Does Primary Care Experience Matter?
Few studies critique primary care workforce sources - especially the popular sources promoted as primary care solutions. The public receives information via the media that is even more distorted and promotional in nature.
One area to consider is experience in primary care delivery. Readers are cautioned that experience in primary care may not translate to quality for any number of reasons, but experience may be important to certain populations, workforce designers, and those in need of the most complex primary care delivery. Those most experienced in primary care contribute substantially to primary care continuity teams. It is difficult to see how continuity is aided by primary care sources with the least experience in primary care and with the least retention within specific primary care practices.
Consistency in Primary Care Experience
Patients visiting family physicians are likely to visit sources with the most primary care experience. Family medicine is a mature stable workforce with about 3% of the family medicine workforce arising from each class year for the past 33 years. Least increase in annual graduates and maximal retention within primary care is a combination that results in most primary care experience.
Rapid Expansion Leads to Less Experience
Primary care sources that have expanded rapidly (NP, PA) contribute to a workforce that is less experienced in primary care. A doubling of annual graduates each 6 – 12 years since 1980 results in substantially more non-physician clinicians who are new to primary care and to all other specialties as well.
Years of Experience
Years of Experience
Nurse Practitioner 2003 AANP
Nurse Practitioner 2007 AANP
Family Physician 2007 and Beyond
0 - 5 years
6 - 10 years
11 - 15 years
16 - 20 years
21 - 25 years
The nurse practitioner data represents generic years of direct care clinician experience. The family physician proportions are 90% specific to primary care experience. Slowing of expansion has led to slightly more experience in recent NP workforce, but experience remains far less than the steady state year to year contribution of FM. Also nurse practitioners will rarely reach 26 or more years as entry into primary care averaging age 40 will result in 25 years of experience by age 65. Departures in the years after graduation will result in only the most dedicated with substantial years of primary care experience.
Departure from Primary Care in the Years After Graduation Leads to Less Experience
Certain primary care sources depart primary care steadily in the years after graduation (NP, PA, IM). Those who begin in primary care often depart primary care. Even physician assistants in primary care departed primary care from 1990 to 2000 under improving primary care policy conditions (Larson and Hart). Primary care retention woes lead to delivery by those least experienced as those more experienced depart primary care.
Lower Volume and Less Primary Care Experience
Primary care sources with lower volume (NP, PA) are likely to have less primary care experience. Fewer encounters, encounters less complex, and encounters with lesser responsibility can all contribute to lesser primary care experience.
Less Primary Care Specific Focus in a Source of Workforce
Sources of training that contribute a minority of graduates into primary care workforce can have training that is also distorted away from primary care. Graduate outcomes are powerful influences upon training. Internal medicine is over 75% not primary care in result. The consequences include dysfunctional primary care training that may drive medical students and residents away from primary care choices (Keirns, Academic Medicine).
Nurse practitioner and physician assistant graduates are found over 65% outside of primary care delivery as direct care clinicians. This could fall to 75% outside of primary care if expansions slow down and non-physician clinician workforce gets a chance to age. Steady departures over time have a number of consequences that few are willing to discuss.
It is tough for training programs or health professional associations to remain focused upon a minority of graduates, alumni, or members.
Payment Designs that Impair Continuity
AAPA studies indicate physician assistants departing for another primary care practice for a 4% increase in pay and departing primary care for a 10% pay increase. Payment designs that favor certain practices and non-primary care career choices distort flexible primary care workforce sources the most. Low pay for primary care tends to drive all primary care sources toward lower continuity and away from the practices with already least primary care workforce.
Does Less Experience Translate to Lower Quality?
Less experience in a workforce does not necessarily mean differences in quality. Research studies will continue to show no difference in the quality of care for different types of providers. The reason is that patient outcomes are more about the patient and patient environment and are less about the provider. Practices that include experienced primary care team members can benefit from the experience in ways helpful to those delivering care who are less experienced.
It is sad that we forget over and over that health care access, health care cost, health care status, and health care quality are mostly about the patient.
Any design that hopes to result in more experience to deal with the increasing complexity of primary care and any design that hopes to result in more continuity…
Must result in greater support of the primary care personnel such that they can remain in primary care and in their current sites – by design.
Steady and consistent is not exciting, but it is Specific, Measurable, Achievable, Realistic, and Timely.