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More Patients Find Doctor Is Not In

Health Care

More Patients Find Doctor Is Not In

More Patients Find Doctor Is Not In

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  • <iframe src="https://www.npr.org/player/embed/129532193/129532184" width="100%" height="290" frameborder="0" scrolling="no" title="NPR embedded audio player">
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As baby boomers age and more Americans obtain health insurance, many health experts predict a primary care doctor shortage. NPR's Julie Rovner discusses her series, 'Primary Care Under Pressure,' and the New America Foundation's Dr. Kavita Patel explores some potential solutions.

NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington.

When we go to the doctor's office, one of the biggest complaints is the wait. And we have some bad news for you, the wait is likely to get longer. Depending on where you live, maybe a lot longer.

There's already a shortage of primary care physicians nationwide. And with the new health care law, there will be tens of millions of new patients.

You may have heard a series of reports of NPR health policy correspondent Julie Rovner last week about the doctor shortage and some proposed solutions. We want to hear your experiences, yes, patients, but doctors, nurses, physician's assistants and nurse practitioners, too. What has changed?

Give us a call, 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, the man who decides on claims from the BP oil spill. If you have questions for Kenneth Feinberg, you can email us now. Again, the address is talk@npr.org.

But first, NPR health policy correspondent Julie Rovner joins us here in Studio 3A. Nice to have you back on the program.

JULIE ROVNER: Nice to be here.

CONAN: And this issue is kind of two-fold. On the one hand, a decrease in the supply of primary care physicians and an increase in the supply of patients.

ROVNER: That's right. We've got it we're getting hit on both the supply and the demand, bigger demand, smaller supply.

CONAN: Why is it so many fewer doctors are going into primary care?

ROVNER: Well, a lot of is it's pretty simple economics. It's expensive to go to medical school. And when you get out, you've got to you usually have big loans, and primary care doctors get paid less than specialists. So you're looking at big loans to pay off. And if you want to pay off those loans, you get paid a lot more if you become a specialist.

Plus, it's hard to be a primary care doctor. The hours are long. The work is difficult. It's, you know, emotionally draining. Plus, there's more and more hassle, if you will, from insurers and bureaucrats and everything else.

So a lot of students go to medical school. And, you know, often they go into medical school thinking they're going to become primary care doctors and then sort of, you know, why bother if I can get paid twice as much to be some kind of specialist.

CONAN: So no shortage of cardiologists, say, in New York or Charlotte, but primary care physicians in Kentucky, that's a problem?

ROVNER: That's exactly right.

CONAN: And so this is highly regional?

ROVNER: It is more regional. But indeed, even in some major cities, there's difficulty finding a new you know, if you move from, say, New York to San Francisco, it can be difficult to find a new primary care doctor.

CONAN: Because they're not taking new patients.

ROVNER: Exactly.

CONAN: So these practices are small. And one of the stories, or some of the stories you did last week were about alternatives to the traditional, you know, single doctor hanging out a shingle.

ROVNER: That's exactly right. One of the ways that there are thoughts of perhaps fixing this problem is making it more attractive for doctors to become primary care practitioners or making it more attractive for doctors who are primary care doctors to stay primary care doctors, perhaps not having them retire early.

It would be this, what they're calling the medical home, where a doctor would think of it as a quarterback of a health care team. And then the doctor would offload some of the things that makes doctors crazy now, some of the paperwork, some of the things that perhaps doctors don't need as much training to do, that they could have a nurse or a nurse practitioner or even a social worker do instead.

It would be better care for the patient, the patient could get different types of care, perhaps, at the doctor's office. The doctor would be freer to do things that only the doctor can do and perhaps have a more sane lifestyle. That's the idea behind the medical home.

CONAN: And still be a lot more intimate and a lot smaller than an HMO.

ROVNER: Yes, this is not an HMO. This is a different type of an organization.

CONAN: There was one you focused on in Maine. Describe it for us.

ROVNER: Well, this is at a place called Martin's Point. It's a large organization particularly of primary care doctors. Now, some of these medical homes have some specialists with them, but this is a particular group of primary care practitioners.

So this is a medical home that really consists of doctor, nurse, medical assistant. And there are nurse practitioners that serve all of the different pods of these primary care doctors.

So they have some specialists, some medical educators. They have an electronic medical record that lets them do a lot of preventive care, a lot of work with their patients. And basically, it makes this very large entity into a series of much smaller entities.

