Chattanooga area doctors make changes amidst nationwide shortage

Physician's assistant Devony Webster talks with patient Amy Hill Tuesday, March 1, 2016 at UT Erlanger Primary Care on Lookout Mountain.
photo Nurse practioner Megan England checks a chart Tuesday, March 1, 2016 at UT Erlanger Primary Care on Lookout Mountain.

The UT Erlanger Primary Care clinic on Lookout Mountain looks like any other doctor's office around town.

A receptionist greets patients from behind a glass partition. The eight examination rooms feature typical beds, blood pressure machines and cabinets for medical supplies. Employees sit at computers, entering data into patients' records, and the staff bustles around with purpose.

The only thing missing is the doctor.

"Dr. Bill Moore Smith comes by on Wednesdays," physician assistant Devony Webster explains. "He's our supervising physician. We can shoot him a text anytime, and he is always available by cellphone."

According to health care experts, the Lookout Mountain clinic is where the medical profession is heading, at least for the average person with a cold, banged-up elbow, low blood sugar or high blood pressure.

A shortage of doctors outside big cities means more and more patients with routine medical problems won't be spending much time with their doctors, unless it's over a video connection. And much of the basic medical care will be done by trained physician assistants and nurse practitioners.

"We are trained to treat appropriately and seek that second opinion if it goes beyond the scope of our practice," Webster said. "We are an extender of the physician's services."

"Patients with minor illnesses or needing general checkups for blood pressure or medication refills are usually fine seeing only the midlevel provider," said Smith, who is perhaps best known as the "Moc Doc," the physician for University of Tennessee at Chattanooga sports teams.

So say goodbye to your family doctor and hello to your local physician assistant and nurse practitioner.

You may not even mind the change.

"She will spend time with you, unlike my past doctors," said Amy Hill, a patient who saw Webster on a recent afternoon. "She will go out of her way to explain what she is doing."

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The physician shortage and rapid advances in technology are transforming what it means to be a family or primary care doctor, health care experts agree.

"The entire system is undergoing tectonic shifts in payment and structure," said Dr. John Graves, assistant professor at Vanderbilt University School of Medicine. "At the same time, technological and medical innovation continues while the population is becoming older, more chronically ill and more insured."

Whether there is an overall doctor shortage is debatable.

A 2015 report by the Association of American Medical Colleges concluded that an additional 46,000 to 90,000 doctors will be needed in the U.S. by 2025.

"When we look at Tennessee, we currently have 4,072 primary care providers," said Dr. Muneeza Khan, interim chairman of the residency program of the University of Tennessee Health Science Center's Department of Family Medicine in Memphis. "In order to maintain the status quo, we would need 1,107 [more doctors] by 2030, a 20 percent increase from our current level."

But other experts say the issue is more one of distribution than numbers.

"I think it's safe to say that to the extent there is a loose consensus, it's that there is a maldistribution of physicians across different geographic areas, with physicians less accessible in rural areas," Graves said.

Overall, the number of doctors graduating from medical school has increased from about 16,000 in 2006 to 18,700 in 2015. But the number of people needing health care keeps growing at a faster pace.

"As we baby boomers get older, we need more health care," said Dr. Jonathan Lewin, executive vice president for health affairs at Emory University. "As compared to a generation ago, baby boomers who are getting to the Medicare age range have a much greater number of chronic illnesses."

Part of that is good news, Lewin said.

Advances in treating cancer and heart disease mean illnesses that would previously have been fatal are now chronic, controllable with regular medical care. But the epidemic of obesity and its accompanying problems of high blood pressure and diabetes is threatening to reverse that progress.

"Patients are developing high blood pressure at earlier ages, and obesity rates are going up across the country," he said. "And that is contributing significantly to the amount of care patients need as they get older."

In addition, the Affordable Care Act has meant more Americans are insured and likely to seek health care.

Medical schools have responded by increasing their class sizes and adding more scholarships, Lewin said. But there is still a bottleneck in terms of the number of medical school graduates who find places to practice, because the federal government has been slow to increase the number of residency positions at hospitals.

After graduating from medical school, most physicians spend from three to seven years, depending on their specialty, in a residency, gaining practical experience working at a hospital under the supervision of a doctor. But those positions are largely paid for by the Medicare program, Lewin said. And the government has not increased the funding since 1996, according to the American Hospital Association.

