Adding more residency slots won’t improve primary care numbers

in Policy | 24 responses

The Senate health reform bill proposes to add 2,000 residency slots, in the hope to increase the number of primary care doctors and general surgeons.

I’m going say right now, that isn’t going to work.

Similar in concept to building more medical schools, nothing is going to change the skewed generalist:specialist ratio unless the professional incentives of each field changes.

And I’m not just talking about money, although that’s a huge factor.

The lifestyle, hours, and bureaucratic requirements all are significantly more favorable, in general, for specialists. The physician burnout rate for primary care is at all-time highs, and only rising.

Furthermore, most residents who enter internal medicine or general surgery residencies pursue sub-specialties, rather than generalist care.

So unless there’s language in the health reform bills that significantly improves the professional satisfaction of primary care doctors, along with minimizing the pay disparity, adding more residency slots or medical schools will simply lead to more specialists.

Comments

http://www.practicefusion.com Glenn Laffel, MD, PhD
Kevin:
It’s also not going to work b/c this represents, at best, a 2% expansion of the Primary Care workforce, which won’t materialize until several years from now when the new folks make it through their residencies.
The AMA and AAFP are on record, I believe, saying we need at least 15,000 new slots…this larger number was in the Senate Finance Committee’s original proposal, but it got cut during consideration on the Senate floor due to cost considerations.
Short term fixes are needed…FMGs, nurse practitioners, even Telemedicine are likely to play a role, in my view.
Thanks!
Glenn Laffel, MD, PhD
Sr. Vice President Clinical Affairs
Practice Fusion
http://www.practicefusion.com
Free, Web-based EHR
jenga
or just eliminate 30% of the specialty slots across the board.
http://dinosaurmusings.blogspot.com/ #1 Dinosaur
Spot on.
Jenga
That idea might work. Eliminating specialty spots is guaranteed to work and much simpler than maybe measures.
Don
Shift GME spend to the primary care end of the spectrum.
Recruit top 10% of med school sophs and if they commit to family medine or other primary care specialty pay 50% of junior year, 80% of senior year, and if they graduate in top 10% then will pick up additional 10% of junior and senior year tuition.
Pay only 50% of income tax charge on services provided to Medicare patients, Medicaid patients, no tax on income from services provided in defined remote underserved county
Fed provide full funding for primary practice EHR implementation with $44k paid back over 5 years by practice unless practice demonstrates ‘meaningful use’ in which case practice retains the $44k
Not surprising Congress is clueless as to why primary care residency matches by US med school grads is so low. Adding primary care residency slots just increases the number of nonUS med school grads trained in primary casre. Congress is surrounded by lobby from AMA and sub specialty reps who all want to protect their turf and funds for high end specialty GME funding.
Need disruptive innovation to separate Part B funds which are projected to be spent on primary care services to be paid for and subscribed to differently than the big Part B pot.
Until primary care medicine is treated as a Wellness-oriented service having it lumped into general ‘repair and recuperate’ health care service … the services of primary care Wellness services provided by physicians and nurse practitioners will be under reimbursed when compared to the value contribution to the health of the nation.
Rezmed09
Eliminating specialty slots would only provoke an outcry of government interference. Americans like all their specialty care, especially the more vocal, higher-income Americans. Reducing specialty slots will only worsen the primary care / specialty split int the medical community and reduce physician’s ability as a group to improve the health care of our nation. (although that might be stretching it).
I agree with Kevin, Medicare, insurers, Medicaid, and our society will have to make primary care more attractive to students and residents for it to survive. This is unlikely to happen. Mid level providers will fill the gap, and for the most part, they will do a great job. Expect them to advance to the level of remuneration of nurse anesthetists.
anonymous
i don’t think the pay is the key issue, it is the non-medical crap you have to do all day long. i think many students might pick primary care, even knowing they won’t make as much, because at the time they make their decision 140k sounds like more than enough money to live well, even given their loan burden. they decide because of the crap they see/hear people in primary care complaining about.
people at age 50 looking back seem to be more focused on the would have/should have aspects of the finances.
in some ways, primary care is not so bad if you have good hospitalists and access to enough specialists. it becomes a very 9-5 job, as long as you learn to be efficient, with only phone calls. to get the resources you need to make it a 9-5 job (enough ma’s and rn’s to do most of the pre-authorizing, someone else to take care of billing/collections, marketing, hr, your own health insurance, negotiations with health insurance, making sure your bills are paid, keeping abreast of legal issues) and still take home 140k, you might have to make trade offs like being an employed physician. but the writing is on the wall–i think the vast majority of physicians will be employed within the next 10 years anyways.
