Healthcare reform will launch a Tsunami in demand for treatment

March 29, 2010

obamaMDWEB.jpgThe healthcare reform vote is a victory for progressives but it is not the start of a radically changed healthcare system free of profit-driven stakeholders. One of the problems with the current system will become clear within a few years. I believe the sudden increase in the number of insured persons will demonstrate the severe shortage of primary care providers that currently is the case in our national healthcare workforce. There simply are not enough primary care physicians, nurse practitioners, or physician assistants available to provide primary care in safety-net/community clinics. Furthermore, it is not possible to train enough to meet the shortage – estimated to be ~40,000 – by the time the newly enrolled patients begin to seek care.
The current proposals being touted are the same old familiar tactic: enroll more mid-levels and MDs. Texas Tech School of Medicine announced it is starting a new affordable PC MD program – the Family Medicine Accelerated Track – to enroll and encourage more medical students to join the ranks of PC MDs. Features inlcude reducing the time from 4 to 3 years and the cost of training from $150,000 to $75,000. Other recent proposals would increase enrollment in the mid-level programs along with National Health Service Cops scholarship funding. Neither proposal works to meet the current and future need.

Here is an outside the box proposal. It is time to look at preparing the hidden healthcare workforce – DCs, NDs and LAcs – to help fill these roles. Safety-net and community clinics are overwhelmed with uninsured patients. They will be even more overrun when many of their patients have coverage. My proposal is to meet the need where the rubber meets the road; at the point of triage.

In my own experience working in what is purportedly the nation’s largest community clinic I evaluated an innovative chronic pain clinic that utilized LAcs (acupuncturists) and DCs (chiropractors) to treat uninsured patients. The single greatest obstacle was triage, i.e., making the referral to the appropriate service. The MDs doing the oversight had to review the charts – not the patients, the charts – in order to refer in (to the chronic pain clinic) or out (elsewhere, e.g., derm, peds, OB). Working half a day a week this process caused the single greatest bottleneck in the otherwise very successful program. Wait times approached 90 days for triage to be completed.

How difficult is triage? I believe LAcs can be trained to conduct basic triage in a one year clinical immersion program. Whether such a program might actually work is the question contemplated by my former acupuncture student who is now in his 3rd year med school. Here is what he says today.
We are discussing the particulars of training in the AOM model versus the medical model especially in terms of integrating LAcs into mainstream medicine.

For instance, a 25-year old male patient comes into the clinic complaining of blurry vision today after 3 days of abdominal pain with nausea. Additionally, the patient reports increased thirst and urination. The patient appears somewhat confused, and family members describe that his mental status has declined somewhat over the past 2 days. There is no significant past medical history. The patient’s respiratory and heart rates are elevated, and the blood pressure is 105/68. There is a fruity odor to his breath. Examination of the urine reveals glucosuria and acetoacetate and the serum panels shows a blood glucose of 350mg/dL and elevated beta-hydroxybutyrate.

Either a medical student or a well-read licensed acupuncturist may have a strong suspicion of diabetic ketoacidosis given this information. But their background understanding is probably quite different. The acupuncturist, based on their foundational training, most likely recognizes a conglomeration of signs and symptoms and makes an association. The scientific mechanisms underlying these signs and symptoms are poorly understood, if at all. Instead, the LAc will likely have a TCM Zang Fu/Vital Substances/Energetic perspective. Conversely, the medical student not only sees the signs and symptoms, but also understands the underlying mechanisms. They know why the glucose is in the urine, why it’s elevated in the blood, why the patient’s condition has resulted in these signs and symptoms. When they learn that they should calculate the serum osmolality, and order an EKG and arterial blood gas, they understand what these tests will show and how they will shed light on the patient’s condition. They know the basics of how potassium and sodium act in the body and how they will be affected by the patient’s condition. They understand the mechanism of action of insulin and how isotonic fluids distribute when given intravenously. They will be aware of significant alternative differential diagnoses to exclude. Based on this background knowledge, their preceptor can have a conversation about the management of this patient that cannot be had with the LAc, because such a conversation with the LAc will be like trying to build a house on a swampland. You could put all the pieces together but eventually it will just sink into the bog because there is insufficient foundation. In many instances this is enough to get by, as long as there is supervision, but it promotes a cookbook approach and suboptimal care.

Postscript: Some of the problems with deficiencies in acupuncture training are presented elsewhere on this blog. My proposal is to set the bar low and keep the new Primary Care LAcs working in a constrained arena where they will not be called upon to make independent assessments as described above. I think Dr. S has articulated differences that seem to consume far too much discussion within other circles where the issues include cultural and historical integrity of Chinese medicine. As an LAc himself who pursued the highest training presently available – the DAOM – he certainly knows where the gaps exist.

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