Cheryl L. Phillips, MD, CMD
Potential Financial Conflicts of Interest: None disclosed.
Phillips CL. Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?. Ann Intern Med. 2009;151:429. doi: 10.7326/0003-4819-151-6-200909150-00010
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Published: Ann Intern Med. 2009;151(6):429.
TO THE EDITOR:
Katz and colleagues (1) present a provocative and appealing model to address the challenge of attracting committed and trained physicians into nursing home care. The barriers to such practice are already assumed. In a 2006 report, Katz and Karuza (2) noted that only 1 in 5 physicians who were identified as primary care physicians reported any involvement in nursing home care, and that those who were involved averaged only about 2 hours per week. Furthermore, the 2005 survey of the American Medical Directors Association (AMDA) (3), the national association of approximately 4000 nursing home medical directors, found that 18% of member respondents had reduced their attending physician hours in the preceding 3 years and that 7% had stopped working as an attending physician in nursing homes entirely (3). Although assumptions abound as to why physicians do not seek to provide care in nursing homes, Katz and colleagues make clear that nursing home care differs from other health care settings. The individual patients are often the same ones whom primary care physicians saw in their office the week before, or even discharged from the hospital the day before, but the domain of the nursing home is complex and highly regulated. It is a team-based dynamic that many physicians have little experience or comfort with. It requires knowledge of the regulatory world, the skills of functional assessment and rehabilitation, and the ability to integrate patient and family goals into care plans that may extend into years, rather than the few days typical of the short-term hospital setting. In addition, the nursing home population is not homogenous by age, goals of treatment, or functional limitations. The nursing home is an ideal setting to apply clinical skills in the care of complex patients in the context of person-centered values over an extended time frame. But without the knowledge, vocabulary, and training required in any unique specialty or system of care delivery, the challenge for most physicians is simply daunting.
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