Robert H. Brook, MD, ScD, is a leading pioneer in the study of health care quality. As a long-time physician leader at the RAND Corporation and UCLA’s David Geffen School of Medicine, Dr. Brook directed seminal studies on the effects of health insurance and payment on quality of care. In winning the 2005 Institute of Medicine’s Lienhard Award, given for outstanding achievement in improving health care services in the U.S., Dr. Brook was cited as "the individual who, more than any other, developed the science of measuring the quality of medical care and focused U.S. policymakers' attention on quality-of-care issues and their implications for the nation's health."
I was fortunate to sit down with Dr. Brook recently. In the first part of my interview, presented below, he addresses the ways roles may shift among primary care physicians, nurse practitioners (NPs) and specialists, and speculates on the future of primary care.
A lot of ink is being spilled on how the primary care shortage is expected to worsen under coverage expansion. How do you see that issue?
The question of whether there is going to be a primary care shortage really depends on the model of primary care. Right now there are about one billion visits a year to physicians, about half of those to primary care doctors. An extraordinary number of these visits are routine physical exams, urinary tract infections, colds, and patients with metabolic syndrome (high blood pressure, cholesterol, weight problems, and diabetes).
Many people argue that all of those things could be treated by a nurse practitioner (NP) and that eventually a large number of these visits will not result in a primary care physician visit at all. About 30 randomized trials show that when nurse practitioners manage such patients, there is really no difference in terms of outcomes. So maybe nurses and NPs are the ones that need to get people to exercise or lose weight, or take their medication. These activities are really important but don’t require seven or eight years of medical training, and other providers may be able to do them as well as or better than physicians can.
Now, the other side of the coin is that many people with chronic diseases – like rheumatoid arthritis, asthma, epilepsy – are being managed by specialists and, in many cases, there is no real need for that. If you have stable epilepsy and take one drug, it’s not clear if you need to see a neurologist for follow-up visits. That is something a primary care physician could do.
If you go down the list of specialists, you’ll see a lot of them are not really working toward the full scope of what they know how to do. So the question of whether there will be a primary care physician shortage really depends on what roles PCPs, NPs, physicians’ assistants, and specialists will end up playing.
Okay, what role do you prefer PCPs play?
In my opinion, a better role for primary care doctors is making complex diagnoses and managing patients who have multiple conditions and medications. Patients also desperately need a physician to coordinate their care when they are moving between their home, the hospital and the nursing home, and across specialties for different conditions. The current coordination across settings is much less than desirable, especially for elderly people. The primary care doc should be spending time with the complex patients and situations that can’t be easily managed.
This may not be a vision shared by the leaders of primary care. However, I think there is value in moving the primary doctor away from sore throats and physicals—and even fine tuning blood pressure or diabetes—and toward more complex diagnoses and coordination. I think there is a good chance PCPs will be spending less of their time with patients who are basically well.
Do you think we actually have a PCP shortage?
At this moment, there is a big push in virtually all states to allow NPs to practice to their full license. If that comes, and with the number of people the NP and nursing schools are producing, there won’t be a shortage.
For any panel of patients, 5-10% make up most of the costs. Clearly, these are the patients for whom you would want the expertise of a well-trained PCP to help manage and coordinate and provide value. For the other 90% of patients, it is not clear to me that they need a primary care doctor.
The difference in the hourly charges of an NP and a primary care provider do not vary much and will not solve the cost problem. The real question is: Will you pay a primary care physician more because he or she can take these very complex patients and reduce the total expenditures on them by a significant amount because their care is managed better? Additionally, will PCPs take on risk for a population’s health and employ other professionals to work with them?
You’ve watched your profession undergo so much change over your career. How do you feel about these changes? How do you advise young people considering medicine?
The sad part of medicine is going to bed and telling yourself, “I could have done this better if all of the physicians and other providers worked together.” We don’t have to spend a lot more money, and we might even be able to do it less expensively, if only we can work as a team.
Technology is increasingly giving physicians more and more information about their patients. The challenge is to use it to provide better care at lower cost.
Finally, I do get angry when people who fill out tax forms or manage money, or do plenty of other things, make gazillions of dollars. A lot of doctors are really struggling in expensive cities. I don’t think that’s fair or appropriate.
But listen, even with the bad part, what can be better than helping someone that’s sick? It’s just a high. If I were a baseball player, I might say that somebody is paying me to play a game. But somebody is paying me to help people. I think going into medicine is the best thing a person can do in life.
The second part of my interview with Dr. Brook will focus on how emerging technologies will affect the future practice of medicine. Look for it next month.