A New Mexico experiment aims to fix the doctor shortage – no new doctors required

August 8, 2012

A primary care resident sees a patient in the District of Columbia (Jahi Chikwendiu -- The Washington Post)

Sanjeev Arora is a Albuquerque-based physician who focuses on the treatment of Hepatitis C patients. Back in 2003, he wasn't an easy guy to get a hold of: Patients waited eight months to nab a spot on his schedule.

"Patients would make about 12 to 18 trips for treatment, and each one might be 200 miles," Arora recalls. "These people were very sick. And we started asking, why is this happening and how can we fix it?"

The explanation was simple: Arora was among a handful of Hepatitis C specialists in New Mexico, which put his services into high demand. The solution was a bit more complicated.

Arora started wondering whether some of the care he delivered, largely diagnosing Hepatitis C and monitoring subsequent treatment, could be delivered by primary care doctors elsewhere in the state. It would save patients the long trips across the state, not to mention free up Aurora's own schedule.

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.

The whole idea, Arora says, is to rethink how health care can best be delivered from a distance. Telemedicine -- where doctors see patients via Webcam -- is one way to increase access in rural areas. But it doesn't necessarily increase overall capacity: A Webcam appointment with a patient 3,000 miles away takes just as long as one conducted in the office.

Arora wanted to find a way to increase capacity, enabling the health-care system to deliver more of the care that patients needed. That's why he decided to work with primary care providers, rather than the patients they see: Armed with the necessary knowledge, they could see way more patients than Arora ever could squeeze into his Albuquerque clinic.

"No patient every comes into this network," he explains. "We have primary care clinicians who are committed to being mentored and learning these skills."

Workforce capacity is a big issue for the health-care system right now: The country is expected to have 63,000 too few doctors to meet its health care needs by 2015. Project ECHO suggests one way to increase the capacity of the health-care system without adding a single worker.

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. Hepatitis C, for example, fits this bill nicely: It caused over 15,000 deaths in 2007. Treatment often consists of a number of self-injected anti-viral drugs. The medication is potent, and physicians are needed to monitor for harmful side effects.

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.

"You can't be an expert in everything," he says, "But you can take on an area of special interest."

Moving that kind of treatment looks, so far, to have been a success. A study last year, in the New England Journal of Medicine, found that Hepatitis C patients had equally good outcomes to those treated in an academic medical center by a specialist. Doctors also felt more confident treating their patients than they had prior to the program.

Physicians in the Project ECHO Network may start off consulting with Arora on each Hepatitis C patient that comes through their door. But over time, he has found himself spending less time consulting with his trainees, who he thinks of as "junior specialists." A separate study showed doctors in Project ECHO to become significantly more confident in their ability to diagnose and treat Hepatitis C patients than they were prior to the program.

Access looks to have expanded, too. Arora can see it everyday, in his own schedule: Ever since Project Echo began, his wait times have dropped from eight months to a few weeks.

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Dylan Matthews · August 8, 2012