Shrink Rap Today

Three psychiatrists explain their work

Not Enough To Go Around

Physician shortages and scope of practice "creep"

In a recent New York Times article entitled "Pharmacists Take Larger Role on Health Team", author Reed Abelson discusses pharmacies that are expanding their revenue by adding services to their usual role of dispensing medication. In addition to watching for drug interactions, pharmacists are recommending alternative cheaper medications to patients and offering life style advice for chronic conditions. In some pharmacies they work with nurses to monitor diseases such as diabetes and hypertension. As one pharmacist in the story put it, "We are not just going to dispense your drugs...We are going to partner with you to improve your health as well."

Why is this happening?

Business forces, of course. Once pharmacists did a lot more than they do now. They used to manually make medications---compounding pills and tinctures and unguents---in a time-intensive process. Now, they dispense packets of pills that are mass produced in factories. That's a lot of education just to stand behind a counter and fill a prescription. The profession becomes more attractive when it is framed in terms of patient counseling and fundamental health care interactions.

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Also, health care plans will pay for it. Medicare pays $1 to $2 a minute for a medication management session with a pharmacist, according to the Time story. Not bad. One person in the story claims that "pharmacists could do as well and better than a physician" for less money. This is a claim doctors hear periodically. There aren't enough doctors to go around, so other professions try to fill the void. Rather than train more doctors, it's quicker and cheaper to grant lesser-trained professionals similar privileges. There's a standard rationale that's given:

1. We're not competing
2. We work under supervision
3. We know when to refer

All of this may be true as a whole, but not necessarily for a given allied health professional. Supervision usually isn't on site, and it doesn't necessarily mean that each case is being discussed with a physician. The "we know when to refer" part should mean that there is a written policy or procedure documenting the limits of the scope of practice or the criteria that should trigger a referral to a physician. And a means to ensure that those procedures are being followed. All of this means that an additional layer of bureaucracy---with its attendant costs---will accompany the broadened scope of practice.

Why don't we just train more physicians? Because the cost of training more physicians will break the hospital's bank.

Teaching hospitals traditionally have higher overhead costs, as well as sicker and poorer patients. The bulk of medical education costs paid to hospitals comes from Medicare and the Veteran's Administration. In addition to paying the residents' salary and benefits, teaching hospitals must bear the cost of the supervising physician and the administrative burden of sponsoring an accredited training program. Medicare reimbursements have not kept up with these training costs. Additionally, the organization which accredits training programs---the Accreditation Council for Graduate Medical Education (ACGME)---imposes limits on the number of consecutive hours that a doctor in training may work. This duty hour limitation adds to the cost of training by requiring the hospital to hire physician extenders to provide temporary coverage during the residents' "off" hours. Some estimates have placed the additional cost of duty hour limitations as high as one million dollars per hospital.

As our population ages the gap between physician demand and supply will grow and it is likely that lesser trained specialties will attempt to fill the gap. How this affects patient safety and treatment outcome remains to be seen.

(c) Copyright: Annette Hanson MD, 2011 [link to original post]

Annette Hanson, M.D., is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

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