Medicine’s Creepy Problem – Part 3: Where Do We Go Cotton-Eyed Joe?

We finish our discussion on exploring the topic of the NP/CRNA/PA scope creep from Part 2: The Congressional Tango. Here, we talk about the possible futures in store for us and our role in all of this.

Where Do We Go Cotton Eye Joe? 

In the end, we are left with the realization that every aspect of our healthcare system is deeply interconnected. Medical school education costs can afford to rise despite competition between different schools because of the scarcity of residency spots compared to the number of people that want them. The creation of residencies as low paying, semi-monastic positions requiring absurd work hours for the sake of “training” justifies the eventual reward to be worth the sacrifice of all those years and dollars. 

How do we go about untangling this endless web of problems? When we create more residency spots, they get accused of being “low-quality” residencies, and current attendings and future residents protest because their average salary is slashed due to more competition for the same jobs. Yet we find physicians burned out because they find it increasingly difficult to give thorough treatment to their ballooning patient populations, and rural areas find themselves with physician shortages since people seem to need more incentive to live in rural areas. 

This is the question of the iron triangle we’ve been told about so often. Where do we strike the balance of the “quality” we are willing to accept vs accessibility? We may scoff at the idea of shortening training times to produce “under trained” clinicians, but if entire communities end up not having care as a result then are we really protecting patients?

Ultimately, no founder of medicine can hope to foresee the problems that come with the changing landscape of social values over 100 years later. The man who envisioned a system where men could “reside” in the hospital while leaving their wives and children alone at home to sort themselves out seems hardly relevant to the systems of today. The starting salary of $66,000 for residents might’ve made perfect sense for when the dollar was worth more, but it is hardly justifiable today where one might be able to earn more than $100K/year in computer science with just a bachelor’s. Rules meant to address the concerns of generations ago, fearing that we’d have too many doctors on our hands, are hardly suited to a nation that’s now facing a daunting workforce shortage of up to 139,000 highly trained professionals in just 10 years.

The case has already been made for shortening medical education, with Emmanuel et al estimating that 30% of training at all stages could be taken out and made more efficient. This future would see us take the model of the 6 year BS-MD programs as well as shorten research requirements and lengths of residencies. It would probably also include an increase in residency pay and actually enforcing limitations on hours worked. After all, does it really make sense that the “value” of labor provided by a chief resident has more than doubled overnight?

Another alternative has also been provided by the NP/PA/CRNA alliance. If physicians insist on becoming more exclusive than Gucci belts then the market will create alternatives one way or another. The Urgent care clinic model and independent NP practices model will expand to include more patients and a wider variety of conditions, involving specialist physicians only when care becomes extremely difficult, diagnosis is unclear, or specific procedures have to be done. The fate of the profession, ultimately, rests in our hands.

To address each of these gigantic structural issues systematically we will have to throw the questions of resource allocation to society at large. We have to let the institutions we’ve created as a democracy act as representatives for the values that their constituents hold most dear and decide on an overall vision of care that makes the most sense for all Amercians.

Which means asking Congress to pass some laws…

Beyond asking for the impossible, I would urge fellow students not to take the matters of creep personally. As scary as the subheadings that I’ve written in this article are, “creep” and “turf wars” seem to be a consequence of the historical choices born during the establishment of medicine instead of anything we as individuals have power over. Even with growing intensity of the argument on the horizon, such as debates about nursing programs using “resident” and “fellowship” to address trainees and increasing push for encroachment on other specialities like anesthesiology, it is ever more important to maintain respect for our colleagues in our own lives, recognizing that as individuals they have little say in the forces that decide organizational tendencies. 

So far, I have received nothing but wonderful, supportive mentorship from nurses throughout my training, and I cannot imagine generalizing bitterness towards these figures in my life just because of a poor experience I might have in the future with a malicious figure. Furthermore, I realize that more courage should be taken to support nurses and other medical professionals that receive unfair treatment, rather than simply breathing a sigh of relief that we ourselves are not on the chopping block that day.

The fate of medicine looks uncertain, but I believe that no matter what we will figure out something that works. Let us do so with intent and organization instead of stumbling upon the answer.