Supply and Demand theory should not rule the medicine world.
Supply and demand: the oversimplified algorithm of any free market enterprise. When there is shortage in supply and/or swelling of demand, the value of an item becomes inherently inflated. The market may respond to such fluctuations with alternative replacements that are more accessible or reproducible and thus more cost-effective. It’s a tale as old as time and an underlying theme of this great nation – but what happens when there are competing variables that are non-financial? When free market enterprise clashes with individual well-being? Well, some may say this represents the unfortunate setting of modern health care – a notion perhaps best illustrated by the pseudo-battle of physician versus mid-level providers.
For the past several years, as with many specialties, the shortage of board-certified dermatologists has steadily risen. Not surprisingly, this has led to an explosion of non-physician clinicians within the field. When used correctly, these “mid-levels” can be masterful instruments of efficiency, extending the reach of an overextended physician. Patients see shorter wait times and improved accessibility; physicians see less redundancies and amplified care delivery. As with most things, however, such benefits may come with unforeseen ramifications.
The evolution has been slow but unmistakably persistent, with midlevel providers ever growing their presence within the field. Growth not only in number of provider numbers but also in terms of scope and responsibility. What started as “straightforward follow-ups” transitioned to “all established patients” and eventually “every level of service.” Likewise biopsy led to excision and neurotoxin…filler injection. In the most American fashion, we exploited the aforementioned benefits of our extenders and perversely created a faux-physician “provider” – one that has become harder and harder for patients to distinguish. And to be blunt, such “provider” confusion is truly inexcusable.
Mid-levels do not receive the training that is necessary to function as independent dermatologists. A practicing NP or PA in dermatology requires roughly five to six years of study, none being dermatology-specific. Further, there is but one dermatology “NP fellowship” in the United States and zero such equivalents for PAs. Instead, the vast majority of mid-levels are primarily trained on-the-job by fellow nurses and other medical professionals, leaving no procedures of standardization or competency assessment. What’s worse, many nurse practitioner degrees can be obtained online without any additional clinical training but rather with significant focus on health policy and administration. In total, mid-level providers often finish their degree with just 1,000-1,500 hours of clinical training, potentially 0 of which taking place in dermatology.
In contrast, the training of a board-certified dermatologist involves twelve years of study and over 12,000 hours of practice, the majority of which being specific to their field of expertise. Overall, the education consists of 4 years undergraduate (e.g. basic science), 4 years medical school (MD/OD), 1 year preliminary (e.g. internal medicine), and 3 years dermatologic residency. Furthermore, dermatologists may then pursue post-residency fellowships of 1-2 years in subspecialties such as Mohs Surgery, Aesthetic Medicine, Dermatopathology, and Pediatric Dermatology. Equally important to duration, the training curriculum is standardized across programs and includes rigorous assessment that ensures basic competency prior to board-certification.
So supply, demand, worth, and cost – these are all integral components to a functional economy. In order to effectively communicate these principles, we rely on systems of currency or legal tender. Money allows comparison of objects that are otherwise incomparable (e.g. the value of toilet paper versus school tuition or an apple versus an orange), but this is only possible through the use of a universal metric. Well, just as there’s a difference between US and Canadian dollars, medical “providers” are in no way an interchangeable currency – though some would suggest otherwise, in what I call healthcare racketeering.