Prescription needed for doctor shortage

By The Camden Herald Editorial Board | Dec 03, 2015

We were troubled to learn that local residents are struggling to find good primary care physicians — what we used to think of as family doctors — to take care of their general medical needs.

Upon investigation, the complaints heard in the community turned out to be the result of a serious doctor shortage.

The causes of this problem are coming into focus, but so far we have not heard much in the way of potential solutions. We hope this is the beginning of a wider community conversation, because this is not a problem we can simply accept, especially in the state boasting the oldest population in the nation.

What we have learned so far is that fewer people are pursuing careers in primary care, while the need for it is increasing because of our aging population. While many aging doctors are retiring and fewer are coming in to replace them, more members of our community are finding themselves in need of medical services.

A 2015 study conducted for the Association of American Medical Colleges predicts that by 2025 the United States will face a shortage of between 46,000 to 90,000 physicians, with up to one third of them primary care doctors.

This is particularly alarming because America’s population is projected to reach roughly 350 million in 2025, with about 19 percent, or 67 million citizens, older than 65.

Pen Bay Healthcare has experienced changes in several of its practices since 2014, which has further compounded the situation here in the Midcoast.

There's the problem. The question now: What are we going to do about it?

Let's start by bringing this discussion to the Statehouse. The Maine Legislature needs to take a hard look at this. How do we inspire and educate the next generation of general practitioners? How do we attract them to this area and retain them?

Sen. David Miramant, D-Camden, said there are no bills currently in the works to address the problem, as the Legislature is only taking up emergency matters at the moment. However, he did say he has talked to a few doctors about the issue and intends to keep asking around for fellow legislators willing to work on the problem in the next session. We know, too, that Rep. Pinny Beebe-Center, D-Rockland, has taken an interest in potential plans to bring a new medical/dental clinic to Rockland.

The idea of locating such a clinic on the former MacDougal School property makes a lot of sense to us.

In some local offices, doctors have left unexpectedly and others have retired, leaving patients without physicians. To remedy the situation, Pen Bay is actively recruiting for internal medicine and family medicine physicians, as well as adult and family nurse practitioners. The organization is also seeking locum tenens physicians, or temporary doctors, who serve a three- to six-month rotation. However, there are 11 requests across the state for these temporary doctors, so competition is fierce and there is no guarantee they will be approved for the Midcoast, as rural areas of the state are suffering severe shortages.

One program that seeks to address the issue is a partnership of Tufts University School of Medicine in Boston, Maine Medical Center in Portland and Maine colleges and universities, according to an article published in our sister publication, the Portland Press Herald.

Under the Maine Track Program, pre-med students in Maine compete for fast-tracked enrollment at Tufts University’s medical school.

The program was designed to help compensate for Maine’s lack of medical training opportunities for aspiring physicians, psychiatrists and surgeons. Maine does not have a traditional medical school for general physicians, although it has schools for nurses, pharmacists, osteopathic physicians and other medical specialties. Maybe we should found one?

However, the students are under no obligation to return to or stay in Maine to practice medicine after they graduate. Changes should be made to this program to mimic other federal programs, such as the military or public health service, that have a payback requirement.

All of these are a start, but there is a long way yet to go, and the status quo is not acceptable.

This Day in History

On Dec. 3, 1967, 53-year-old Lewis Washkansky received the first human heart transplant at Groote Schuur Hospital in Cape Town, South Africa.

Washkansky, a South African grocer dying from chronic heart disease, received the transplant from Denise Darvall, a 25-year-old woman who was killed in a car accident. Surgeon Christiaan Barnard, who trained at the University of Cape Town and in the United States, performed the revolutionary medical operation. The technique Barnard employed had been initially developed by a group of American researchers in the 1950s. American surgeon Norman Shumway achieved the first successful heart transplant, in a dog, at Stanford University in California in 1958.

After Washkansky’s surgery, he was given drugs to suppress his immune system and keep his body from rejecting the heart. These drugs also left him susceptible to sickness, however, and 18 days later he died from double pneumonia. Despite the setback, Washkansky’s new heart had functioned normally until his death.

In the 1970s, the development of better anti-rejection drugs made transplantation more viable. Barnard continued to perform heart transplant operations, and by the late 1970s many of his patients were living up to five years with their new hearts. Successful heart transplant surgery continues to be performed today, but finding appropriate donors is extremely difficult.

