Reflections on meeting with Dr. Purcell

Debra L. Glasser, M.D.

PHOTO BY GLORIA TOWNE

Back home in Olympia from my second  ‘post-Covid’ January of travel to warm places, I have reflections to share.  Last year I served on a volunteer medical team in Belize. A key takeaway from that experience is that we have an advanced medical care system that saves lives!  

This year  I chose to travel to St. Vincent and the Grenadines with no medical agenda. It was to be pure recreation. However, synchronicity had its way with me.

Being one gifted with the interest and ability to talk to anyone, I found myself standing in the swimming pool at the hotel on St. Vincent, striking up a conversation with a professionally dressed woman who sat down at the poolside table with a glass of wine. You never know who you are going to end up talking to!  Turns out she is the Dean and Provost of one of the five medical schools on the island, the only one fully accredited. Being dinner time with my traveling group and wanting to talk to her for hours, I asked if she would meet me for more conversation at breakfast the next morning.  

I had burning questions to ask someone in medical education about what is going on with the medical care in our country that seems to be falling apart at the seams in a myriad of ways, even with ICUs that save lives not remotely possible in the third world.

I wanted to know why we have a shortage of doctors in general and particularly in primary care. Why are Nurse Practitioners and Physician Assistants being substituted for physicians, and does she consider that problematic? How is the school working with the (third world) community on St. Vincent… to be answered in a subsequent column.

Here is what I learned in 2 short hours from Dr. Frances Purcell (Ph.D. Education), Dean and Provost of Trinity School of Medicine located in Roswell, Georgia and on the island of St Vincent, who has worked in the field of medical education for more than two decades. Personal commentary in italics.

The physician shortage we have here in Thurston County is nationwide. The shortage of primary care physicians (this includes pediatricians, family practice and internal medicine) and psychiatrists has been a direct result of the large student loans incurred by medical students which has driven so many into higher-paying specialties. There are few, but not nearly enough, student loan forgiveness options. I attended my state’s medical school (University of  Massachusetts class of 1980) when the tuition was less than $1000 the first year, incurred ~$20K loans (compared to $250K for a current medical student on average), many of my co-students took on public health scholarships to work in underserved areas to defray their costs and student loan interest was very low (~1% if my memory serves). This allowed us to choose lower paying primary care specialties which the school was established to produce.

Medical schools have enlarged their classes and the US is training more physicians. The current bottleneck is that there are not enough residency slots. After four years of college and four years of medical school, new physicians do 3 to 7 years of residency in their chosen specialty. During residency, new doctors earn a living salary if you don’t calculate the per-hour wage (vs. incurring debt - I thought I was wealthy in residency! Some weeks I worked up to 120 hours – fortunately, there are laws against this now) and are considered trainees in the hospitals where they serve. Perhaps some of you have received care from the terrific family practice residents being well-trained in the programs here in Olympia and Centralia.

Residency programs are supported by Medicare and the current requirements to set up a program are rigorous to the extreme such that it has become too difficult for many small community hospitals to set up (which makes us here in our small community extremely fortunate  to have this residency). Residents are known to often settle and practice in the community they train. I did (Portland, Oregon). Three of the residents I precepted here pre-arranged a relationship with Mason General to practice in that community upon completion of training. What a boon to the medically underserved county abutting ours.  She says these federal rules are slowly changing, but it will be a timely process from which the results will not be felt for some years, considering the duration of physician training.

Dr. Purcell prides herself on the rigor of her school’s training program with the process of teaching the students facts as well as how to think. Her perspective on mid-levels, specifically  Nurse Practitioners (NPs) is that nurses are well-educated medical professionals trained in what and how to DO things.  They learn to follow protocols.  Critical and key skills needed in medical care. (God forbid you ever asked the likes of a doctor i.e. me, to change an iv or hang a unit of blood for a transfusion). It is a big leap for an RN to learn to think like a doctor before doing it. Because of this difference, she agrees that it is problematic to substitute Nurse Practitioners (and Physician Assistants, PAs who are similarly protocol trained) in physician roles. In the current shortage and corporatization of healthcare this is exactly what is happening.  Mid-levels are less expensive to hire. Most people I talk to about their health locally and nationwide don’t know if their medical practitioner (now called ‘providers’ in the corporate world of healthcare, a term I consider demeaning to all medical professionals) is a doctor, NP or PA. I have worked with both graduated and  NP trainees finding myself doing exactly as Dr. Purcell stated, working to help them learn how to think (about the clinical situation being presented by the patient) first and do only after careful thought of what condition they are pursuing and treating. Part of the difference is focus of training, another is duration.   Doctors, nurses, nurse practitioners and physicians assistants are well trained, albeit with different focus of study, and thus work ideally in teams as they have complementary strengths.

We will all need patience as our country’s medical professional shortage is met over this next decade (this includes RNs as well). In the meantime, stay tuned for more reflections on healthcare from the travel mirror and take care of your health in this interim period of staffing challenges!

Debra Glasser, M.D., is a retired internal medicine physician who lives in Olympia. Her laughter is infectious. Got a question for her? Write to her at drdebra@theJOLTnews.com