Patient Beware of the New Primary Care Workforce

Once again a most important area of primary care is being ignored. The primary care workforce has moved from the most experienced workforce to the least experienced - without so much as a warning.

The focus for primary care has been elsewhere other than significant changes in the workforce in areas such as consumer focus, convenience, quality, metrics, or lower costs.

But there has not been much about changes in the primary care workforce itself.

No, this is not about the movement from physicians to non-physicians, although this change is a big factor in the changing of primary care experience. All of the primary care workforce is impacted - MD DO NP and PA. Fewer enter and even fewer remain. Because they depart and take their primary care experience with them, the remaining workforce is more and more likely to be inexperienced.

Not even researchers are asking many of the important questions with regard to primary care. 

  • How is the primary care workforce changing and what does that mean? 
  • What does the practitioner or physician bring to the table?
  • Is there a depth, breadth, intensity, and volume of previous experiences that matters to care?
  • What if the provider has little experience and you have a complex health care need?
Does it matter that the US primary care workforce is heading from the most experienced to the least experienced in just a short period of time?

Appeal to Common Sense

Since there is no research on the importance of primary care experience, perhaps we should appeal to common sense.

Ask yourself what would you like in your physician or practitioner as you approach a health care visit for primary care, mental health, women’s health, urgent care, or retail care?

These are the changes seen


Most years of experience – 10 to 15 on average
Least years at 3 to 6 years
3000 – 4000 experiences or encounters a year
2000 – 2500 experiences or encounters a year
40,000 to 60,000 experiences on average previous to the current visit
8000 to 12000 experiences previous to the current visit
High intensity, broad scope experiences, many patients who were very ill
Low intensity, narrow scope, few patients who were very ill
Supervisory role across career, must deal with the issues, less referral
Less autonomous role, can defer to others, more referral
Engagement level high with each patient encounter as this is your career, it is all that you expect and plan for and prepare for
Less engaged as this job is likely temporary and you will be going to another primary care job or leaving for a specialist job
High levels of continuity and contact with patients and family after a visit to see outcomes
Low levels of continuity and contact due to constant changes in insurance, practices, etc.

Now if you think that I am singling out nurse practitioners and physician assistants for criticism, note that the situations apply to all primary care trained physicians and practitioners. I do not focus on the training differences. Training means little in 5 or 10 years. Mainly I do not like to argue small points when there are major concerns to address. 

Also I will continue to point out that it is the financial design that is killing primary care experience - directly and indirectly. And this has been going on for decades.

What Has Happened in the Past 50 Years?

The primary care workforce built by the 1970s and 1980s class years of physician graduates was rich in experience. The health policy of the time supported 30 year careers in primary care with higher volume, intensity, scope, and engagement. The options for them other than primary care were few. The expectation was a career in primary care and this was the result. Options to specialize were few. There were some who left for emergency room careers, but fewer compared to now. There was no hospitalist or urgent care or retail care. There were fewer administrative options.

The primary care workforce based on the graduates of the 2000s and 2010s will be the opposite. This is not just due to the massive increases in graduates. The nurse practitioner and physician assistant higher turnover/transitional role has also been the case for primary care trained physicians.

Physicians go back and specialize. Primary care physicians depart primary care for hospital, urgent, emergent, and other jobs outside of primary care taking their primary care experience out of the primary care pool.

The Inadequate Financial Design Is Resulting in Inadequate Primary Care Experience

Primary care experience is best retained within a workforce by retaining that workforce within primary care over a career. The financial design sends primary care workforce away from primary care. Each class year has fewer who enter and fewer who remain – for a less and less primary care experienced workforce.

The Nurse Practitioner Design

MASSIVE EXPANSION Shapes Least Experience

Each passing year there are 2000 more rookies added to the workforce. A few years ago, NP graduates added to the workforce were only 10,000. Now the annual graduates are past 35,000 and still increasing. With experienced primary care nurse practitioners departing and their replacement by rookies with little experience, the NP workforce is the least experienced.