Additionally, doctors tend to end up in urban areas, because that is where most patients are located. But research shows doctors also tend to remain in the cities where they do their residencies, so some states have tried to lure physicians to their areas by boosting state-funded residency positions.

"What has been shown is that when someone trains at a program at a certain location, they are more likely to stay in the area," Khan said. So the University of Tennessee has developed residency programs in Chattanooga, Knoxville, Murfreesboro and Jackson, as well as in Memphis.

Some states also are adding more medical schools, according to Dr. Barbara Ross-Lee, dean of the New York Institute of Technology College of Osteopathic Medicine. Her school is launching a medical school in partnership with Arkansas State University, where some of the lectures will be shared via video link between the two locations, reducing the cost of the school.

The team-based approach, combining doctors with physician assistants and nurse practitioners, will be a big part of the new school's program, Ross-Lee said.

"Private practice is disappearing, and you are seeing many more groups that include non-physician members as part of the team," she said.

Where in the past, family doctors' practices were often independent, many are now connected to local hospitals.

The physician assistant specialty got its start in 1965, in part because medical corpsmen with extensive field experience in the Vietnam War began returning to civilian life. Without medical degrees, they could not use their experience in the U.S., but Duke University Dr. Eugene Stead realized they had valuable skills and were useful as assistants for physicians. He started a program for a two-year degree with an initial class of four Navy medical corpsmen, according to Yale University.

Today, the specialty is booming.

The average pay in 2014 was $95,820, according to the U.S. Bureau of Labor. The number of openings is predicted to increase by 30 percent by 2024, a rate the Labor Department calls "much faster than average."

While the specific things physician assistants are allowed to do depends on the state and area of practice, in general, they can do many of the tasks done by a typical family doctor, including examining injuries or illnesses, ordering diagnostic tests, prescribing medicine (except for Schedule II narcotics such as oxycodone) and setting bones or providing immunizations.

"For common injuries and illnesses, there is no difference in what we provide and those provided by a physician," said Webster, who was a field medic in the Army and spent seven years as a licensed practical nurse before getting her 27-month physician assistant degree at Emory.

Nurse practitioners have similar skills to physician assistants, with a few key differences. A nurse practitioner is a nurse with a master's degree, who can perform examinations and write prescriptions, in most states. While physician assistants work under the supervision of a physician, a nurse practitioner can operate more independently, although many are now working as team members in a doctor's practice.

Average pay nationally for nurse practitioners is about $95,350, according to the Department of Labor, with a projected 30 percent increase in jobs available over the next 10 years, very similar to the prospects for physician assistants.

"Comparing a PA and an NP in Georgia and Tennessee, the practices are very similar," said Megan England, a nurse practitioner at the Lookout Mountain clinic. "The NP focus is more on the caring, holistic model, but you get the same end result."

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While the team approach is helping doctors' offices see more patients, technology is allowing them to see more patients farther afield.

As Internet speeds and inexpensive video cameras have improved, more and more doctors are using video connections, commonly called "telemedicine," to see patients remotely.

"It's so good you forget the doctor is not in the room with you," Ross-Lee said. "The images are real life-size, you're not just looking at a little picture."

Khan said telemedicine can really help give patients in rural areas access to specialists.

"It widens the pool of physicians who are available to patients without them having to travel long distances to get to a place where they can get medical care," she said.

But it's not without its own challenges.

Not all insurance companies will pay for sessions conducted by telemedicine, and some state laws that bar doctors from practicing in states where they are not licensed (such as a Chattanooga doctor connecting with a North Georgia patient) need to be reviewed, Khan said.

The next wave of technology is boosting doctors' ability to monitor patients remotely, and that will also allow them to work more efficiently, Lewin said.

A proliferation of sensors, including bracelets such as Fitbits that monitor a person's movements, Internet-enabled scales, blood pressure devices, and pacemakers connected to the Web already are available.

"A patient can get engaged in their own care - they can weigh themselves, take their blood pressure and then send all of that data over the Web to health care providers," Lewin said.

"It's a number of years away, but I believe it is coming," he added. "We'll see savings in both cost and physicians' time and resources."

In the end, most of us may not care whether the name tag on the person examining us ends with "MD," "PA," or "NP."

"She knows as much as my past physician," Hill said of physician assistant Webster while sitting in the Lookout Mountain clinic examination room. "To me, she is a doctor."

Contact staff writer Steve Johnson at, 423-757-6673, on Twitter @stevejohnsonTFP, or on Facebook,