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Would a Nursing Home Physician Specialty Resolve the Workforce Crisis in Long-Term Care?
- Paul R. Katz, MD;
- Jurgis Karuza, PhD; and
- Vincent Mor, PhD
- From University of Rochester School of Medicine and Dentistry, Rochester NY, 14620, and Brown University School of Medicine, Providence, RI 02912.
IN RESPONSE:
Although the authors of these letters seem to agree about the need for physicians with the knowledge and skill set unique to nursing home care, they each describe several challenges, including the complex organizational, quality improvement, team management, and regulatory interface that is required.
Dr. Phillips and Dr. Villa note that the industry must take a central role in defining the priorities for medical practice. A first step is establishing quality metrics, such as preventing rehospitalization and assuring seamless care transitions. As Dr. Phillips suggests, full system reform will take decades to implement. Still, these new metrics can be used to reward high performers, whether through a pay-for-performance mechanism or through avoidance of survey citations.
We agree with Dr. White and colleagues' contention that physicians are the practitioners best trained to manage the care of nursing home residents. Rather than resorting to alternative care models that rely predominantly on nurse practitioners or physician assistants, the focus should be on physician recruitment, retention, and performance. As Drs. Libow and Wolf-Klein point out, a 2-tiered approach to caring for frail elderly persons must be vigorously debated. Although nurse practitioners can provide quality care, the benefits of collaborative models of care that include physicians remains largely unexplored (1).
Populating the physician nursing home workforce will require that trainees have contact with high-quality teachers. We agree with Drs. Libow and Wolf-Klein, Dr. Villa, Dr. White and colleagues, and Dr. Freedberg that nursing home physicians who demonstrate commitment and competence are ideal role models. Currently, internal medicine residents often graduate without ever stepping into a nursing home. The fact that many of these residents become hospitalists, a specialty in which knowledge of the continuum of care is critical, cries out for reforms from the Accreditation Council for Graduate Medical Education.
Dr. Freedberg is right that nursing home physicians get no respect. This underpins our rationale in calling for the creation of a nursing home specialty. Instead of fearing a “silo mentality,” as Dr. Phillips suggests, specialty status can be an effective first step in evoking credibility and attracting physicians to the field.
Defining the prerequisites for a nursing home specialist remains a challenge. Dr. White and colleagues aptly point out the risk for excluding physicians who spend only a small percentage of their time in nursing home practice. We chose 20% as the minimum threshold because of evidence from settings other than long-term care that demonstrates a relationship among competency, patient volume, and experience (2, 3).
Paul R. Katz, MD
Jurgis Karuza, PhD
University of Rochester School of Medicine and Dentistry
Rochester, NY 14620
Vincent Mor, PhD
Brown University School of Medicine
Providence, RI 02912
Article and Author Information
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Potential Financial Conflicts of Interest: None disclosed.