Information from history.com

Comments (6)
Posted by: TREVOR MILLS | Dec 07, 2015 12:26

In response to Mr. Possee's concern:

"Are PT's trained to rule out myocardial infarction in that patient with left arm/shoulder pain? What about a dissecting aorta in that patient with back pain? "

In short- Yes. Physical therapist's have extensive differential diagnostic skills and take a detailed history. When there is ambiguity about the origin of a patient's complaint, we are a pretty conservative profession, and refer to the most appropriate provider before proceeding. This happens regardless if a patient is referred from a physician or self-refers to physical therapy. And, yes do we "catch" non-musculoskeletal origins of pain, unfortunately yes. More commonly, blood clots, tick bites, angina, medication side effects, but occasionally more serious findings including cancer, unstable fractures and aneurysms.

Trevor Mills, PT



Posted by: Maggie Trout | Dec 04, 2015 21:41

Reposting Brian Pierce MD comment with note that reporters couldn't very well make inquiries of Pen Bay/Maine Health-associated physicians; administration speaks for them.

It's disappointing to see Village Soup investigating a local primary care physician shortage and publishing an article and an editorial without apparently contacting any physicians.

 

As a local family physician for over 13 years who has recruited several other physicians to the area, I have more recently both contributed to the local physician shortage and offer a likely solution with my recent change in practice.

 

The problems that have led to the primary care physician shortage have been affecting us local physicians for years.   Commercial and government third party payers talk about the importance of primary care while steadily increasing their demands and shifting payments towards procedures.  As a result, many primary care physicians have retired early, others have given up their practices and retreated to the apparent shelter of large hospital systems that can charge facility fees or shift money from profitable tests and procedures to primary care clinics.  The rest of us worked smarter, harder and longer to sustain our practices with varying success.  Medical students and resident (trainee) physicians are well aware of all this and most avoid primary care.

 

However, primary care is undergoing a growing renaissance in many parts of the country.  Direct Primary Care is an affordable version of the high priced concierge practices enjoyed by the wealthy.  Direct Primary Care cuts out the middlemen and greatly simplifies the business of primary care for physicians, allowing them to lower prices back to levels affordable by almost all patients while giving those patients great access to their own physician.  Most importantly for this discussion, Direct Primary Care sustains successful practices that are drawing young physicians back to primary care. While Maine lags behind other areas of the country in this, Maine will soon have its seventh independent, direct primary care practice this winter.

 

The prescription to solve the primary care shortage does not require new government programs or further expansion of large hospital networks but simply the two groups that have lost the most in the current primary care mess, Maine physicians and patients.


 

 

 

Brian Pierce MD

 

Megunticook Family Medicine

 

Rockport



Posted by: Ronald Horvath | Dec 04, 2015 18:50

For those for whom Direct Primary Care is new and puzzling term here's a little clarification.

 

Advantages:

Direct primary care practices do not typically accept insurance payments, thus avoiding the overhead and complexity of maintaining relationships with insurers, which can take as much as $0.10 - $0.20 of each medical dollar spent.[2] Consequently, because direct pay members are usually automatically billed a physicians practice's cash flow can also be improved.

An emerging model of direct primary care involves the medical practice contracting with self-insured (or self-funded) employers who offer the direct primary care option as a means of accessing care for free or drastically reduced office visit fees. The employer pays the membership fees on behalf of the employee to the DPC practice directly. This option usually provides the employee same or next business day access to care. This allows workers to address evolving health concerns rapidly in order that the condition can be treated more quickly and the number of sick days or days of decreased productivity from illness might be reduced. Many DPC practices provide phone or email access to providers so that employees or patients may not even need to leave their workplace to seek medical advice.

Because direct primary care payments are typically paid over time, rather than in return for specific services, the economic incentives are such that the long-term health of the patient is the most lucrative situation for the doctor. As such, preventative care gains greater emphasis under DPC.

Criticisms:

Opponents to direct primary care schemes have stated that direct primary care is unethical, benefitting only providers and not patients. Opponents believe that direct primary care preys on patients who do not have insurance, as some insurance plans are more costly than entering into such a DPC arrangement. The Patient Protection and Affordable Care Act requires that DPC practices offering such services must include in their plans a secondary qualifying health plan (QHP) that covers other hospital services that the DPC provider may not offer if they choose to offer their DPC arrangement in the healthcare marketplace. Therefore, the patient is required to pay for an insurance coverage plan in addition to the DPC arrangement if he/she purchases this plan from the healthcare marketplace. It is argued that DPC plans are more expensive in the long term, since none of the payments made to the DPC practice are counted towards deductibles because the provider does not submit claims to the insurance plan for their services; meaning that hospital-performed services are potentially more expensive because less of the deductible may have been paid prior to the hospital service being performed.

https://en.wikipedia.org/wiki/Direct_primary_care



Posted by: Brian Pierce | Dec 04, 2015 16:59

It's disappointing to see Village Soup investigating a local primary care physician shortage and publishing an article and an editorial without apparently contacting any physicians.

