The Not Quite a Doctor of the Future

A recent article highlighted the sometimes acrimonious dialogue between physicians and advanced practice providers regarding the capacity of the latter to function as PCPs.  Obviously, there are both pros and cons to substituting a nurse practitioner or physician's assistant for an MD.  On the one hand, many APPs bring extensive experience with hands-on patient care as well as a commitment to compassionate service to their work.  These qualities resonate with patients, some of which even prefer an APP as their primary care provider over an MD. 

Conversely, with some states only requiring an additional year in school to upgrade from an RN with a bachelor's degree to a nurse practitioner, many physicians point out that the training most advance practice providers receive could not possibly prepare them sufficiently for independent primary care provision.  Although many clinical encounters involve common conditions, the competent primary care provider must also be trained to identify and treat a broad range of unusual conditions in order to maximize clinical outcomes and minimize patient risk.  12 months of education, many would argue, is simply not adequate to master all of the necessary knowledge and skills.

Barring some major change in the current laws, advanced practice practitioners are, however, here to stay.  Between the support of enthusiastic patients and the cost benefits to healthcare companies, the number of APPs will skyrocket over the next ten to twenty years.  Given the reality of the changing landscape of American healthcare, it is critical to develop efficient and effective models of teamwork and to ensure, above all, that patients continue to enjoy effective and safe healthcare services.  What might this mean for patients and how will CAM providers fit into the new healthcare model?

Currently we see fewer and fewer MDs going into general practice, and salaries for family medicine providers languish far below that of most medical specialists.  At the junction where the disincentives for MDs who would go into family medicine intersect with the growing interest in advanced practice lies a trajectory carrying us towards a revolution in care.  In the American healthcare system of the near future, it is likely that MDs will primarily be specialists waiting on referrals for especially complicated or specialized cases, while APPs will provide the bulk of our basic healthcare needs.

As primary care service shifts from doctors to APPs, new tools will be developed, ranging from diagnostic aids to better treatments, that will allow healthcare workers with less formal training to practice better medicine.  For example, a nurse practitioner will be able to utilize genetic testing to ascertain which type of antidepressant is most likely to afford a good clinical outcome for a particular patient.  As another example, new electronic medical record systems will be introduced that will organize and prioritize data more efficiently.  By organizing medical information better, the APP of tomorrow will be able to avoid mistakes, improve diagnostic accuracy, and track the results of treatment.

Assuming that the torch of responsibility for primary care can be successfully passed from MDs to APPs without a significant impact on clinical outcomes, the immense savings of healthcare dollars will accelerate the evolution towards a system where primary care is exclusively provided by advanced practice practitioners.  Additional impetus in this direction will come from the limits placed on MDs who continue to provide primary care.  Despite their extensive medical training, if the companies that control healthcare services are only willing to employ general practitioners or family medical doctors who can sustain practices with heavy patient loads, inevitable medical mistakes coupled with crippling practitioner burnout will result in more and more MDs relinquishing the reins of primary care to advanced practice practitioners.

For CAM practitioners, the future looks bright.  Advanced practice practitioners tend to be pragmatic clinicians who are open to the consideration of alternative treatments.  Compared to their MD counterparts who spend more than a decade steeped in a singular perspective on healthcare, APPs are often more likely to have a broader background and perspective.  In the Acupuncture and Oriental Medicine community, we look forward to a collaborative effort with advanced practice practitioners to not only provide effective treatments but to also work towards a healthier society.