The Black Hole of US Subspecialization

Subspecialization and Academization and Hospitalization and Centralization:
Spells Workforce Concentration and Lack of Access for Most Americans
Various health corporations and health professional associations want government and everyone else to stay away from regulating health care. The reason is clear. The design is near perfect for academic, subspecialty, and hospital interests. The corporations and associations and their stockholders and members stand to gain from more and more health spending diverted to non-primary care areas. Health insurance companies benefit from ever greater spending. More non-primary care workforce results in even more non-primary care spending and more non-primary care workforce. Total health spending captures more and more of the Gross Domestic Product. More invest in health care and share in the profits, resulting in subtractions from health care delivery.
Divisions of the United States into rich and poor are facilitated by the health design that sends so much to so few for so little benefit. Inefficient government at all levels from loss of government personnel (due to health care cost increases), inefficient business (current and past health care costs cripple), and cuts of teachers by school districts as well as poor support for basic education and basic health access are just a few consequences attributable to the US designers.
Subspecialization, Academization, Hospitalization, and Centralization are a means to an end - bad for US and good for a few. This of course is what more and more are realizing as the real United States design that impacts not only health but finances, government bailouts, and more.
The Conversion of NP and PA By Subspecialization and Academization
Nurse practitioner and physician assistant associations are also dominated by academic and subspecialty interests. More dollars per hour results in more found in non-primary care and also more ability to pay for dues, attend meetings, and participate in leadership positions. The health access workforce is busy delivering health access, has fewer other than office direct clinician care, and does not have the employer, benefit, and salary support to allow association participation. This is the same as has been found in physician associations for decades. How many more interviews devoted to the importance of primary care will be given by subspecialty nurse practitioners, even in states like Alaska that need pure strains of permanent family practice NP and PA workforce?
Nurse practitioner associations have strong connections to health insurance foundations such as United Health Care. They have testified together (for Congress) and have even implicated the best health access sources to be impaired. Those promoting the primary care source with lowest primary care delivery over a career have chosen to spread misinformation about the best source. Nurse practitioner associations, health insurance corporations, and non-for profit foundations are not the only ones who are pointing fingers at the international medical graduate component of family medicine. The NP and United testimony was a prime example of half truth and innuendo. The truth is that international graduate non-citizens choosing family medicine are number 3 or third highest as a primary care source and one of only 3 permanent sources.
  • The family physician from US origins delivers 25 Standard Primary Care Years as compared to about 4 for a nurse practitioner graduate.
  • The Caribbean graduate of US origin also delivers about 25 SPCYrs as a family physician.
  • The non-citizen international graduate delivers about 20 – 22 Standard Primary Care Years during a career.
It takes 6 NP grads to equal the primary care delivery of a US MD or DO school family physician or one from a Caribbean school. It takes 5 NP graduates to reach the primary care delivery of a non-citizen family physician.
It is not quite deception as few understand the limitations of fewest years, least activity, low primary care retention, and lower volume.
Doctoral Degrees Dictate Decline
In the controversy about the NP doctoral movement, the really important information about workforce capacity has been lost. While various people argue quality or academic points, the facts about health care delivery during a career are lost. After 2015 it will take 10% more NP graduates to accomplish the same workforce as doctoral requirements will kill off two more years of a career (8 – 10% loss). The change will result in fewer in primary care, fewer active as direct care clinicians, and fewer serving where needed.
Readers can judge for themselves why a source that is in last place in primary care delivery should compare themselves with the number 1, number 2, and number 3 best sources of US primary care when they are number 8 and only the smaller family practice component does the real primary care and health access work of NP.
Academization, Subspecialization, Hospitalization, and Centralization Marginalize Health Access
Global directions are clear over the last century, the last 40 years, and especially the last 15. Various foundations continue to promote NP and PA workforce – in some ways contrary to their health access missions. Foundations also continue to promote innovation and reorganization when the major need for the next 20 years will remain enough entering primary care and remaining in primary care – something that flexible primary care sources cannot supply. When you present solutions that cannot work because of failure to address primary care workforce, you are clearly delaying health access recovery.
Policy Impact Forces Replicating the Subspecialty Dominant Design
Physician subspecialization dominated medicine for decades with more new specialties and more in each new specialty. Nurse practitioners and physician assistants have followed suit in the past 20 years. With the demise of managed care in the 1990s, the subspecialty avalanche accelerated. NP and PA graduates keep finding their way to a wider range of specialties and more are entering these new specialties.
NP and PA academization also continues to longer and more formal and more expensive training. This is exactly the design followed by physicians over the last 50 years as well.
The NP and PA subspecialty workforce is ideal for keeping subspecialty offices and office equipment going longer with more services and with more lab and other revenue generations.
All the above is evidence that the real designers of US health care involve academic institutions, health professional associations, health insurance corporations, those who sell medical equipment and technology, Wall Street and other investors, and representatives of these groups serving in foundations and government.
Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at and he is the author of the World of Rural Medical Education, and Physician Workforce Studies


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