The patients like it better. The doctors like it better. It makes things work a little bit more smoothly. They are moving into a new building. I didn't get into that in the story. Later this year that's designed, that will have a physical design that will make it much easier for them to work in these small teams. Again, it's sort of harkening back to this old, solo provider but in a much more organized sort of way.

CONAN: So some of this is just about efficiency. You're using computers and that sort of thing. You described a chart the doctor had on his wall, saying 98 percent of my patients, I can show this, are controlling their blood pressure.

ROVNER: That's right. Some of it's about efficiency, but that's also about better quality health care for those patients. It's about knowing whose what patient is doing what, and what patient is being cared for.

And, you know, in that case, that was knowing which patients haven't been in and should be. So it's a lot more than just efficiency. It's also about quality.

CONAN: We're talking with NPR health policy correspondent Julie Rovner about her series "Primary Care Under Pressure." You can go to our website at npr.org if you'd like to hear her stories or read the transcripts or some of the blog posts she put up.

800-989-8255, if you'd like to get in on the conversation. Or email us, talk@npr.org. We'll start with Nancy(ph), and Nancy's with us from Moscow in Idaho.

NANCY (Caller): Hi, yeah, I'm a certified professional midwife, and I take care of low-risk women in a rural area. There's also a family there are a couple of family practices in the area who also do OB care.

And I'd like to say that for rural areas, I think CPMs can fill in a lot of the gaps for a very low cost and take some of the burden of large numbers of normal, healthy, low-risk women and provide them care outside of the hospital setting.

CONAN: You said CPMs. That's certified midwives?

NANCY: Yeah, certified professional midwife.

CONAN: Okay, just trying to get through the alphabet soup, which we can get...

NANCY: Sorry.

CONAN: ...into very easily here because all you guys know what all that means, and most of us don't.

Julie Rovner, is this part of the this is part of the solutions that people are working on?

ROVNER: Yes, that was one of the stories I did was about a physician assistant. But indeed, you know, midwives again, nurse midwives, are another one of those mid-level practitioners who do a lot of work, particularly in rural areas, where there are fewer doctors.

But again, a lot of primary care can be provided and is being provided by these mid-level practitioners who are an increasingly important part of delivering primary care.

CONAN: Nancy, are you busy?

NANCY: Yes. I'm getting busier all the time, yeah. I mean, from month to month, I'm getting busier right now.

CONAN: Well, that's good news. Thanks very much for the phone call. Good luck to you.

NANCY: Thank you.

CONAN: Bye-bye.

NANCY: Bye.

CONAN: Physicians assistant, you explained it in the piece, is someone who goes two years to medical school, rather than four, gets a lot of the same training a doctor does, has a lot of the same skills but, well, obviously not all of them.

ROVNER: That's right. Same thing with a nurse practitioner, gets more training than a registered nurse but not quite as much as a doctor. Sort of think of it as a nurse with a master's degree, which is essentially what it is. There are also nurses with master's degree.

Again, they do a lot of primary care. Patients are very happy, frequently. I mean, all of the polling that's been done, you know, shows that patients high patient satisfaction, patients who see nurse practitioners and physician assistants. They know, you know, when they get over their heads, they need to go consult a doctor. They can prescribe drugs in virtually every state, most drugs.

Now, a lot of them are becoming specialists. That's actually also a problem. In many cases, these mid-level practitioners can also make more money by going into specialties. So sometimes you have a problem with them not practicing primary care. But mostly, they do practice primary care, and they are more likely to be in some of those rural areas. And they are, I might add, less expensive. So this is another way to save money in health care.

CONAN: Let's get Greg(ph) on the line, Greg with us from Cedar Rapids.

GREG (Caller): Yeah, I'm a physician assistant. I work in the E.R. here. And I do see a lot of patients that are unable to get into their doctors' offices.

And so we already see a lot of people like that, and I am a little concerned if a lot more people do get insurance that the E.R.s are going to see longer waiting times.

We do a pretty good job in Cedar Rapids to see patients quicker. We actually separate our E.R. into what's called a fast track, and we get patients in and out pretty quickly for minor illness.

But I do think it's a great opportunity for mid-level physician assistants and nurse practitioners to really take advantage of this opportunity and really make a difference.

CONAN: Greg, thanks very much for the call, appreciate it.

GREG: You bet.

CONAN: Bye-bye. Joining us now is Dr. Kavita Patel, a physician in internal medicine. She directs the Health Policy Program at the New America Foundation, which is a nonpartisan public policy institute in Washington, D.C., and she's been kind enough to join us today here in Studio 3A. Thanks very much for coming in.

