Top Ten Reasons for Future Subspecialist Physicians To Be Concerned

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This guest piece, by Robert Bowman, MD, of the AT Still School of Osteopathic Medicine in Mesa, AZ, can be considered to be a sequel to his guest blog from January 15, 2009, Ten Biggest Myths Regarding Primary Care in the Future. In that piece, Dr. Bowman discussed how, of the five primary care training “forms” (General Pediatrics, General Internal Medicine, Family Medicine, Nurse Practitioners and Physician assistant) only family physician provided enough “Standard Primary Care Years” per graduate, and distributed to the areas in which people live, to provide sufficient primary care. In this piece, he presents information on how the change in the workforce is likely to have an even greater impact on subspecialists.
I think that this is very timely. The idea that family physicians, or primary care doctors in general, will be “replaced” by nurse practitioners and/or physician’s assistants keeps rearing its ugly head despite evidence to the contrary. Dr. Bowman demonstrates that reimbursement policies that pay far more for “partialism” encourage both physicians and non-physicians to enter subspecialist practice. We still do and will need more primary care and it is not going to happen by magic. It is going to happen by changing reimbursement policies. (See, for example, Mary Carmichael's "The Doctor Won't See You Now", in Newsweek, Feb 26, 2010).

The first two graphics demonstrate trends in the number of primary care providers by "form" if there were not movement into subspecialism, and what the real trend will be.
The final graphic compares the retention in primary care, over time, for the different "forms" based on whether they are more "permanent choice" primary care (e.g., family medicine) or "flexible choice" (e.g., internal medicine).

10. “Midlevel” Growth: Nursing leaders have promised to deliver health access where it was most needed and received numerous concessions to move beyond nursing but have largely left health access behind along with basic nursing. Nursing leaders continue to promise primary care while nurse practitioners steadily depart primary care to become specialty workforce and appear poised to become “nurse doctors” (DNPs). There is every reason to believe that DNPs will be no more – and probably less – likely to practice in underserved or rural areas at greater rates than current NPs. Physician assistant leaders are likely to follow the independent "successes" of nursing. Future subspecialist physicians will face competition no other physician subspecialists have ever had to face.

9. Increasing NP, IM, Ped entry into subspecialties. About 40% more nurse practitioner, 50% more internal medicine, and 60% more pediatric graduates are entering specialty workforce compared to a 10 - 15 years ago, and specialization rates have continued to increase. In addition, more internists and nurse practitioners convert from primary care to specialty care in the years after graduation.

8. Increasing PA production, also entering subspecialties. Over 220% more new physician assistant graduates are entering the sub-specialty workforce, increasing from fewer than 1500 in 1998 to over 4600 in 2008. The percentages in emergency care, orthopedic, and surgical subspecialties are now greater than those in primary care. Physician assistants also are converting from primary care to specialty care after graduation. Only 28% of 2008 graduates entered primary care in AAPA surveys.

7. Postive Cost-Benefit ratio for “midlevel subspecialists. Nurse practitioner and physician assistant graduates have lower employment costs than subspecialist physicians. It is possible for 2 or 3 NP or PA subspecialists to generate more revenue than one subspecialist physician for less cost of salary, benefits, and other physician perks.

6. Increased “midlevels” in subspecialties decrease need for more subspecialist physicians. More and better nurses, assistants, and other health care team members are recruited to subspecialty workforce because the higher reimbursement for subspecialty services as compared to primary care allows these subspecialists to pay them more. Physician assistants and nurse practitioners are on track to increase to 450,000 that are more than 70% subspecialty care. The US is moving to a specialty workforce that can deliver more specialty care with fewer specialty physicians.

5.Increasing US graduates likely will further increase subspecialist production. US graduates deliver twice the workforce of non-citizen international medical graduates due to delays in entry and departures from the US workforce after graduation. Expansions of US medical schools are likely to replace more non-citizens with US origin graduates. This replacement results in twice the specialty workforce for each position transitioned from a non-citizen to a US origin graduate.

4. Increasing subspecialist production of US Medical Schools. The United States produces 40 - 50% more subspecialist workforce from each type of medical school compared to a decade ago. Currently no one can estimate just how much specialty workforce will be produced as the annual graduates entering the workforce continue to increase with higher percentages found entering specialty care in physicians and in non-physicians.

3. Threats to very high subspecialist reimbursement. To the extent that there is any decrease in subspecialist reimbursement, these physicians will face the possibility of longer hours, more services, less vacation, and more years of work per subspecialist physician.

2.Supply, demand, and cost of care. All physicians will be blamed for continued health care cost increases as all levels of government and all businesses and all of the US people pick up the tab. There is potential for even more costs with subspecialists increasing services to compensate for an oversupply of subspecialists.

1. And, finally, when the United States finally invests in sufficient primary care substantially fewer visits will be needed in specialty offices.

Add to this
· the steadily increasing disconnect between subspecialist physicians separated from their patients by additional assistants
· the admission patterns of medical schools favoring upper-income students leading to subspecialists with ever more exclusive origins who are less and less like lower and middle income Americans .

In other words, our medical education leaders and medical association leaders and subspecialists...
...will probably never see it coming.

Robert C. Bowman, M.D., rcbowman@atsu.edu

Only those unable, those unaware, or those with another agenda fail to understand that solutions for basic health access have worked for over one hundred years.

http://www.basichealthaccess.org/ http://www.physicianworkforcestudies.org/ http://www.ruralmedicaleducation.org/

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