if we got rid of all the preauthorization crap, i truly think primary care would be a pretty good gig, as long as you don’t keep comparing your pretty good income to the ridiculous incomes enjoyed by colleagues. but to my mind, comparing yourself as a successful primary care doc to a successful orthopedic guy is a little of a false comparison. you feel closer to the person since you went to medical school with them, but in truth the job isn’t that similar that income comparisons should be easily made. you might as well compare yourself to successful bankers or lawyers or whatever and begrudge the fact that they make more than you.
note: if you are in primary care and on call all the time or don’t have access to specialists, well, personally i feel you have a real tough job. i don’t know what income would be appropriate for that kind of job, but i would move. if i had to, i would move my whole extended family because that job would kill me even if i made 300k. ymmv.
alex
“Mid level providers will fill the gap, and for the most part, they will do a great job. Expect them to advance to the level of remuneration of nurse anesthetists.”
So mid levels are going to make substantially more than primary care doctors then? Interesting.
jsmith
Kevin is right that the proposed slot expansion will be useless. Anon makes some good points, but I really think that money is the solution here, not that it is forthcoming. More money per pt means fewer pts means more time per pt means less total administrative burden means more satisfaction. I agree that adding more money and doing nothing else will not work, but the point is that increasing generalist reimbursement would allow us to make other practice changes to make our professional lives better. And of course med students would see this and be more likely to sign on. A virtuous cycle. Unfortunately, this HC bill addresses none of these important issues.
Pierce Hibma
As a second year medical student, here’s my two cents on the primary care shortage:
I concur with Dr. Pho’s assessment that more residency spots will not translate into more and better primary care physician. The incentive to enter primary care for medical students is extremely low considering not only pay but lifestyle and career satisfaction.
I do not agree with Don’s proposal to pay a greater part of a medical student’s education if they agree to enter primary care. Financially speaking, it still doesn’t make sense. Yes, a medical student could be in debt for a shorter period of time but that amount of money is minimal compared to the double, triple, or quadruple salary that can easily be earned by specializing. The programs like this that already exist get very little interest from medical students.
It’s not all about the money, but imagining a career of working just as hard (and perhaps even harder) than my colleagues in a primary care position making $140,000 while another classmate makes $440,000 through specializing does not encourage me to choose primary care. Furthermore, if you add the fact that my classmate who specializes is more likely to have a better lifestyle AND receives more respect/prestige then I’d be crazy to actually choose primary care.
The only way I’d considering becoming a primary care physician (PCP) is if it became a position of leadership. What I mean is that the PCP should be in “control” of each patient’s health care (obviously with input/consent form the patient). Thus, a patient would be referred to a specialist if the PCP deemed it appropriate and then the PCP would receive a financial kick back from the specialist for the treatment. Financially, this could create more balance between all physicians. More importantly, this type of situation would elevate the prestige of PCP since they would be the leaders in health care. This is the brief version of what would interest me in choosing primary care and if anybody has questions, please let me know.
Pierce Hibma
phibma@creighton.edu
http://www.blog.greatzs.com ZMD
Eliminating specialty spots would only make the specialties even more attractive to medical students, encouraging only the best and brightest to apply. Plus with the law of supply and demand, the specialists will wind up making even more money than internists.
jsmith
Pierce, Thanks for your thoughts, always very interesting to hear from med students. BTW: Kickbacks are illegal and will probably remain that way.
http://www.iMedicalApps.com iltifat
Completely agree with this article. Increasing residency spots for internal medicine isn’t going to do anything. A lack of spots is not whats causing the shortage. Relative to other residencies there were plenty of medicine residency spots that even went unmatched this past year.
Just a rough estimate from my peers, out of the ones that are matching for internal medicine, I’d say 70% want to pursue a fellowship afterwards. My friends who want to do strictly primary care are sticking to family and peds.
jenga
There is no supply and demand in medicine. Otherwise the incredible shortage that we hear about in primary care would translate into the highest salaries. The American public doesn’t value it as much as specialty care. That is the problem. If you want more primary care physicians add primary care specific residency spots. Done. No maybe measures. When someone posts and says it’s not about the money. Guess what? It’s about the money.
http://Curbside.posterous.com Nuclear Fire
Shortage does not equal demand, jenga.
http://gmail.com Bob
Are PCP’s, nurses, pharmacists really needed to do all they do now, order tests, review results, enter data, renew prescriptions, file paperwork, etc.? How much time is consumed that could be done as well by lower priced but skilled personnel.
How does 2,000 more “slots” fill the current and expanding shortage of 16,000? With life expectancy expanding yearly 2,000 more PCP’s just “keeps up” with population growth!
Where do the “slots” open and who are the “teachers” who if active make more working less hours in their practice than a University slot pays?
