The impending doctor shortage: do you really need a doctor anymore?!

The fallout and unintended consequences of the Affordable Care Act (Obamacare) continues. With so many more people being brought into the “insured” category with the expansion of Medicaid across the country, the very real concern is that there will instantly be a doctor shortage. Since it takes at least 7 years to take a college graduate and make them a fully accredited doctor, the doctor shortage can’t be fixed immediately. So how is the US coping with the doctor shortage? Here are a few approaches.


According to the Association of American Medical Colleges (AAMC), medical school enrollment has increased from 70,099 in 2003 to 82,067 in 2012. So while the number of doctors being produced is increasing, as mentioned previously, there is at least a 7 year delay from the time a medical student begins their studies, completes medical school 4 years later and then finishes the shortest possible residency 3 years later.


A second approach is to take the existing pool of health care professionals, specifically nurse practitioners and other advanced practice nurses (nurses that get a masters or a PhD in nursing) and expand their roles. In other words, give them more responsibility that was historically only delegated to physicians. In many states a nurse practitioner must work under a physician’s supervision but in a third of states, they don’t have supervision. The most common roles for nurses in these situations is primary care, such as providing Pap smears in a woman’s clinic.  The most common concern about shifting these roles to advanced practice nurses is that their education hasn’t prepared them for these responsibilities. But in areas where physician availability is limited, many physicians have been satisfied to relinquish some of these responsibilities. Additionally, I think the education of advanced practice nurses does prepare them for these expanded, but still limited roles as they have been defined up to this point. But it’s a slippery slope.


Finally, the most controversial approach to fill the doctor shortage are what’s called “scope of practice” bills submitted to state legislatures across the country. For example, in California, bills have been introduced that would expand services provided by nurse practitioners, optometrists and pharmacists in order to help alleviate a shortage of primary care physicians, particularly in rural areas and inner cities.  The bills would allow nurse practitioners to see Medicaid and Medicare patients even if the doctors that supervise them do not accept Medicaid or Medicare.  Optometrists could check for high blood pressure, and pharmacists could order laboratory testing to detect diabetes. On the surface, this doesn’t seem awful because these are non-invasive procedures.


But in Louisiana, house bill 527 has just passed out of committee and is on its way to the full House for a vote that would give optometrists an expansion of their role, into the realm of procedures. Optometrists, as far as I understand, “fit lenses to improve vision, and diagnose and treat various eye diseases.” I am not aware of any invasive procedures that they are generally trained for nor sought out for.  They want the right to perform a wide spectrum of basic ophthalmic procedures using a scalpel, allowing them to give injections, and also allowing them to prescribe all drugs except Schedules I and II (heroin and Percocet are examples of Schedule I and II narcotics, respectively).


The bill does specifically exclude many common ophthalmic procedures such as cataract surgery, LASIK, and PRK, as well as the administration of general anesthesia but the bill also gives the Louisiana State Board of Optometry sole discretion to “determine what constitutes the practice of optometry.” Thus, they have provided themselves a loophole to expand their scope of practice on a daily basis in the future, out of the limelight of the legislative session.


The major problem with me complaining about this is that I’m not seen as objective, since as a plastic surgeon, I see ER doctors, Ob-Gyn’s and others performing cosmetic procedures that require fundamental training I know they didn’t receive. So it only appears that I, along with my ophthalmology colleagues, are trying to protect our turf. It’s a shame that we aren’t seen a advocates for what is right.  I can’t, on any level, understand how it’s within reason that an optometrist would be allowed to perform invasive procedures on the eye. I wonder if the legislators on that committee that sent the bill to the full House would be OK seeing an optometrist for a procedure involving a scalpel?!


But I have to give the optometry lobby (nursing and pharmacy lobby in the case of California) credit for seizing this opportunity. With in an increase in Federal funding with the expansion of Medicaid, they recognized that this could be a bonanza of reimbursement. They will be sorely disappointed. The expansion of Medicaid will be an expansion of an insurance that reimburses inadequately.  Many doctors and facilities can’t accept Medicaid anymore because the cost of treating those patients is more than potential reimbursement for those services.


The most egregious aspect of the scope of practice legislation being pushed by these parties is that they have misrepresented themselves.  They told their legislators that they could fill in the doctor shortage. It’s one thing to say we need “all hands on deck” to help the many newly insured patients in the country, but it’s quite another thing to say we can do what doctors do without the same level of training. This latest round of economically motivated lobbying has finally crossed the line in giving optometrists responsibility that is not supported by their curriculum in school. They told their legislator that they didn’t need a doctor anymore…and the legislator believed them.


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