AcuteCare Telemedicine Blog


Solving the Physician Shortage: Should it be Left to an Act of Congress?

Since 1997, the number of physicians entering the workforce each year has essentially been capped, while the demand for everything from hip replacements to treatments for diabetes to angioplasties has soared with our growing and aging population. Now, the Obama administrations newly proposed budget seeks to spend an additional $5.23 billion over the next decade to manufacture new physicians. While this sounds like a lot of money, given the magnitude of the doctor shortage issue, it won’t be nearly enough to solve the shortage problem on its own merits. The proposal is designed to swell the ranks of primary care doctors, those family physicians, general internists, and pediatricians that constitute the healthcare workforce that is predicted to experience the greatest shortage of all the medical disciplines.

But primary care is not the only medical care discipline that is facing future short falls.  According to a study by the American Academy of Neurology (AAN), by 2025 the demand for neurologists will far outnumber the supply, creating a 19 percent disparity in the number of doctors needed to adequately care for all patients. Those who suffer with neurodegenerative diseases like multiple sclerosis (MS), Parkinson’s, and Alzheimer’s will have to wait longer to see a specialist.

“The doctor shortage is worse than most people think,” says Steven Berk, M.D., dean of the School of Medicine at Texas Tech University. “The population is getting older, so there’s a greater need for physicians. At the same time, physicians are getting older, too, and they’re retiring earlier,” Berk says. And graying doctors, nearly half the nation’s 830,000 physicians are over age 50, are seeing fewer patients than they did four years ago.

The flow of doctors entering the market each year is determined by the number of U.S. residency positions, chiefly in teaching hospitals. Those positions are funded primarily by the program that oversees Medicare and Medicaid. In 1997, the federal government essentially froze spending on residency slots, limiting the number to around 100,000 over three-to-four years, and in turn freezing the number of newly licensed physicians available for hire each year to around 26,000. Over the past 17 years, a few hospitals have established new residency programs for primary care doctors, raising the number to around 27,000, or a less than 4% increase. Meanwhile, the U.S. population has risen by 50 million, or almost 20%. The American Association of Medical Colleges estimates that the U.S. will face a shortage of 46,000 primary care doctors by 2020, equivalent to one-quarter of everyone practicing in that category today.

The Affordable Care Act promises to magnify the problem but does attempt to address some of the issues to help stem its effect on the shortage by allocating an additional $1.5 billion in funding for the National Health Services Corps, which provides support to health care professionals in exchange for their service in areas with a more prevalent shortage. The law also puts more money toward training in hopes of increasing the primary care workforce and it offers more graduate positions for primary care doctors and more scholarships. It even offers a 10% bonus to primary care doctors who agree to see Medicare patients through 2015.

But many in the medical care industry do not see the solution reserved for government legislation alone. “Keep in mind the Affordable Care Act didn’t create this crisis,” said Dr. Reid Blackwelder, president of the American Academy of Family Physicians. “We’ve got an aging population that needs more care and a growing population.”

Many believe that new technologies will extend the reach of medicine in ways that will ameliorate the shortage problem. Health care professionals can serve more people by using telemedicine technologies to examine, treat and monitor patients remotely as well as providing patients increased access to advanced stroke care. These technologies are already keeping patients out of hospitals and doctors’ offices and providing improved recovery results. Creative new ways medicine is delivered, such as the use of “medical homes” and “accountable-care organizations” to better coordinate patient care, are also expected to improve efficiency and keep patients out of the hospital. Telemedicine enhances productivity and outreach while cutting costs, it improves diagnosis and care management in remote areas, and it reduces unnecessary care. The technology also strengthens partnerships between community based hospitals and advanced regional care centers.

“I understand there is a sense of worry, and change can be scary, but our present system is broken,” Dr. Blackwelder said. “We pay twice as much for our health in this country and have worse outcomes than other countries. Looking to government to fix a problem often harbors complexity, inefficiencies and long-term implementation of solutions. Dr. Blackwelder’s opinion reflects that of many other medical industry professionals, “We will have to start coming up with creative solutions to this problem, ones that won’t have to wait for an act from Congress.”



Stroke Mimics in the Emergency Setting

The role of the neurologist in treatment of acute stroke often focuses on the decision to use clot busting medication (tissue plasminogen activator; tPA), recommending care setting (e.g. ICU vs routine admission) based on patient deficits and prognosis, and of course, patient education in the midst of this emotionally charged experience. However, an often overlooked mandate for the neurologist is the proper recognition of stroke itself. Dr. J. Stephen Huff, Associate Professor of Neurology at the University of Virginia, provides a clear and comprehensive review of what are termed stroke “mimics” – disorders which may appear to be a stroke, but are not.

Stroke, broadly defined, is any prolonged disruption of focal neurologic function due to decreased blood flow from blood clotting in a specific region of brain. If that disruption is transient or intermittent it is typically referred to as a transient ischemic attack (TIA). If brain function is disrupted by a cause other than a blood clot, treatment with tPA may not only lack benefit but expose the patient to unnecessary harm. Recognition of “stroke syndromes” that result from specific artery involvement is the bread and butter of neurology. The abrupt onset of aphasia (language deficit) and right sided weakness almost certainly indicates a patient has blocked their left middle cerebral artery. Blocking this same artery on the right results in the classic presentation of left sided weakness and “neglect,” an inability to recognize one’s own physical deficits. In either case, the immediate administration of tPA can be life-saving.

Other disorders may cause brain dysfunction unrelated to a blood clot. This is the case in approximately 13-20% of patients presenting with presumed stroke. If the duration of symptoms is unclear, this number may even be as high as 30%. The most common mimic is seizure. Excessive electrical and chemical brain activity may result in focal weakness (Todd’s paralysis) and other deficits. If the seizure was not witnessed (especially in patients with previous stroke as the cause of seizures), excluding an acute stroke can be difficult. Focal neurologic injury from brain tumor, inflammation (e.g. multiple sclerosis), or even peripheral nerve palsy may be mistaken for stroke.

Stroke can be mimicked without direct injury to the brain. The most common mimic in this category is a complex migraine in which visual disturbance, weakness, numbness and even aphasia can occur. Hypoglycemia or, less often, hyperglycemia (low and high blood sugar) can cause general symptoms of lethargy or coma, but focal brain dysfunction (particularly weakness) often occurs and can outlast normalization of blood glucose. Finally, 30% of patients presenting with psychiatric causes of physical illness (i.e. conversion disorder) exhibit neurologic deficits, typically weakness.

Determining the cause of a patient’s deficits can sometimes be accomplished in an emergency setting through the use of CT imaging and appropriate diagnostic tests. Often the results of serial examinations, detailed history and, increasingly, advances in MR imaging can eventually lead to the correct diagnosis. However, certain diagnoses, notably migraine and conversion, are diagnoses of exclusion, so repeated events and extensive negative testing may be required for confirmation.

Among patients presenting with neurologic deficits, emergency department physicians correctly identify stroke before applying diagnostic studies in about 75% of cases. This means as many as 1 in 4 cases are incorrectly diagnosed. It is the role of stroke experts, like those of AcuteCare Telemedicine, to quickly and accurately determine the likely cause of neurologic deficits, the risks and benefits of multiple treatment options and convey a plan of action simply yet fully to the patient and loved ones. It is a difficult but rewarding task.