How to fix the primary care shortage

by John Horstkamp, MD

The primary care physician (PCP) shortage has attracted a lot of attention recently, and for good reason. Individual Americans are concerned that they will not have timely access to needed medical care, and policy makers are concerned that our specialist-heavy medical system is failing, giving us expensive but disjointed, poor quality care. Many experts rightly think that a robust primary care system would give us better health care for less money. But a thriving general medicine sector is a pipe dream unless we can convince many more medical students to choose careers in general internal medicine or family medicine. How can we do this?

First, why is there a PCP shortage? Why do medical students avoid primary care? The two main reasons are money and working conditions. Money is the more important reason. PCPs earn much less than specialists. It varies by specialty, but a rough approximation is that PCPs earn about $100,000 less per year, or about $3 million less over a career. A study in the Journal of the American Medical Association in 1989 found that the fill rate for residencies in a given specialty was highly related to starting salaries in the specialty. The same author repeated the study in 2008 and got the same results. The main factor influencing medical students’ specialty choice is expected future income.

Working conditions are a problem for many PCPs, for many reasons. Medicine has become more complex over the last several decades, and a typical PCP now sees more elderly patients and those suffering from multiple medical problems. The administrative burden has also worsened significantly. And the shortage of PCPs puts more work on the shoulders of those that remain in the field. These factors and others make for difficult work. Indeed, in a recent article in the Annals of Internal Medicine, 48% of general internal medicine doctors and family physicians termed their work environment “chaotic.” Medical students are aware of this situation, which is not nearly so bad in many specialties, and so they avoid primary care.

What can be done? Some have proposed loan forgiveness. This might help a bit, but a repayment of $200,000 or less in educational loans is small compared with $3 million in foregone income. Others have suggested training more mid-level providers, such as physician assistants and nurse practitioners, to fill the gap. These providers certainly have a role to play, but a general medical system with little physician leadership and labor would be a step into the unknown. Certainly other advanced countries have not embraced such a system. The American College of Physicians has proposed the Patient Centered Medical Home, a concept that aims to allow doctors to use practice organization changes and information technology, among other things, to improve care and doctor satisfaction. Although this idea has attracted much attention from political decision makers, whether it will actually work is questionable. It will take years to know. Policy makers routinely propose such things as more training spots for PCPs and opening more Community Health Centers. These efforts are unlikely to do much good; the problem is a lack of doctors, not a lack of jobs for them.

This year has seen a proposal to increase Medicare payments to primary care doctors by as much as 8% in 2010. While this is a step in the right direction, whether medical students will be impressed remains an open question. The best thing to do to get more family doctors is very simple, although not very pleasant for a debtor nation in economic crisis: we must increase the pay. A significant increase in reimbursement, in the range of 30% to 70%, would attract more medical students. This would lower the burden on the current workforce, allow doctors more time with their patients, and allow for a more manageable practice. It is an open question whether such a significant pay increase would in and of itself give America an adequate supply of generalist physicians, but our current pay structure virtually guarantees a severe and worsening shortage in the coming years.

John Horstkamp is a family physician at Washington State University in Pullman, Washington. The views expressed here are his own and do not reflect the views of the university.

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