Family Physicians versus Nurse Practicioners

How do you feel about the decline in family practice doctors? Do you think nurse practitioners and the like will fully replace family doctors in the future?
 Anonymous

Thank you for your question!

I know many extremely smart, talented, and capable Nurse Practitioners and Physician Assistants working across various specialties.  We are blessed in the health care community and as a population to have them in our ranks as health care professionals.

I don’t believe that mid-level practitioners are the ultimate solution to our ‘physician shortage’.  The real issue with physician shortages is regional (excluding the looming ‘baby boomer’ issue).  If your community is in a very rural and isolated area the problem isn’t that there aren’t enough physicians to cover the region, it is that health care providers, regardless of profession or specialty, tend to want to move to areas that offer more social opportunities, strong schools, and spouse employment opportunities.  If you increase the number of Nurse Practitioners and increase their scope of practice, they are just as likely to not want to practice in these areas as their physician colleagues.  

Regarding Family Medicine in particular, a Family Physician is a specialist in providing care to the individual, the family unit, and the community.  Not including undergraduate pre-medical education and the first two years of medical school, the 3rd and 4th year medical school clinical years and the completion of residency training in Family Medicine encompasses between 20,000 and and 22,000 hours of clinical training to become a Family Doctor.  As you can see from this blog, Family Physicians are trained to work competently in various settings- from continunity outpatient clinics, emergency rooms, and the ICU, from providing obstetrical and maternity care, pediatrics, or working as hospitalists.  A Family Doctor is expected to be able to care for 90% of the problems a patient may present with 90% of the time.  Compare this with between 2800 and 5300 clinical hours for masters-level to doctorate-level Nurse Practitioners.   

Most people don’t know a Family Physician who practices the full scope of clinical Family Medicine, usually because the full-scope of Family Medicine is encountered in the rural or international setting.  This has generally been self-imposed by Family Physicians themselves.  Most people hate getting up in the middle of the night to deliver a baby or stay up admitting and managing a complex patient to an ICU requirng ventilator management and pressors.  The inconvenience to lifestyle is a factor that is also causing OB-GYN’s to give up obstetrics as part of their practice and only focus on office and operative gynecology while laborists manage the burden of hospital obstetrics.  The same for pediatricians and internists who have stopped admitting their own patients to the hospital and allowed hospitalists or nocturnists to manage this time-consuming aspect of care.  The era of HMO’s in the early 90’s allowed Family Doctors the role of gate-keeper, which proved to be lucrative and offered a high income for many Family Physicians without the burden of long hours and having to practice in various areas of the hospital and clinic.  These physicians then stayed comfortable in this role well past the era of the gate-keepers into the present.

That being said, there is a recent and strong resurgence of interest in training in a procedural and broad-scope practice of Family Medicine.  This charge has been led by forward- thinking residency programs like Wesley Family Medicine (my training program), Ventura County Medical Center, the Contra Costa Family Medicine Residency, Via Christi, and several other programs.  Residents in these residencies graduate with a broad range of high-volume, evidence-based procedural and management skills to offer the care intended to be provided by a Family Doctor.  

I don’t believe that just because somebody is a Family Doctor they should be allowed to work in any setting or perform whatever procedure they desire.  They should be extremely well trained and meet the exact same requirements that specialists working in those areas or performing those procedures must meet.   I believe Family Medicine residencies should be extended to at least 4 years of training, especially in the face of recent work hour changes imposed by the ACGME.  

There are some aspects of the Affordable Care Act that are leveling the finanical incentives for those deciding to enter primary care training out of medical school versus more lucrative specialty training, but they are certainly not enough to convince medical students to make this decision at this time.

While I am extremely grateful for and impressed by the role many of my Nurse Practitioner colleagues play, in answer to your question, I don’t believe that they are capable of filling the gap that the true practice of well-trained Family Physicians offer to communities.  I think a solution to our regional physician shortages should be focused on both aggressive student loan forgiveness and high financial incentives for medical students who both enter Family Medicine as a specialty and relocate to rural areas in need of comprehensive health care coverage.  Then emphasis should be placed on physician retention to these areas so there doesn’t need to be turnover every 1 to 4 years once loan forgiveness ends.  High job satisfaction and good pay are the ultimate recruitment tools.  There are currently plans like this in place by the National Health Service Corps, and the Indian Health Services, but I don’t believe they go far enough and are too difficult to obtain for students deciding to pursue Family Medicine. 

