The University of Arizona’s Center for Rural Health collects data frequently to explore public health issues faced by the state, and a number of its recent reports and statistics point to a concerning future for the Arizona medical workforce. Arizona (AZ) faces a potential crisis in the near future when it comes to the state-wide shortage of physicians. Primary care in particular is an area of concern; in fact, it is immensely alarming that AZ is only meeting about 40% of its primary care provider (PCP) need [1]. As of 2019, AZ needed 558 PCPs to make up for its shortage, and by 2030, that estimate is projected to skyrocket to 1941 providers. It is intuitive that primary care is important; after all, the analysis of virtually every medical problem begins in a primary care setting before patients are connected to specialty physicians. Addressing this shortage is a crucial public health concern, and one of the potential ways of doing so is to consider utilizing other healthcare professionals or expanding their roles in order to utilize them more effectively.
There has been a great deal of research devoted to examining the substitution of other medical professionals into the roles normally managed by primary care physicians. In fact, the ongoing lack of PCPs has already made these types of substitutions necessary in a number of practices, especially by nurses. A 2014 systematic review examined the outcomes across various studies in which nurses performed autonomous care or were delegated clinical responsibilities which physicians normally held. While not many of the analyzed studies had enough data for proper analysis, the pooled relative risk values obtained by the reviewers showed a significant reduction in risk of both hospital admissions and all-cause mortality when nurse-led care was utilized [2]. The absolute numbers for hospital admissions among usable studies showed that 194/2108 (9.2%) nurses’ patients were hospitalized whereas 210/1782 (11.8%) of physicians’ patients were. The respective mortality rates for nurses’ and physicians’ patients among usable data sets were 1456/8094 (18.0%) and 1207/6558 (18.4%). It should, however, be noted that the researchers found that results varied between studies, with some studies even making opposing conclusions (though often without statistical significance). Further studies have also explored the utility offered by healthcare professionals other than nurses. For instance, a 2019 systematic review analyzed the utility of physician assistants (PAs) in primary care. It was found that family practice physicians often showed a high level of support for the concept of the PA role [3]. While data regarding productivity was often inconsistent and descriptive in nature, studies examining the efficiency PAs create by reducing physician workloads showed that physician productivity could increase with PAs involved, though this would often also increase the amount of time physicians spent with PAs as supervisors. Of note, while AZ guidelines in 2016 recommended that one physician oversee two-four PAs, the Center for Rural Health suggested increasing the number to four-eight to allow more patients to be seen [4]. In 2019, the AZ limit was accordingly raised from a ratio of 1:4 to 1:6 [5].
While expanding the roles of various medical professionals seems to be an adequate measure to take, there are potential problems with this sort of solution. One particular barrier worth noting is the perceptions patients may have of their new providers. For instance, a review study analyzing patient responses to nurses and physicians showed that whereas patients often found nurses approachable and were willing to work with them for follow-ups, they preferred that physicians handle more “medical” tasks [6]. Nurses themselves noted the need for additional training for their expanded roles and struggled with the burden of increased documentation. However, physicians and nurses both found the program to overall be a useful measure that allowed nurses to become more independent and gain new skills while reducing the workload of physicians, indicating that this type of intervention still holds promise. Ultimately, the physician shortage in AZ and beyond has the potential to become a real crisis. While past interventions have seen some limited success by utilizing other medical professionals in the role of a primary care physician, these measures are not enough on their own. Future steps in addressing this problem could include refining the use of other healthcare professionals by providing adequate and expanded training programs and increased compensation, allowing them to properly take over more physician duties and see increasing numbers of patients.
References
1. The University of Arizona Center for Rural Health. Arizona Primary Care Physician Workforce Report. Tucson (AZ): The Center, 2019 March.
2. Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:214.
3. Halter M, Drennan V, Chattopadhyay K, et al. The contribution of physician assistants in primary care: a systematic review. BMC Health Serv Res. 2013;13:223. Published 2013 Jun 18.
4. Tabor J, Jennings N, Kohler L, Degnan B, Eng H, Campos-Outcalt D, et al; The University of Arizona Center for Rural Health. AzCRH 2015 Supply and Demand Study of Arizona Health Practitioners and Professionals. Tucson (AZ): The Center, 2016 February.
5. The American Academy of PAs: PAs Celebrate a Year of Unprecedented Wins at the State Level. https://www.aapa.org/news-central/2020/01/pas-celebrate-a-year-of-unprecedented-wins-at-the-state-level/. Published Jan 28, 2020. Accessed June 7, 2022. 6. Karimi-Shahanjarini A, Shakibazadeh E, Rashidian A, et al. Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2019;4(4):CD010412.
Salman Azfar is a fourth year student at the University of Arizona, College of Medicine Phoenix. He graduated from UCLA in 2020 with a degree in Physiological Science. He loves dodgeball, swimming, playing games, and spending time with his friends and family. He can be reached at smazfar@arizona.edu.