The Regrettable, Fixable State of Preventive Medicine

This week's TIME Magazine has a story about how nurse practitioners—who have substantially less training than doctors, but are authorized to make many of the same treatment decisions—are growing more important due to a growing shortage of internists (that is, doctors who provide "primary" or "preventive" care—things like your annual physical):

Even without reform, experts on the health-care labor force estimate there is currently a 30% shortage in the ranks of primary-care physicians. Fewer than 10% of the 2008 graduating class of medical students opted for a career in primary care, with the rest choosing more lucrative specialities [sic]. That could pose problems if a national health-care bill is enacted. After Massachusetts enacted mandates for universal health insurance in 2006, those with new coverage quickly overwhelmed the state's supply of primary-care doctors, driving up the time patients must wait to get routine appointments. It stands to reason that primary-care doctors could be similarly overwhelmed on a national scale. . .

But there is an existing group of providers that health reformers are hoping can help fill this gap: nurse practitioners. Depending on the state in which they practice, nurse practitioners, with advanced training often including master's degrees in nursing, can often treat and diagnose patients, as well as prescribe medication. And they can do these things at a lower cost than doctors — Medicare, for example, reimburses nurse practitioners 80% of what is paid to doctors for the same services.

Nurse practitioners may be a stopgap solution, but their growing role is unfortunate. It's great that they can take their time with patients. But a doctor who takes her time will bring more training and expertise to the table, and have a better chance of catching problems early. Detection of early stage cancers, for example, often turns on subtle and eminently overlookable anomalies in patients' lab results—and often saves lives, not to mention substantial amounts of money. A doctor who is forced to see six patients an hour, or a nurse who has more time but lacks the expertise to hone in on early warning signs, is simply not as good. The obvious step is to narrow the pay and prestige gap between primary care and other specialties. Sometimes people talk about a ten percent increase in the rates paid to primary care physicians. Given how bad things currently are, however, that won't be enough. We might save money and lives with physicals that last thirty or forty minutes, rather than seven or ten, but it would take a fundamental realignment of a pay structure that currently forces primary care physicians to rush through their analyses of lab results and patient complaints. We should work backwards from the world we want—the one in which primary care does not represent a substantial opportunity cost for new doctors, relative to other specializations—and set fees to give us that world, with unhurried physicals and robust early interventions.