Dr. KAVITA PATEL (Director, Health Policy Program, New America Foundation): Thank you for having me.

CONAN: Now is this a doctor shortage, or is this a primary care physician shortage?

Dr. PATEL: It's both. But the essence of the primary care physician shortage really has to do with the kind of work that we're asking primary care physicians to do.

So in some parts, as Julie mentioned, we do have a shortage of specialists. That's certainly a problem with neurosurgeons, heart surgeons, et cetera. But the primary care physician shortage has been something that's been looming worse and worse each year.

CONAN: And are the is there any way to address it other than these kind of alternatives we're talking about?

Dr. PATEL: Absolutely. One of the things that I try not to talk about is how many doctors do we need, but more about what should primary care physicians be doing in their day.

Most of what I did when I was in a full-time practice was spend time chasing charts, answering phone calls and trying to track down other specialists. So there was a lot of work that didn't have to do with an actual patient that spent probably up to about half of my day.

And that's where we need to be more efficient and retransform the way we work.

CONAN: So if you'd had a qualified assistant, it sounds like...

Dr. PATEL: Absolutely.

CONAN: ...you could have spent a lot more time with patients.

Dr. PATEL: Absolutely. And also empowering one thing doctors are very bad at is saying when we need help. So part of the idea that Julie touched on in her series that I thought was of use is not that mid-level providers are just useful in areas where there are no doctors, but that we need to start incorporating them into the team more effectively and let me do more of what I want to do with a patient.

CONAN: But she also pointed out a potential problem there. Doctors tend to be control freaks, and doctors would have to give up some of that control, the same way physicians assistants have to accept the fact that there's some things they can't do.

Dr. PATEL: That's right. There's very much a not-in-my-backyard mentality with a lot of my colleagues. But there's enough work to go around, and I think that health reform has shown us we'll have a lot more to do.

CONAN: More on this in just a moment. Stay with us. We're talking about the national shortage of primary care physicians, a problem expected to grow even worse. If you're a patient, if you work in medicine, what is changing? Give us a call, 800-989-8255. Email us, talk@npr.org. Stay with us.

I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington.

Already, some 65 million Americans live in areas with a shortage of primary care doctors. That number is expected to grow as boomers get older and as the new health care law takes effect.

We're talking today about what's driving the shortage and what's being done to address it. We want to hear your experiences, patients of course, but also doctors, nurses, physicians assistants and nurse practitioners. What's changing? 800-989-8255. Email talk@npr.org. And you can join the conversation on our website, that's at npr.org, click on TALK OF THE NATION.

Our guests are NPR health policy correspondent Julie Rovner, her series "Primary Care Under Pressure" ran last week on ALL THINGS CONSIDERED. You can find a link to that series at npr.org. Again, just click on TALK OF THE NATION. Also with us, Dr. Kavita Patel, a physician and director of the Health Policy Program at the New America Foundation.

And let's see if we can go to another caller. And let's go to Ron(ph), Ron with us from Chico in California.

RON (Caller): Yes, thank you. Well, in terms of providing for the volume or numbers of primary care physicians, I think we could take a leaf from the Cuban educational notebook.

Something that I've read about that's recently emerged is what I might call distributed education. That is, instead of having their students exclusively at the medical centers, they have a (unintelligible) set of students who, together with their scholarly studies, began immediately clinical practice in, indeed, rural areas.

And while they're doing their regular studies, to the surprise of the Cuban medical authorities, these students who begin practice in rural settings doing clinical work concurrently with their studies actually do better on the scholarly aspects of medical work. And this in turn, at least for Cuba and a lot of the help that it's giving in other countries, has solved the volume or the numbers needed of physicians.

CONAN: Dr. Patel, do we have something to learn from the Cuban system?

Dr. PATEL: Well, we're actually trying to do some of that. Asnd I'm not sure if it was Cuba or us who did it first, but we're what we're talking about is de-centralizing the way we teach doctors, which is something we've been trying to do, taking things out of a hospital-based system and putting doctors in the very community that they would practice in.

RON: And right from the onset with their studies.

Dr. PATEL: Exactly. So when I started medical school, I was stuck in a classroom all day long, over time. Now, students from the very first day are actually being put into community settings with real doctors, real patients, watching, observing and learning.

CONAN: Ron, thanks very much for the call.

