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It's Time to Redefine the Practice of Medicine


From the emergence of non-physicians to the role of EHRs, it is time for America to take a fresh look at how we care for patients.

I’ve been involved in healthcare as a medical provider for almost 30 years. During that time, I’ve also been an active proponent of legislative actions to make it as easy as possible for those of us practicing medicine to focus on both disease prevention and patient-centered care.

Every day of my professional life, whatever the legislative environment, my colleagues and I have faced human resource issues delivering healthcare in nearly every environment and venue. In fact, the issue of resource constraints was the core rationale for the emergence of the physician assistant (PA) profession, at a time when there was a very real threat of a profound shortage of primary-care physicians.

Dialogue around this matter has been repeated over the years as we have used models to look at how we staff healthcare and those models have remained basically unchanged. But technology has evolved over that time changing the way we practice medicine and perform the administrative functions fundamental to that practice.

Researchers and others are now questioning the assumptions underlying the current ratios of practitioner to population.

A recent article in Health Affairs focuses on the findings of some research that current predictions of shortages of physicians and other healthcare providers are not accurate and do not take into account how medicine is currently practiced.

What I take away from the article is that there are two significantly problematic areas of uncertainty in traditional models of medical human resource: supply and demand. The traditional methods of defining how many physicians and other healthcare providers are needed do not take into account changing patient demographics on the demand side. They also don't take into account alternative methods of delivering care on the supply side.

The authors opine that we need to perform a comprehensive analysis that considers access, patient demographics, and changing practice plans. On the supply side, we need to look at better ways to deliver care using teams, information technology, data sharing, and the use of non-physicians, such as PAs, who have the potential to offset increased demand for physician services while improving access to care.

Researchers point to a 2009 Kaiser Permanente study that reported the effect of how an electronic health record streamlined delivery of care. Providing patients with alternate ways to access their care, which didn’t necessarily require an office visit, reduced office visits per patient by nearly a quarter. Clearly there are ways to rethink how we deliver care to improve our efficiency.

In the real world, I know far too many PAs and physicians who spend a significant amount of time outside of "clinic" time completing the administrative work of delivering healthcare to their patients. I feel the same way because I’ve been there. I am using EHRs in both my outpatient and inpatient work. This has freed up my “nonclinical” time, but has not changed how many patients I actually see. It has just created a better quality of life where I don’t have to take work home or feel guilty that I haven’t completed my administrative patient care work in a timely manner. This needs to be taken into account in any research and modeling about how to determine the appropriate ratios of physicians and other non-physician providers to patients.

The practice of medicine has changed dramatically since the middle of the last century and continues to evolve. The PA profession was born out of the idea that there were many traditional medical roles that could be performed by non-physicians with no loss in the quality of care being delivered, or patient satisfaction. That is truer today then it was in the 1960s at the start of my profession.

We are seeing a significant impact of the EHR on medicine. Some of this is welcome and anticipated, and some of it is unwelcome and unanticipated. Much more research is needed to truly understand the impact of the EHR on the efficiencies of delivering healthcare. I’m a firm believer that EHR is making a positive difference in how we deliver and document healthcare. I’m also convinced that we will have much better data as EHRs become ingrained in every level of the healthcare system. However, we need to be cognizant of real world experience and the implication of the same as we look to determine what our human resources needs are in the healthcare system in America.

This is a critical area for researchers to explore that will require significant study and attention in the coming years.

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