Multiple issues compete for headlines: immigration reform, nursing PhD programs, physician extenders, and California's high school exit exam. How do these topics impact our concerns? They indicate a physician shortage.

The effort by Congress to address immigration ignored its impact on physicians. If some form of guest worker program becomes law, demand for physicians will soar. The number of guest worker immigrants could reach 100 million over 20 years, according to The Heritage Foundation.

In the meantime, the California Medical Association and UC San Francisco are monitoring physician supply in California, and the trends aren't good. Young physicians with exorbitant debt exceeding $125,000 are choosing specialties that earn high per hour incomes. Young physicians value a comfortable lifestyle and are working fewer hours. And physicians are generally retiring at earlier ages. The net result is a reduced supply of physicians.

The University of Texas and the UC system suggest one answer to increasing healthcare supply--a PhD in nursing, adding another form of physician extender to physician assistants and nurse practitioners.

Patients often come to my office demanding to see a specialist. I refer them to the consultant and receive a written consultation from the PA or NP of the consultant. Ironically, specialty care consists of visits to the specialty physician extender.

Earlier in my family medicine career, I assisted in surgery and cared for inpatients on a routine basis. Now the PA or NP assists and hospitalists care for inpatients.

With time, will extenders demand increased scope of practice to include independent practice from specialists? With primary care extenders referring to specialty extenders, where does that leave the medical profession? Will surgical extender programs emerge as well? Will extenders open their own clinics, surgical centers and hospitals?

The extender trend suggests that healthcare access can be improved by reducing the educational requirements to practice medicine. California's lower courts took the first step in this regard. They decided that the exit exam for high school students discriminated against some adolescents. Therefore, those students should not have to pass the exam to graduate. Arguments abound to challenge this decision, and the final ruling is pending.

The issue revolves around competency. Can we assess competency by examinations? Is it fair to demand that people pass the Bar Exam to practice law or the National Board Exam to practice medicine? Should mere attendance at an educational institute qualify a person to practice?

In concierge practices, patients are paying extra to see a practitioner who received a medical degree. The experiment by internists and family practitioners could expand to subspecialty care. Endocrinologists, neurologists and rheumatologists could establish access fees.

Will the delivery of medical service separate on the ability to pay? Will the immigrants choose a physician or an extender? Will the wealthy, retiring baby boomers pay directly for physician care?

We need economic deregulation to allow patients to determine where they spend their medical dollars.

Lytton W. Smith, MD, editor for the OCMA, is a physician practicing family medicine with the St. Jude Heritage Medical Group in Yorba Linda. Dr. Smith welcomes feedback on his articles and can be reached at editor@socalphys.com.