RON: Yes, well, I didn't know that. And I'm glad to hear it. Apparently, it's been done with great success in Cuba.

CONAN: Julie?

ROVNER: Yeah, there's a story that I'm going to be doing later this fall about a medical school in New York that actually is trying to, particularly training primary care students by training them not in the hospital but actually in the community, in primary care practices.

And one of the doctors, I was in a meeting where they were talking about that. And they said, you know, it's hard to train environmentalists in a lumber yard, meaning that when students, when medical students are in a hospital all the time, it's hard for them to envision themselves becoming primary care doctors because primary care doctors don't work in hospitals, they work in the community.

CONAN: Here's an email from Lauren(ph) in Oakland: Why doesn't anyone talk about the AMA and how they control the number of doctors admitted to medical school? If you let more in, you'll get more out.

ROVNER: Well, that's been an ongoing issue. I might add, in the health law, they did do some reconfiguration of what they call the graduate medical education slots.

Now, that's not medical school. That's what happens after medical school, how many residency slots there are. And they actually moved some of those residency slots for specialists back to being primary care residency slots.

So that's going to change a little bit of the configuration of what happens because often what happens it's not so much how many students go into medical school, because remember there are students in medical school in other countries. It's who gets trained to do what kind of specialty.

So really, what controls it is how many medical residents there are. And the hospitals tend to dictate the number of medical residents because it's how many students they need in those specialties.

So you end up with an excess supply of specialists because the hospitals want that cheap labor for those specialties, rather than having enough primary care residents. So it tends we tend to have this oversupply of specialists because of the needs of hospitals, rather than an oversupply of primary care because of what we need, what the society needs to serve the patient base.

CONAN: Let's go next to Leah(ph), and Leah's calling from San Francisco.

LEAH (Caller): Hi, I just wonder if Dr. Patel and Julie Rovner have any thoughts on the problem of overutilization of primary care physicians for problems which really don't need a trip to the doctor's office.

CONAN: Dr. Patel?

Dr. PATEL: Absolutely. So the problem with overutilization and overtreatment, in general, is not unique to primary care. But a great example is when a patient comes in because they were told they needed to see the doctor in three to six months.

I'll get the chart, which takes forever to track down. Even if it's electronic, I have to review it, and then I come to find I actually didn't need to see that patient. But oh, you're here in the office with me, so let me just go ahead and make sure you get X, Y and Z.

Some of that might be necessary. A good chunk of what we're doing probably didn't need to have you come in to see a doctor. So I think as our information systems evolve, and we're putting medical records and getting doctors onto computers. And I think as patients get better information, we'll be able to eliminate and reduce some of that. And that's the inefficiency, Neal, that I'm talking about.

CONAN: All right, Leah, thanks very much. Can I ask also about, there are more and more primary care physicians who have what they call concierge practices.

Dr. PATEL: Yes.

CONAN: And this is where they have a limited number of patients, a small practice of people who pay to have access 24/7 to a doctor. But, of course, this limits their availability to everybody else.

Dr. PATEL: That was one of the first jobs I was offered out of residency was to be a concierge primary care physician for a very high level of executives in a very important company.

And I would have been limited to 250 patients. This is in contrast to my panel size that I had of 2,200 patients. And I would be made available 24/7 to them. And it was a very attractive financial offer. And certainly coming out of residency with that kind of debt, it's very it's something that's hard to pass up.

CONAN: But you passed it up.

Dr. PATEL: I did pass it up.

(Soundbite of laughter)

Dr. PATEL: Maybe much to my parents' chagrin, I passed it up, yes.

(Soundbite of laughter)

CONAN: But this is creaming off any number of primary care physicians.

Dr. PATEL: It is, absolutely, and that's being done, and that's a that seems like a holistic version. There's also some hybrid versions where, if you pay a certain, a flat fee every year, you get a better level of access to your practice.

CONAN: Let's go next to Peter(ph), Peter with us from Madison in Wisconsin.

PETER (Caller): Thank you, Neal, for taking the call. Just a quick, brief comment. My daughter is a doctor. And she always was concerned that the system is too set up to create an industry that is lucrative for doctors by restricting the number of who are admitted.

I know that when she applied to Madison and many other schools, she was among thousands of applicants, and very few selected, of course. But that aside, I think a solution would be many importing other doctors who from other countries who are very well-trained.

And the previous caller mentioned Cuba, for example. Those doctors are very well-trained, and I know that there are some political issues. But still, I know that many of those doctors would be readily available to come to this country.

