nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Wednesday, April 21, 2010

Primary Care Doctor Shortage Under Health Care Reform

I'm hearing the details of how we'll expand the number of providers to meet the increased demand of 30 million new patients.  But it doesn't sound a lot different from what was tried--and didn't work--back in the 70's.

The critical shortage is expected to be in rural communities.  Reformers are convinced that if you preferentially admit and fiinancially support students from rural towns and minorities they will have family and community ties that motivate them to return to those communities when their education is complete, serving those groups that have less access to care.

Along with preferential admission that targets rural and low-income students, the new health care reform law gives financial incentives to go into primary care and family practice.  Few students are interested in primary care, and primary care doctors make less.  Therefore, to interest more students in primary care, we bump up their income and scholarship opportunities.  QED?  Actually it's more complicated than that.

Income is not the only, or dominant, reason men and women want to become doctors.  Studies vary, but the high respect doctors receive is  a strong motive.  Some studies also suggest that medicine has become more attractive as fewer working hours and availability of family time increase.

When I was in medical school in the 70's, there was a similar perception of shortage.  The swing away from primary care was already well on its way.  Efforts were made to support rural students, and the new specialty of Family Practice was getting started.  In my class we had several low-income students from rural communities.  They either had scholarship or other financial commitments to return to their town, or when they arrived at medical school they expressed a wish to practice back home.

Most of them either didn't return home, or they went back for the minimum time required before returning to the city.

Think about what the potential primary care doctor will experience.  She or he will be referred to as the "local MD" by the med center staff,  or LMD, as they are referred to in the history &  physical...a derogatory slang that says "this is the doc that sent us this patient because they couldn't handle the case, or didn't know what to do."  I've been in that small-town situation, and years of that disrespect, largely untrue, wears on you.  (the professional dis-incentive)

Also, consider the lifestyle:  a medical center around the corner, malls, culture, refinement...versus a Dairy Queen, strip mall, and a beer joint.  No movie theater in that small town, but you can get Netflix. (the cultural dis-incentive)

Lastly, consider the challenging and exotic cases you are exposed to in the big city medical center versus that 10,000th case of ear ache back home.  (the intellectual dis-incentive)

While nurse practitioners and physicians assistants are eager to step into medical practice, my guess is that they are also people who value the same things as doctors in their personal and professional lives.

I've exaggerated some of the differences for effect, but the contrast is accurate.  Until our broke culture of medicine is fixed, I'm dubious that recruiting and income increases are going to be final answer to provider shortages.


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