One Size Does Not Fit All: Balancing Individual and System Needs in Primary Care and Beyond

Abstract

In this issue, Dewan and Norcini invite readers to reconsider the basic minimum standards for independent primary care practice. Their willingness to push boundaries, question turf wars, and suggest innovative ways forward is laudable. Although their piece is timely and provocative, it does not fully consider the interplay between individual and system factors that influence people to pursue different kinds of degrees and practice in this context. In this Invited Commentary, the authors discuss imperatives that are underacknowledged by Dewan and Norcini: the importance of diversity in health system planning; status, power, and privilege; the extension of their argument beyond primary care; the conflation of time in training with competence; and important issues of distribution of health care resources. Ultimately, the authors argue that there may be strength in diversity, one that should not be obscured by attempts to normalize training time.

Elsewhere in this issue, Dewan and Norcini¹ consider the amount of training needed to be an effective, independent (or relatively independent) clinical practitioner in primary care in the United States. To do so, they examine a “natural experiment” that has taken place with physicians, nurse practitioners (NPs), and physician assistants (PAs) all providing primary care services in the United States, while arriving at independent practice through different training pathways. While the authors acknowledge up front that the literature on this topic is neither large nor robust, their interpretation of the available data is that the quality of care provided by these different practitioners appears to be comparable. Dewan and Norcini conclude with a call for more research looking at how much time is required to properly train practitioners in diverse areas of medical care, as well as a plea to move beyond “turf battles” between professions to address the severe shortage of primary care providers in the United States and ensure high-quality care.

We want to thank Dewan and Norcini for bringing up this important topic, and for challenging the traditional turf wars between professions. Their inquiry raises important workforce planning and policy implications, all with significant downstream effects on patient care.

We found many aspects of Dewan and Norcini’s argument interesting and provocative. One key thread in their argument is about the costs of training, both for individuals and for the system, in terms of efficiently filling the primary care gap in the United States. If equivalent primary care is provided by NPs, PAs, and physicians, they suggest, it may not be worthwhile for individual trainees to invest in advanced degrees or for systems to invest in professionals who are more expensive. Their “tallest giant” metaphor suggests that current requirements for primary care physician training are excessive and that other, more efficient ways of training primary care providers should be used preferentially. Although looking for efficiencies is always important in resource-strapped health systems, we were somewhat surprised that Dewan and Norcini did not refer to the large body of literature about effective, efficient, and equitable primary care systems.^2,3 This literature shows that strong primary care systems are complex, multidimensional, and multiprofessional. Simply choosing the cheapest primary care provider training option among several others might not meet the potential of primary care as the “linchpin of effective health care delivery”^2(p1) or provide optimal patient outcomes.

Although the authors do not mention or cite the World Health Organization (WHO), their suggested approach to the U.S. problem of a primary care provider shortage shares much with the WHO’s goal of universal health coverage by 2030.⁴ The details of the WHO competency framework for health workers are still being finalized, but certain principles are known. One of these principles is that health workers’ competencies should not be profession-specific. Instead, the analysis of needs and gaps is left to be determined at a country level, and competencies distributed accordingly. Like Dewan and Norcini, the WHO tries to move away from professional turf battles and focuses instead on appropriate redistribution of tasks.^4,5

In seeking efficient approaches to training, Dewan and Norcini suggest a new group of potential primary care providers: medical school graduates who failed to match to a U.S. residency position. Raising issues of fairness, they suggest that these graduates have already individually invested time and money that exceeds that invested by NPs and PAs who are allowed to practice independently upon graduation. The unmatched medical school graduates, in this logic, “deserve” the opportunity to practice. Allowing them to provide clinical care is thus positioned as feeding two birds with one scone: filling a health system gap for primary care practitioners and minimizing individuals’ expensive and otherwise wasted training years.