And there are other countries, as well, that I think train very good doctors who would be very willing to come here. And, of course, we should put them through the paces and all the rigorous testing that we do here. But you would think that they are much further ahead than, for instance, the physicians assistants who are training now and putting actually in line.

CONAN: Julie, there seem to be a lot of people, doctors coming here from abroad already.

ROVNER: Oh, we do import a lot of doctors from other countries, and that's actually much to the chagrin of those other countries that we important them from. We are bleeding dry many other countries of their doctors...

CONAN: And nurses, as well.

ROVNER: And nurses, as well. But one of the interesting things that I discovered, actually in the process in reporting this story, is that in a lot of those other countries, their students want to become specialists, too.

(Soundbite of laughter)

ROVNER: So there aren't that many primary care doctors to import from those other countries, even in some of the sort of less-developed countries. And we're not you know, I'm not talking about, you know, mostly we're getting them from English-speaking countries, you know, from India is a place where we get a lot of our doctors from.

But even, I was talking to one of the doctors who was in charge of primary care development at Martin's Point, the place where I did the medical home story.

And he said even in Africa and some of the less-developed parts of the world, the doctors who are coming out of medical school there, they want to be specialists for the same reasons that doctors, that medical students in this country want to be specialists, it pays better.

(Soundbite of laughter)

PETER: Right, and that gets back to my first point, that the lucrative component of it. So a lot of the selection process is aimed towards folks who are getting into that field for that reason, rather than for a dedication of service to humanity.

So I don't know what is it that we need to change, to inspire good people to stay with it and serve.

CONAN: Well, here's an email exactly to that point, Peter, and thanks very much for the call. This from Travis(ph) in Michigan: As a third-year medical student, why would I want to get into primary care?

Mid-levels are doing more and more for less money and less training. Pay for PCPs, primary care physicians, will only drop as competition increases. For a few more years' training, I will have job security and more pay.

ROVNER: Well, I would agree with Travis except to the extent that I think we're redefining what a primary care physician is doing. I would agree that a lot of what you've seen primary care doctors do, a lot of what I did was not necessary. But I never really practiced to the maximum of what my skill level was. So part of our challenge, I think, especially with health reform, is making this attractive to someone like Travis, who sounds like he would think about doing this if he would actually get paid more.

CONAN: Let's go next to Andy(ph), Andy with us from Jacksonville.

ANDY (Caller): Hi. Thank you for taking my call.

CONAN: Sure.

ANDY: I'm actually an applying medical student right now. And just - I took a year off and I work actually at my father's practice. He's a primary care physician. He's actually a foreign graduate. And there's a lot of interesting things that are going on right now with, I think, foreign graduates and national graduates and how they're placed into the residency program.

And another thing is actually the EMR. I think EMR need to be handled a little more seriously. Like, I think EMR, in some ways, has taken just as a business aspect and not so much as something thats needed in the medical community as much.

CONAN: EMR is electronic medical records?

ANDY: Yes.

CONAN: Okay. Took me a while to figure that out.

ANDY: Okay.

CONAN: And that needs to be applied, as you're suggesting, as indeed Julie's story suggested, widely and not just in hospitals.

ANDY: Yeah. I feel like it's more of like a business solution and not - they don't center so much around what the patient and how - like pharmacies and small practices and hospitals - just I think a better connectivity would be much more useful for everybody.

CONAN: I don't think we could get much argument there. Have you thought about what you're going to specialize in, Andy?

ANDY: No. I actually wanted to do primary care. Again, I work with my father as a primary care in Jacksonville, Florida. And I think what he does is actually -is great because we're bilingual and the growing Hispanic community here in Jacksonville is huge. And I think we need more primary care than anything else.

CONAN: So you see this as something about community and indeed following in your father's footsteps. Do you plan to take over his practice or join his practice?

ANDY: I don't know about his practice in particular because, you know, the way health care is going, you know, I feel like small, private practices are not going to be as successful the day tomorrow as so much as like community physician groups that are controlled, you know, through, you know, hierarchy.

CONAN: So you may join one of those larger groups.

ANDY: Yeah. Just - I mean, maybe for more efficiency and just, you know, not so much commercialized, but just - I don't know, just it would be easier for patients and physicians to understand, you know, where a patient may be, you know?

CONAN: Andy, we wish you the best of luck. Third year is just a piece of cake. Don't worry about it.

(Soundbite of laughter)

ANDY: All right. Thank you.