anonymous
pierce, i hope as you go through medical school, you find something you have a passion to pursue. if that passion is primary care, you may not mind making ‘only’ 140. or if you love primary care and need to make more, you will live someplace that allows you to make more. if you focus on the money, i question whether medicine is going to be something that keeps you happy over a career. there is always someone making more and who has an ‘easier’ lifestyle. i sympathize with you though. we have 250k in loans at 8% interest. the monthly payments are significant. still, i would be doing worse off emotionally if i had pursued something i didn’t love because believe me the hours and responsibilties are nuts. i don’t see too many docs getting home early these days.
unfortunately for people who are in medical school now, the days of 440k incomes for most specialists are likely done for as well. will your classmates still pursue these specialties when the income variation doesn’t support the opportunity cost of extra training? will the demands of emergency call coverage create dangerous shortages in trauma and neurosurgery if their incomes drop to 200k? the loan burden however is not dropping like the incomes will with health care legislation and the economy killing us.
interesting that you mention prestige as a factor. i am going to guess that in about 10 years you won’t give a hoot about prestige. or at least that your perception of prestige will be radically different.
good luck to you sir
Tom
Nuclear Fire nails it: “Shortage does not equal demand.” The question is why. The answer is, in part, a market that does not allow for proper reimbursement for services. The distorting effect from insurance and government programs allows for low reimbursement for services that patients are used to receiving, as they see it, for free. The best healthcare plan for the nation is one where people pay for the basics, and have insurance for catastrophes. People might become more cognizant of their healthcare dollars. This would be a godd thing, but it won’t happen. Congress appears to be insistent that everything be provided, which will lead to collapse sooner, rather than later, of the healthcare system, with primary care going first.
Do you want a model for what will happen? Look to psychiatry, systematically devalued, and now almost impossible to obtain. Primary care, look at your future.
jsmith
“Shortage does not equal demand” is a statement that makes no economic sense, like “His weight is 6 ft.” Supply/demand analysis is a flexible, nifty tool that can deal with a lot of situations, including analysis of shortages. Basically, when prices are capped, you can get a disequilibrium situation where demand exceeds supply. The amount of shortage is equal to demand minus supply at that particular capped price. See http://livingeconomics.org/images/glossary/shortage.gif for a graphic of this.
http://curbside.posterous.com Nuclear Fire
Pretty picture jsmith but you miss the point. Perhaps that is my fault for putting brevity ahead of clarity.
Demand is what individuals are willing to part with their money for. It’s not what they want or what they should get but what they are actually willing to give up something else for.
Shortage, as is used in the colloquial conversation i.e. when the AAFP or ACP say their is going to be a shortage, is what someone else other than the consumer judges the need will be and how much less than that need the actual ability to produce will be.
My point being, although patients may want something or we may say they need it, if they are unwilling to actually pay in exchange for it, there really isn’t a demand. In a way, I’m agreeing with jenga. His point was there is no “supply and demand” in medicine or else PCP salaries would be high given the shortage. My point is that patients really don’t have a demand for PCP care (which I think is wrong) but clearly we (as patients also) are much more willing to pay a cath jockey to save my life when I have crushing chest pain than pay a pill pusher to prescribe me lisinopril to prevent that heart attack 10 years from now.
The work we do is not valued. It’s sad, wrong, pathetic but painfully true.
R Watkins
I think Nuclear was implying that there is no patient demand for primary care services, which is absolutely false. Primary care docs are the most highly recruited in all areas of the country, and every one I know is turning patients away. But even with this demand, the perverse system is hostile to higher income for the in-demand docs.
R Watkins
Nuclear;
My previous post was written before I read your clarification.
But I still don’t agree with you. I know that my patients value my primary care services: I have no problem getting close to 100% collection on co-pays, deductibles, non-covered charges at the time of service. And the Medical Groups Managemnt Association has just come out with a report that, during the recent bad economy, primary care visits have gone up, while procedures have gone down. Patients are avoiding screening colonoscopies and such, but still seeing their PCP when sick.
It’s not the patients who undervalue primary care. It is the AMA and its perverse RVU system that is the source of the devaluation of PCP work.
jsmith
Nuclear, Do you mean that there is in fact no true economic shortage in primary care because demand from patients is really lower than what worthies think it should be , for the reason that patients demand more specialty care than worthies think they should have and don’t demand as much primary care as worthies think they should have? If that is what you mean, I agree.
jsmith
Sorry. The last word is my last post should be “understand,” not agree.

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