In order to meet the healthcare needs of populations at the local, national, and global levels, we’re going to need to think carefully about which providers can do which kinds of tasks. Pieces in Washington Post and New York Times blogs this week highlight projects that reconsider what kinds of providers patients need to see to get care for particular conditions.
In the Washington Post’s Wonkblog, Sarah Kliff describes efforts by Albuquerque physician Sanjeev Arora to make Hepatitis C treatment available to patients across New Mexico. Arora is one of a small number of Hepatitis C specialists in the state, so his schedule would be booked months in advance and many of his patients would be traveling long distances to see him. (Hepatitis treatment, Kliff explains, often requires ongoing physician contact to monitor for harmful side effects of potent anti-viral drugs.) Rather than trying to increase the supply of specialists, Arora created a model for turning primary-care doctors into Hepatitis C treatment specialists (semi-specialists, perhaps?). Kliff writes:
Arora reached out to primary care doctors across the state and found 21 that were interested in additional training on how to treat Hepatitis C themselves. They began holding weekly video-conferences, where the primary care doctors peppered Arora with questions about diagnoses and a subsequent treatment plan. Then, they went back to their clinics and delivered the care themselves.
A subsequent study would show that care to be just as good as what was delivered in an academic medical center — minus the 400-mile round trip.
“Normally, the doctor would tell the patient ‘now you have to go Albuquerque’ and make 18 trips there,” Arora says. “Now, his doctor can say, ‘I can treat that here.’ The primary care clinician serves as the specialist.”
His experiment in medical learning collaboratives, dubbed Project ECHO, is now used by everyone from the Department of Defense to the Brazilian health-care system. Last month, he received a $8.5 million federal grant to use Project ECHO with 5,000 Nevada and Washington state residents.
…Arora’s project, now housed at the University of New Mexico School of Medicine, currently works on 15 conditions that range from asthma to palliative care. Specialists host weekly video conferences with primary care doctors across the state on a set schedule. Hepatitis C trainees meet from 8-10 a.m. on Mondays, followed by primary care doctors learning about rheumatoid arthritis.
Project Echo focuses on common diseases that cause a high number of deaths and could easily be managed in a primary care settling. … The idea isn’t necessarily to make every primary care doctor well versed in all 15 diseases. If one doctor focuses her time on learning about Hepatitis C but has a patient with asthma, she can ideally send that patient down the hall to another doctor with that skill set.
Places with the most severe provider shortages are coming up with approaches that are even further outside the box. In the “Fixes” series of the New York Times Opinionator blog, Sarika Bansal describes a medical licentiate program that’s training clinical officers in Zambia to perform basic surgeries like caesarian sections and hernia repairs. These providers have at least five years of clinical experience when they enter a three-year program for limited surgical training; they commit to working for at least three years in a rural or otherwise high-surgical-need area after finishing the program. While handing scalpels to providers who are trained significantly less than surgeons is not something to be done lightly, the alternative for many people is going without surgery altogether. Bansal describes Zambia’s provider shortage this way:
Zambia has only 44 fully licensed surgeons to serve its population of 13 million, who are spread over an area slightly larger than Texas. …Only 6 of Zambia’s 44 surgeons live in rural areas, and all of them are expatriate missionaries. “Most doctors that are trained in Zambia don’t want to work in the rural areas, though they’re needed there more than anywhere else,” said Emmanuel Makasa, the deputy director of emergency health services at the Ministry of Health.
Fully licensed doctors are also in high demand in other lines of work. Some leave public sector clinical practice to pursue careers in administration, private clinical practice and international NGO work — all of which can be more lucrative. “People will pay me more to speak about H.I.V. than to save dying surgical patients,” said Nthele, the surgeon in Livingstone. Other doctors leave Zambia altogether for higher pay in more industrialized countries.
Bansal reports that the program, which started training providers in 2002, has produced 117 medical licentiates, and 116 of them are now practicing in public-sector facilities across the country. No peer-reviewed articles on the program have been published, but results in Malawi and Somalia, where less-trained providers are also performing selected surgeries, indicate that post-surgical mortality rates are comparable to those of fully trained surgeons.
Such “task shifting,” as it’s called, must be done carefully and with full consideration of potential risks. But we should also be clear about the downsides of the status quo, in which millions of people worldwide can’t get the care they need.