As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:
The issue we’re facing
The primary care physician workforce in Kansas–family doctors, internists, and pediatricians–is aging. Of the 1,976 primary care physicians in Kansas as of April 2020, 15.6 percent are already over 65, and 39.2 percent are over 55. The simple demographics of this are intimidating: even though they provide the most essential, cost-effective care in medicine, only 43 percent of practicing physicians in the U.S. are primary care providers, similar to the average of eleven Organization for Economic Cooperation and Development countries. But the fraction of graduating students entering primary care is steadily decreasing. Even more ominously, older physicians are much more likely to be harmed by infectious diseases like SARS-CoV2, the causative virus behind COVID-19, adding to the inevitable workforce turnover caused by death. This all portends an uncertain future for primary care provision in many Kansas communities, since Kansas is already underserved relative to most other states at baseline.
As if that weren’t enough to worry about, physician skills appear to deteriorate over time. A 2017 study in the British Medical Journal found, for example, that elderly Medicare beneficiaries’ hospital adjusted 30-day mortality rates were 10.8% for physicians aged <40 and rose steadily to 12.1% for physicians aged ≥60, a 15% relative increase in risk for patients cared for by older doctors. Not only that, but costs of care were slightly higher among older physicians. This may not simply be due to age-related decline; it could be that younger doctors were trained in a way that improved their care. For example, “evidence-based medicine” is an integral part of medical training in the modern era. Older doctors who were not trained under this philosophy are demonstrably less likely to follow evidence-based care guidelines. This is hard for me to read. Statistically, I am likely a worse doctor than I was fifteen years ago. But I digress.
What can be done about this problem?
The Association of American of Medical Colleges, predictably, has argued for years that the solution is to train more physicians, by two mechanisms: first, the AAMC advocates for increasing the cap on Medicare funding that limits the number of residents at a given institution. Second, the AAMC supports greater incentives such as scholarships and loan repayment for primary care providers working in underserved areas. Examples of this are the Kansas Medical Student Loan Program, which pays for medical school for a limited number of students in return for an agreement to practice primary care in underserved areas in Kansas; and the Kansas Bridging Plan, which gives resident physicians additional funding during their training in exchange for a three-year commitment to practice in a rural community. On the federal level, the AAMC advocates for increased recruitment of international medical graduates, who already represent about a quarter of practicing physicians in America, through programs like the J-1 Visa Waiver program.
Others point toward increased use of non-physician practitioners like physician assistants (PAs) and advanced practice registered nurses (APRNs). This is clearly the preferred short-term option. PAs and APRNs require drastically less training than physicians, which eliminates the seven-year gap between policy and practice that we see in traditional medical training. And the health outcomes of patients seen by non-physician providers seem to be roughly equivalent to those of patients seen by doctors. Another British Medical Journal systematic review of randomized trials and observational studies–one of several such reviews in various journals, all with similar conclusions–concluded that “Patients are more satisfied with care from a nurse practitioner than from a doctor, with no difference in health outcomes.”
But long-term, if the skills of physicians like me decline with age, we can be certain the skills of other providers fall as well. How do we ensure that quality care continues to be delivered over the lifespan of the practitioner?
Automation may be the answer
Let’s look at my specialty, endocrinology. Six years ago, when I left full-time practice, the management of blood glucose levels was mostly an intuitive art/science, driven mostly by the experience of the physician-patient dyad. But in the last few years we’ve seen the emergence of “smart” glucometers that quadruple the likelihood of of a patient controlling their blood sugars while reducing their risk of dangerous low blood sugars. We’ve seen the development of automated insulin devices in the hospital that outperform conventional treatment of blood glucose levels. The FDA approved an artificial intelligence-based device to scan and diagnose the eyes of diabetic patients with diabetic eye changes (the most frequent complication of diabetes) without even having an ophthalmologist or optometrist involved. Newer, even more innovative, devices are in development, such as an app that can allegedly detect the presence of lung disease by the sound of a patient’s cough.
Some of these devices will pan out in the long run, while others won’t. But even a conservative projection is cause for optimism. It is not unreasonable to predict that practitioners with far less training than physicians will have the tools and skills to provide very competent care–elements of both primary care and specialty care–in the near future. Technology must be carefully monitored by humans, but its abilities do not decline with age. On the contrary, a given technology’s performance today is the worst that it will likely ever be. Best Buy will sell faster computers next month than it does today, and faster yet a year from now. And automated devices aren’t resistant to delivering evidence-based care; it is programmed in. I welcome the Rise of the Robots.