As a local family physician for over 13 years who has recruited several other physicians to the area, I have more recently both contributed to the local physician shortage and offer a likely solution with my recent change in practice.

The problems that have led to the primary care physician shortage have been affecting us local physicians for years.   Commercial and government third party payers talk about the importance of primary care while steadily increasing their demands and shifting payments towards procedures.  As a result, many primary care physicians have retired early, others have given up their practices and retreated to the apparent shelter of large hospital systems that can charge facility fees or shift money from profitable tests and procedures to primary care clinics.  The rest of us worked smarter, harder and longer to sustain our practices with varying success.  Medical students and resident (trainee) physicians are well aware of all this and most avoid primary care.

However, primary care is undergoing a growing renaissance in many parts of the country.  Direct Primary Care is an affordable version of the high priced concierge practices enjoyed by the wealthy.  Direct Primary Care cuts out the middlemen and greatly simplifies the business of primary care for physicians, allowing them to lower prices back to levels affordable by almost all patients while giving those patients great access to their own physician.  Most importantly for this discussion, Direct Primary Care sustains successful practices that are drawing young physicians back to primary care. While Maine lags behind other areas of the country in this, Maine will soon have its seventh independent, direct primary care practice this winter.

The prescription to solve the primary care shortage does not require new government programs or further expansion of large hospital networks but simply the two groups that have lost the most in the current primary care mess, Maine physicians and patients.


Brian Pierce MD

Megunticook Family Medicine

Rockport



Posted by: Diane Possee | Dec 04, 2015 15:37

Are PT's trained to rule out myocardial infarction in that patient with left arm/shoulder pain? What about a dissecting aorta in that patient with back pain? I will continue to see my PCP as a first point of contact when I have musculoskeletal pain and let them rule out a medical problem that you are not trained to diagnose. 

Rick Possee



Posted by: TREVOR MILLS | Dec 03, 2015 20:35

Physician Shortage? An Opportunity.

 

As a physical therapist in this community, the dearth of primary care physicians is certainly evident, as my patient’s seek recommendations for doctors for their non-musculoskeletal issues, often I have little to offer them in terms of referral options.

 

For musculoskeletal concerns- back and neck pain, strains, sprains, joint pain, arthritis, patient’s can go directly to a physical therapist for an evaluation and treatment plan. A physical therapist has completed rigorous schooling, achieved state licensure and has the differential diagnosis skills to determine if a patient’s symptoms are truly muscle, tendon, bone, or nerve in nature, or if best handled by a physician. A 2005 study in the Journal of Orthopedic & Sports Physical Therapy (Moore et al.) found that PTs had better diagnostic abilities related to musculoskeletal issues than all other providers except orthopedic surgeons.

 

The physical therapists in our community will spend at minimum 30 minutes, and often 60 minutes per visit directly with the patient, and complete a comprehensive assessment of the issue at hand. Physical therapists have the time to educate the patient and determine a customized plan for the injury and situation. Physical Therapists can determine when imaging or further consultation is needed. Manual therapy, corrective exercises and education don’t have the side effects or adduction risks of medications, and can often resolve the root cause of the injury, not just treating the symptoms on the surface.

 

There are many good physical therapists in this community, with different areas of specialities and different payment methods. Some participate with insurance, which may be helpful if one had a low deductible insurance plan. Those with higher deductible insurance may find their PT is less expensive with an out-of-network provider who doesn’t have the high overhead costs to pass along to the patient. I’m confident that between all the local PT clinics, all patients with musculoskeletal issues can find a PT they feel confident in, and meets their healthcare budget. Physical therapist care sought directly has a lower cost- on the healthcare system as a whole, and often to the patient, compared to physical therapy received after a physician visit. (Ojha et al, Physical Therapy, 2015).

 

Of all visits to primary care physicians, 10-15% are for musculoskeletal complaints and 70% of new injuries are seen by a primary care physician first. However, “the musculoskeletal exam and procedures are often inadequately performed by primary care physicians at all levels of training.” (Houston et al, Journal of General Internal Medicine, 2004).

 

How many of those patients would have been better served by seeing a physical therapist as their first point of contact?  Can we use physicians for what they do best, and use physical therapists for what they do best? How much more time could a physician spend with the patients best suited to their skills?

 

Who is your PT?

 

Trevor Mills, PT

Owner, Snow Sport and Spine

Rockport, ME.



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