or poor.”

Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey
http://www.ajph.org/cgi/content/abstract/96/7/1300


PUBLIC HEALTH: BRITISH POPULATION HEALTHIER THAN U.S. POPULATION
http://www.ncpa.org/sub/dpd/index.php?Article_ID=3289

Disease and Disadvantage in the United States and in England
http://jama.ama-assn.org/cgi/content/abstract/295/17/2037?ijkey=cd73e7029a5ddfbafee100ff68515c2c306f269 7&keytype2=tf_ipsecsha


6. Americans spend less time waiting for care than patients in Canada and the United Kingdom. Canadian and British patients wait about twice as long—sometimes more than a year—to see a specialist, have elective surgery such as hip replacements, or get radiation treatment for cancer. All told, 827,429 people are waiting for some type of procedure in Canada. In Britain, nearly 1.8 million people are waiting for a hospital admission or outpatient treatment.

Wait times is another favorite target.
What is the effect of waiting for hip arthroplasty on long term outcomes?
You must weigh the benefit of broader preventive care against immediate elective needs.



7. People in countries with more government control of health care are highly dissatisfied and believe reform is needed. More than 70 percent of German, Canadian, Australian, New Zealand, and British adults say their health system needs either “fundamental change” or “complete rebuilding.”

More BS. Cite a reference. There are TOO many studies to mist here that demonstrate high levels of satisfaction in these countries. Did you read this before you copied and pasted it?

8. Americans are more satisfied with the care they receive than Canadians. When asked about their own health care instead of the “health care system,” more than half of Americans (51.3 percent) are very satisfied with their health care services, compared with only 41.5 percent of Canadians; a lower proportion of Americans are dissatisfied (6.8 percent) than Canadians (8.5 percent).

Again, reference.

There are excellent studies of US insurance consumers that show how those with insurance, who are younger and healthier (the MAJORITY of US insurance customers due to underwriting) are- surprise- happy, because they are healthy and don’t use many resources. A better analysis would be of those that actually need care- >65 yrs with pre-existing conditions. The US insurance industry doesn’t want to see those numbers.


9. Americans have better access to important new technologies such as medical imaging than do patients in Canada or Britain. An overwhelming majority of leading American physicians identify computerized tomography (CT) and magnetic resonance imaging (MRI) as the most important medical innovations for improving patient care during the previous decade—even as economists and policy makers unfamiliar with actual medical practice decry these techniques as wasteful. The United States has thirty-four CT scanners per million Americans, compared to twelve in Canada and eight in Britain. The United States has almost twenty-seven MRI machines per million people compared to about six per million in Canada and Britain.

What physicians identify can be misleading given the established numbers on the poor execution of evidence based medicine. If HALF of primary care patients don’t get their BP measured by their physician, how can they be trusted to know the utility of technology?

Not to mention that you’re citing downstream medicine, when the emphasis needs to be on upstream methods- primary preventive care, not procedure and revenue driven modalities.

10. Americans are responsible for the vast majority of all health care innovations. The top five U.S. hospitals conduct more clinical trials than all the hospitals in any other developed country. Since the mid- 1970s, the Nobel Prize in medicine or physiology has gone to U.S. residents more often than recipients from all other countries combined. In only five of the past thirty-four years did a scientist living in the United States not win or share in the prize. Most important recent medical innovations were developed in the United States.

There’s no reason that needs to change under a universal/single payer system, why would it?


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And regarding your statement that a big chunk of complaining is coming from specialists, well, duh? What do you expect when you slash down reimbursements, effectively cutting down take-home pay? I'd think that anyone in any profession would complain about pay cuts, not just in medicine. Doctors aren't gods; I don't see why they should not be allowed to complain about pay cuts.

It’s the economic pendulum swinging back. Who cares if they are complaining, as long as we as a nation are focusing our resources on cost effective care.