Sometimes, It Takes a Village to Keep the Child Healthy Once He is Grown

New Mexico Needs 400 Family Physicians!

I read this headline online last week. I kept going back to the site---sponsored by a public health group in New Mexico. The sheer audacity of it boggled the mind. I mean, I don’t think there are 400 new FP graduates in the US each year. Let me go look that up…Thank goodness. There are, in fact over 2000 family practice doctors who graduate each year in this country. But wait! If New Mexico needs all these new FPs because so many people now have insurance, that means that at least 25 other states have the same need. And even the ones that refused the Medicaid expansion will have more insured people on private plans. Where are we going to get…who knows how many family practice doctors or nurse practitioners (NPs) or physicians assistants(PA) to take care of all these people? Maybe if we normalize relations with Cuba last week we can steal all their doctors. I hear they have great health care system. Plus, they probably all speak fluent Spanish, a real plus in the Southwest---

How do we deal with the shortage? The pediatricians faced this crisis about ten years ago, when it suddenly became extremely uncool to allow children to die for lack of health insurance, even in the most devoutly red state. With almost all children covered by some form of insurance, there was a tremendous need for more pediatricians. One of the ways that the pediatricians addressed the problem was by encouraging pediatricians who had left practice to stay home to have kids—mostly women, often the wives of other physicians--- to get retrained and get back to work. Now, physicians in other specialties are starting to join in. I was a stay at home mom. I have been back at work for almost five years, thanks to one of the re-entry programs (see the link below).

What about the country as a whole? A study from the Department of Health and Human Services last fall estimated that if nothing was done



This is truly scary. This is the kind of number that makes primary care doctors think about closing their practices to new patients. The study goes on to suggest that the shortage can be reduced to 6400 FTEs by 2020 if we get started right training NPs and PAs nonstop. And of course, the patient centered medical home model will help with the shortage. Instead of seeing your doctor every two to three months, you may see your doctor once or twice a year. You will get your diabetes education from a health coach. Your medications will be adjusted by a clinical pharmacologist. A NP or PA will treat your bladder infection or upper respiratory infection----

Think of them as physician helper, sort of like hamburger helper, designed to stretch those doctors a little further.

But will it be enough? Maybe we need to go one step farther. Maybe we need to move beyond the patient centered medical home---an office with a doctor surrounded by lots of doctor’s assistants---and make the community the center of health care.

I got the idea today while reading about an effort in Dallas. One particular homeless patient keeps running out of his thyroid medication and going into thyroid coma. He keeps getting admitted to Parkland Hospital. The medication is very cheap. But if he does not have it, he does not take it---and then he is back in the hospital, requiring critical care over and over again. Which is not a bad metaphor for the costly US health care system. Dallas has decided to partner with the homeless shelters and food banks to get this patient his meds. When he checks in, they will check his medical records and make sure he is on his meds. All he has to do is agree to participate. Suddenly, the Dallas community becomes his medical “home.” He risks dying every time he goes into a coma, so this will probably save his life.



At first glance, it all sounds very Big Brotherish. But ever since HIPA put our medical records online where every Chinese and Eastern European computer hacker can access them, medical privacy has become something of a fiction. So, since we are all hooked up electronically anyway, maybe there are ways that we can use that to our advantage. Like special warnings for people with heart and lung conditions when ozone is high---I would have loved that one when my son was in public school and they insisted upon having him stand on the freeway for a hour at a time during peak ozone season for fire drills, setting off two week long asthma attacks that kept him home from school and on steroids. A simple email message to the school saying "Students a, b and c should stay indoors today" would have prevented that problem. Food allergies could be programed into grocery store checkout lines. It would not relieve the consumer of the responsibility to check, but it might make it a little bit easier if the scanner said "No, stay away. Has peanuts." Gyms could record your weight, blood pressure and pulse and send it to your doctor's office, cutting down the need for visits just for BP checks---as well as sending info about your improving cardiovascular fitness. As you work out and your weight drops, your blood pressure control may improve. Maybe you can reduce your dose of blood pressure medication before your blood pressure bottoms out--if your health care provider is getting regular updates.

With a huge primary care physician shortage looming, we are going to have to get creative. There is no reason that we can not use this as an opportunity to get healthier, too.

http://www.aafp.org/media-center/releases-statements/all/2013/residency-census-report-family-medicine.html
http://www.ama-assn.org/ama/pub/education-careers/graduate-medical-education/question-of-month/graduates-being-denied.page
http://physician-reentry.org/the-physician-reentry-into-the-workforce-project-history-and-timeline/
https://www.ama-assn.org/ama/pub/education-careers/finding-position/physician-reentry.page
http://www.dallasnews.com/news/metro/20140418-12-million-grant-to-help-parkland-pioneer-information-exchange.ece
http://www.sparetheair.org/Make-a-Difference/Get-the-Facts.aspx#05