COMMENTARY

Face-Off: How Nurse Practitioners and Physicians View the Primary Care Shortage

Tom G. Bartol, NP

Disclosures

March 18, 2015

Viewpoint

Primary care is changing. A shortage of primary care clinicians is predicted and the demand for primary care clinicians is rising. Increasing the training slots for physicians or NPs will not necessarily resolve primary care provider shortage if the current workforce is dissatisfied with their careers. Redesigning the work through new models of care to increase efficiency, quality, and career satisfaction may be a more effective strategy than simply turning out more primary care clinicians of any type.

The changes in primary care will present challenges, but they will also bring opportunities. The roles of primary care providers will change in keeping with the increasing demands on the practice of primary care. Meaningful use of electronic health records (EHRs), patient-centered medical homes, accountable care organizations, and other quality-of-care initiatives will result in changes to the primary care visit. The focus of the patient visit now is different from in the past, with an increased emphasis on meeting and documenting various measures and data.

How will the predicted shortage of primary care providers be filled? The number of NPs in the United States has been increasing, whereas the number of PCPs has been declining. In March 2014, the American Academy of Family Physicians released a policy paper recommending increasing family practice residency positions from 3500 to 4475 by 2025 as a solution to this crisis.[1] Will increasing these residency positions create more primary care providers? Only 56% of the PCPs who completed the survey would recommend their careers to others, and less than half reported being very satisfied with their career. Could there be other reasons that these PCPs express pessimism about the role of the PCP? Filling the anticipated (and real, in many parts of the country) shortage of primary care providers may take more than increasing training slots and funding. It may require a culture change in the way primary care is practiced in the United States.

Primary care has become more difficult as a consequence of pressure to see increasingly more patients more quickly. At the same time, the pressure to track and document proscribed measures is increasing. Relationships with patients are changing, resulting in less total time spent with patients. Less time with patients and pressure to see more patients have been associated with job dissatisfaction among PCPs.[2]

EHRs, in and of themselves, have changed the way an office visit is conducted. In most cases, a computer or electronic device is involved in the primary care visit. There can be both advantages and disadvantages to this electronic addition, but it has undoubtedly changed the relationship and the workflow for both patient and primary care clinician. The clinician now spends much of the office visit interacting with the computer, which can lead to reduced satisfaction for both clinician and patient.

Increasingly, patient care medical homes and other initiatives are not evaluated by such outcomes as patients living longer and healthier lives; rather, they are judged by process measures, cost reduction, and increased visit volume. Do these initiatives meet the needs of patients, clinicians, payers, or EHRs? Do the reports of "quality" measure the "value" of care?

PCNPs expressed higher job satisfaction, career satisfaction, and likelihood of recommending their careers compared with PCPs, but simply replacing PCPs with PCNPs may not solve the primary care shortage. PCNPs are capable of filling these roles, but as they do, they may find the current system challenging, eroding their career satisfaction over time. Traditionally, PCNPs have been required to see fewer patients, a fact that may have contributed to higher job satisfaction, but continued forces that detract from what nurses value—their relationships with patients—could change the relationship or lead to burnout of the nurses.

Healthcare will continue to evolve for the many players in the process—clinicians, payers, and patients. We must actively participate in this evolution, looking outside the box, beyond the way things have always been done or the way we have been paid to do things and beyond simply minimizing cost. Instead, we must focus on maximizing the value (the outcomes that matter most to the patient) of care over the lifetime of the patient. It is possible to make primary care a place where clinicians will want to work and will recommend to others as well. The opportunity is ours.

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