I also believe there should be programs in place that help fast-track excellent Nurse Practitioners who have been in practice for several years through medical school and into Family Medicine residencies that will mitigate the costs of further training and shorten their total time in school as some of the training will be redundant to them (for instance some of the basic sciences of the first and second years, but not all of that course work).  I have a brilliant colleague who is a Nurse Practitioner who wants to move beyond the limitations of his clinical training towards becoming a phyician, but it is unfair that he should need to take on another 150 to 300 thousand dollars of debt and 7 more years of training.

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Travelling To versus Travelling Through

When I first arrived in Chinle I had all of these plans of how I was going to order up some coffee from New Harvest in Rhode Island and use my hand grinder to start brewing brilliant cups of coffee in my hotel room.   Part of this was because I love coffee, part was because I felt obligated to do so since I wrote the book on having good food and coffee in small spaces, and part was because I was being a touch snooty and indulging every single one of my personal preferences.

I had a few pounds of my favorite coffee in the online cart and was about to hit 'purchase' when I had a thought: why on Earth would I travel to all of these places only to drag my preferences along with me?  Why move to an area if I was just going to bring my safe bubble of personal culture with me?  So instead I went to the (only) grocery store in town and found whatever coffee there was to buy.  There was Folgers and the usual stuff, but eventually I found a beautiful bottle of Cafe Combate instant coffee.  And it was as terrible as it sounds.

Instead of having my perfect cup of Cafe Merika every morning (and trust me, I would love it), I had a steaming cup of acrid Cafe Combate, and it became part of my daily routine for 8 weeks, taking the time to find an optimal water to freeze-dried crystal ratio to mute the aftertaste.  And now I have a story for myself about this horrible instant coffee that is made in Mexico City (out of what, I'm not sure) that I eventually came to love.  The taste of that coffee flavors all of my memories there.  If and when I ever have Cafe Combate again, in my mind I'll be instantly transported back to that first trip to Chinle, just like the smells and flavors of travelling abroad to Asia, Europe, Haiti, or Africa do the same.  

The upshot is I think it is one thing if you bring food with you when you travel because you have specific allergies or dietary restriticions, or you don't want to eat pizza every day and gain 60 pounds and get diabetes.  But when it comes to the little things that go along with travel ask yourself if you are traveling to a place versus through a place.  I doubt many people in Chinle drink Cafe Combate besides me, but if I was only drinking coffee from home, and reading the same books, and listening to the same music- then why go to a town in the first place?  You might as well stay home.  

Travel to the destination, not through it.

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*As a side note, the author in no way advocates drinking horrible coffee for the sake of drinking horrible coffee.  Whenever possible drink great local coffee and brew responsibly!  ​

**Yes, it means 'combat coffee'.  It is in fact, that awesome.  ​

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Car smells like good coffee and green chiles and sun is coming up over the mountains. Life is wildly good.

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Sad Like Leaving Kansas

This morning I'm drinking coffee, enjoying a beautiful Spring morning in the desert with the breeze blowing in through the window.​  In a few minutes I'll start packing up the car and I'll be moving out of my cozy little Navajo Best Western.

I'm really quite sad to be leaving Chinle.  Sad like I was when I left Kansas.  

This was my first Indian Health Services(IHS) assignment.  When you hear people discuss working for IHS they talk about how depressing the experience can be.  I don't know where those people worked, but I have no idea what they were talking about.  Working at the Navajo hospital here has been one of the most joyful experiences of my career. Chinle Hospital has attracted physicians of incredible quality and talent from around the country.  The hospital and clinic staff are approximately 99% Navajo and there is incredible investment into the community as a whole, and the patients are some of the most delightful people I've ever worked for.  

Chinle is what you would expect for a rural high-desert community.  It's a one-horse town (it's actually a seven horse town- those jerk horses run the place wandering through the streets wherever they want) but it lacks nothing in charm or sophistication.  There are only three restaurants, but there is always something to do, from potlucks to  yoga, trail running to ultimate frisbee.  There's even the random dance party in IHS housing from time to time.  And if you look in any single direction you'll see some of the most beautiful and sacred scenery you've ever seen in your life.  

So I'm heading out to Albuquerque for the night to visit with a friend, get the desert sand vacuumed out of the car, eat at the Frontier, and use some normal-speed internet. After those simple luxuries, it's up to another Navajo hospital in Shiprock, New Mexico for a few weeks and then off to China.​

If you're a physician or nurse who has considered IHS but has been scared off by people's perceptions or comments, I highly recommend you rotate through some facilities as a contractor and get a feel for the system.  I think you'll be pleasantly surprised at the opportunity to work with great colleagues and a wonderful patient population. 

​As for me, I'll be back for sure.  I just have the curse of wanderlust to deal with first. 

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