Such a massive expansion is unprecedented. The annual NP growth is 14 times the annual population growth rate which has slowed to 0.6%


Consider the basic spreadsheet findings with the massive expansion of nurse practitioners. This is what happens when you go from 10,000 to 35,000 annual graduates within a generation of NP workforce. There are so many more with fewer experiences and few with a decade or more of experience. About 39% of the NP workforce has only been out in practice for 1 to 5 years.




Actual figures for primary care experience prior to an encounter would be much less.

  • Departures from primary care would need to be considered
  • Graduates associated with less activity, part time, additional training, time between jobs would have less experience
  • There is no correction for lower volume per year

The primary care research community 

...could help to document the problems that arise from lack of experience in primary care, urgent care, emergent care, etc. Critique of primary care has been lacking across major primary care areas involving expansions, workforce deficits, and dysfunction in primary care due to major changes. Some research in specific areas could help, but primary care researchers have been compromised for some time and what remains is being distracted.

1. They have been chronically underfunded
2. They are shaped by the usual bandwagons rolling over us, groupthink, lack of independent critique in journals, and defense of whatever mishaps arise from HHS
3. Which means they chase whatever federal dollars or foundation dollars are out there

As an Example -The 117 million by AHQR - dollars that are supposed to work for quality improvement (which we know is about the patient, not about the health care encounter)

And what useful research arises from these millions is a side effect of real primary care people who apply practice observation to research focus (Usual Disruptions impacting small practices, Mold, Annals of FM) But of course the payments were not increased to compensate small practices for these additional consequences or lower collections or higher relative costs of forced regulations.

Concerns about Experienced Workforce Are Required

We as primary care experienced persons, have a good bead on the problems arising from lack of experience. We see the patient consequences and frustrations, but these are so far anecdotal. And the funding fathers and mothers are not willing to critique the new workforce types, who are willing to organize against this and even get physicians with critique - fired.

Meanwhile the US primary care workforce is headed like a juggernaut to the least experienced in the history of "modern" health care - from a workforce with physician to patient interactions with the physician averaging 40,000 to 60,000 encounters over 30 year careers to the new primary care workforce with perhaps 8000 to 15000 previous patient encounters.

This is due to
1. fewer years prior to an encounter (due to higher turnover between practices and also before leaving primary care and taking primary care experience out of the remaining primary care workforce pool)
2. less engagement (primary care is a transitional job, learning and application are impacted, likely even less experience per encounter like rotations you did not like)
3. lower volume per year - 2000 to 2500 and not 3500 to 4000 (combines with fewer years)
4. lack of experience in a supervisory role across the encounters (not observational, not sideline, not an assistant or doing the will of someone else or some protocol)
5. less intensive practice - less complex, less acuity, less ill, less engaged (screen and ship, largely sent out)
6. narrow scope - little hospital, procedural, women's health, surgical experience, what happens in the larger range of health care is likely to be missing

Not only primary care is impacted as the same is happening across primary care, womens health, emergency care, urgent care, retail care, and more.

If you come in to see me in a patient encounter, you benefit from over 100,000 encounters over 30 plus years of higher volume, scope, intensity, and engagement including multiple academic boosts (osteopathic clinical skills training and supervision lacking in MD schools, NP, PA, and others), Balint engagement enhancement, video reviews, small groups, clinical presentation model, rural practice, community engagement programs), ER, urgent care, 500 babies, nursing home, expert witness, learning derived from watching colleagues work a specialist to push out the cutting edge to handle more and understand how to handle more and when to refer, also research involving referrals, managed care, workforce, and the many follies of regression analyses

Also you benefit from my experiences with my diseases, conditions, and situations and those of my family, kids, and grandkids - which help in everyday application of practice.

We benefited from many mentors over many years or decades. I doubt whether the short termers have mentors advancing them clinically (mentors yes, just not clinical focus mentors)

This is difficult for many because the financial design only supports 25% of generalists and general specialists where 40% of the American population is found. The concentrations of the worst public and private health insurance plans in these areas are what shape shortages and help prevent people with these plans from getting care. 


Comments

  1. Fourth misdiagnosed common skin condition by a retail clinic seen this month.

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