CONAN: Bye-bye. We're talking about the primary physician care shortage.

You're listening to TALK OF THE NATION from NPR News.

And let me remind you, we're speaking with Julie Rovner, health policy correspondent here at NPR, and with Dr. Kavita Patel, who's director of the health policy program at the New America Foundation.

Email from Gale(ph) in Tucson. Julie, with the shortage of GPs and the trouble of obtaining new GP in care of move or change of insurance, how are insurance companies addressing the problem of referrals to specialists? It seems most of the insurance companies I've had to deal with in the past have required I see a GP gatekeeper before I can get care.

ROVNER: That's an interesting question. You know, most of the companies -insurance companies are having trouble, I think, filling, you know, filling out their panels of having internists or general practitioners or family practitioners to send people to, or to send people to who are taking patients. It is an issue.

If I could go back for a second to what the last caller mentioned, too, about the electronic medical record, that remains controversial. Obviously, there's a big push to computerize medical records. But even just when I was in Maine, you know, talking between the doctors who had the medical records and liked it and the doctors who didn't, I mean, the idea of having the medical record in the exam room with the patient, you know, some patients found it intrusive to have a doctor, you know, typing away in the exam room. But - and yet - and some of the doctors found it intrusive.

On the other hand, that's sort of where you need it if you're going to get the information into that medical record at that point and you sort of need it there, that's where the information has to be input if you're going to use it for what you need to. So there is a big transition that's going on. I mean, we really are seeing, I think, a change in paradigm in the delivery of medical care, particularly the delivery of primary care that we haven't seen, you know, maybe since the advent of antibiotics. I mean, this is a really big change that's going on.

CONAN: Let's get Spencer(ph) on the line, another caller from San Francisco.

SPENCER (Caller): Hi. Thanks for taking my call.

CONAN: Sure.

SPENCER: I'm a second year medical student. And I belong actually to a school that's one of the top 10 producers of family practice physicians. And Im just - every day, you know, you get to see and hear new things that are so exciting. And so I wanted to point out even though most of us will have $400,000 in debt before we start a residency, which accrues interest at approximately eight percent a year...

CONAN: Mm-hmm.

SPENCER: ...there is just the fascination with certain systems. So, you know, I personally want to be a specialist but it's not because of the money. It's more so because I'm in love with, say, the cardiovascular system or my classmate might be in love with orthopedics.

CONAN: And you're right, Spencer, we should not immediately assume just because someone goes into a specialty that they're in it for the money.

SPENCER: Mm-hmm. Exactly. Orthopedic surgery is an 80-hour a week residency for at least five years. So it's not like it's an easier, more lucrative thing to go into. It's definitely for the love of what you're doing.

And I feel fortunate to have professors who every day encourage us and teach us as though we'll be family practice physicians. And a lot of my classmates have, before they started medical school and almost being done, decided to keep with it. But, you know, that's - it's a good point, I thought, that needed to be brought up. And thanks for taking my call.

CONAN: All right, Spencer. Thanks very much.

ROVNER: You know, this caller makes a point though about something that we don't talk enough about in terms of medical schools. He's lucky enough to go to a medical school that seems to pride in producing primary care physicians but all too often there is still this kind of what we call hidden curriculum in medical schools...

CONAN: Mm-hmm.

Ms. ROVNER: ...where primary care is looked down upon and it's not prominently placed within an academic structure and that there is much more of just an emphasis on the specialties. And so, it just influences what people see and do.

CONAN: And finally, this email we have from Tam(ph) in San Antonio. Please stop calling NP a midlevel. Its a nurse practitioner. What do you mean by midlevel, Julie, when you call her?

Ms. ROVNER: Well, that's the medical jargon that is used for the nurse practitioners and physician assistants and certified nurse midwives and they are - that is the...

CONAN: They are considered midlevel as opposed to nurses who are...

Ms. ROVNER: As opposed to nurses - sort of between nurses and doctors.

(Soundbite of laughter)

CONAN: So, all right, that leaves it...

Ms. ROVNER: If they dont want to be called midlevel be called midlevels, I'd like to know what they would like to be called.

(Soundbite of laughter)

CONAN: All right. Julie Rovner, thanks very much for your time as always, NPR's health policy correspondent. Again, go to npr.org and you could find a link to her series "Primary Care Under Pressure." Our thanks again to Dr. Kavita Patel, director of the health policy program at the New America Foundation which is here in Washington D.C. And both of them are kind enough to join us here in Studio 3A.

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