Interestingly, this framing touches on—but then skirts around—major controversies related to power and hierarchy in health care systems and across health professions. For instance, MD salaries—even those of primary care physicians—are significantly higher than those of PAs or NPs. MDs also have more status in society than their NP and PA colleagues. In raising arguments about replacing MDs, Dewan and Norcini’s article opens up a highly contentious conversation: What aspects of clinical practice are (or should be) exclusively reserved for MD providers? Would the implication then be that these activities require MD expertise, status, power, and privilege? How would this help diminish preexisting turf wars?

Importantly, while the authors focus solely on primary care provision, a discussion about the efficient division of medical tasks should not end there. Why not reconsider all health care sectors and include further scope redefinitions?⁶ If NPs, PAs, and failing-to-match-to-a-residency-spot MD students are all potential replacements for MDs in primary care, who else, where else, and how else might these providers also replace MDs across the spectrum of health care? Given the reality of professional boundaries and hierarchies that remain very much alive and at play in health professions education and health care institutions,⁷ will calls for action overcome institutional structures? If not, what kinds of restructuring at educational and health care institutions might be necessary to create such change?

Another important question to consider is whether the nature of the training received by MDs who did not match is appropriate and adequate for primary care. Because only a small percentage of medical students in the United States choose family medicine as a specialty, can we guarantee that the residency training others have received has prepared them to deal with the undifferentiated symptoms that primary care providers face daily? If a student fails to match to radiology, gastroenterology, obstetrics, or ophthalmology as their choice, for example, will they have the interest in and skills for independent practice in primary care? Or might the system not benefit more if they were given the specific skills training necessary to be successful radiography technicians (drawing on artificial intelligence technologies),⁸ colonoscopy technicians, C-section technicians, or cataract surgery technicians?^9–11

Somewhat puzzlingly, Dewan and Norcini’s argument about the time-to-practice question partially conflates time in training and competency, and it is at odds with much of the current competency literature. First, they suggest that a PA or NP is—so far as can be ascertained by their review of the literature—as competent as a primary care physician, while spending less time in training. Then they suggest that an MD who fails to match to a residency program has spent more time in training and is therefore likely at least as competent as a PA or NP who has spent less time in training. Can we assume that a person who completed medical training but did not match to a residency position is systematically more competent than an NP or PA? Or might the failure to match into a specialist residency position be an indicator of other issues, at least in some not insignificant number of cases?

While we heartily applaud the authors’ bold and brave foray into these contested waters, we suggest that focusing on individual practitioners to solve primary care provision issues will not suffice. More consideration should be given to the specifics of health care structures and contexts. In our urban Canadian context, for instance, decisions about residency spots are made by provincial governments in line with expected population needs, and just under half of those are currently designated for family medicine. Yet, primary care physicians do not work alone; they work interdependently to provide team-based care as appropriate for individual patients with nurses, NPs, pharmacists, social workers, dietitians, physiotherapists, and occupational therapists. While an important first step, taking a population approach to assigning residency positions does not in and of itself fix health care gaps. Some rural and many remote parts of Canada have highly inadequate health care services available to persons with great health care needs. Beyond mere numbers of primary care providers, issues of distribution of resources are critical; and here, individual preferences may clash with system needs.

Comparisons across health systems and contexts can add nuance and clarity to understandings of the complex interplay of issues and values in these contested spaces. As an international community of health professions educators and researchers, we need to recognize tensions that must be balanced and managed. There will always be tensions between individual goals and systems goals. Balance must be found between time in training and competency. When looking at what constitutes a reasonable health workforce mix, different decisions will be made in different contexts and cultures. Our field has had a tendency to focus on that which is similar, standardized, or universal. When it comes to issues around health workforce planning to support population health needs, perhaps it is time to pay more attention to differences. If we are willing to do so, we may find that there is a lot to learn from each other, perhaps even seeing ways to move toward less hierarchical health workforce structures in which diverse health workers interact and provide care based on population needs.

Acknowledgments: The authors gratefully acknowledge the support of Mary Beth DeVilbiss and Carrie Cartmill in manuscript preparation.