Primary care providers are needed to support health reform

by Vanessa Hurley

Like many American patients, the American health care delivery system suffers not only from acute crises, but also from a chronic, poorly managed and debilitating disease.

Primary care is in trouble. Not only are primary care physicians (PCPs) fleeing the profession in droves, but fewer and fewer medical students express an interest in pursuing a primary care career.

Those entering the profession don’t last long – 1 in 5 general internists become specialists by their tenth year in practice. The workforce pyramid needed to support effective health care reform – with a broad base of primary care providers – is being steadily eroded.

The coming crisis was the topic of a recent conference hosted by the American Board of Family Medicine and the Robert Graham Center. Dr. Robert Phillips, director of the Graham Center, emphasized that while the average ratio of individuals in the U.S. to PCPs is 1500:1, that ratio ranges from 500:1 to 5000:1 depending upon the region you’re talking about. While we don’t know the “right” ratio, we do know that rural communities are particularly barren of PCPs.

A perfect example is Pennsylvania. Nearly one half of the state’s doctors practice in the three most populous counties. This leaves the other half of physicians to practice in one of Pennsylvania’s 64 other counties, which hold three-fourths of the state’s population. The need for more students to enter rural primary care in Pennsylvania was recognized nearly four decades ago. In 1974, under the leadership of Dr. Howard Rabinowitz, Philadelphia’s Jefferson Medical College introduced the Physician Shortage Area Program (PSAP). The program seeks out applicants who grew up in a rural area and expect to practice in a rural setting (with priority given to those with an interest in family medicine). Students enrolled in the PSAP partner with advisors on the family physician faculty and complete a third year family medicine rotation in a rural area and a fourth year outpatient internship in family medicine. Graduates of the program are expected to follow through with a family medicine residency and to eventually practice family medicine in a rural area.

The last formal review of the program’s outcomes was conducted in 1999 by Dr. Rabinowitz and made use of data from PSAP grads between 1978 and 1991. A comparison of the percentages of PSAP graduates who entered rural family practice as compared to graduates of the other 7 allopathic medical schools in Pennsylvania revealed that approximately 21% of rural family physicians practicing in the state were PSAP grads, even though they account for only 1% of total medical school grads from the state. Compared to their peers in the rest of the state, PSAP grads were almost 9 times as likely to practice family medicine in rural communities. But the truly important news was that PSAP grads persevere in the practice of primary care. 87% of the program’s 1989 grads remained in rural family practice a decade later, a nearly unheard of retention rate.

Programs like this are among what Representative Jim McDermott, writing in the New England Journal of Medicine, calls the “innovative curricula that defy the current pedagogical trend toward producing superspecialized physicians and researchers.” Encouraging the creation of programs similar to PSAP is one step forward in building a base of primary care practitioners in the places that need them most. It’s also a recognition of something that we very easily lose sight of in an era of “superspecialized” medicine – that primary care doctors truly matter. Jefferson Medical College has not only acknowledged that a problem exists regarding primary care, they’ve acted upon it. We would be wise to take heed of their prescription.

Vanessa Hurley is an analyst for New America’s Health Policy Program and blogs at The New Health Dialogue.

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  • Smart Doc

    “Primary care providers are needed to support health reform”

    I can’t think of a greater disincentive for potential pimary care “providers” than to realize that they will be the shock troops of ObamaCare. Medical students are simply not that stupid.

    • ninguem

      Much like “Gatekeepers” a generation ago. Sounds like one step up from prison guard.

      That some in politics and the bureaucracy think this is a compliment to primary care physicians…..amazes me.

      That some in organized family medicine, and all too many family physicians themselves, see this as a compliment…..disturbs me.

      • Smart Doc

        I am similarly amazed and disturbed at the lunatic “reforms” from Washington.

  • Steven Reznick MD

    Great post. Years ago SUNY Downstate started a similar program in family medicine and produced a large number of generalists who practiced locally. Ultimately, until the Medicare Payment Review Commission is represented by a substantially increased number of PCPs , medical students will look at the economics of the discipline and go elsewhere. No one wants to put in the hours of work , financial resources to pay for an education and spend the rest of the life worrying about meeting a weekly payroll or monthly mortgage payment and paying off your student loans

  • tpouw

    Kevin: Glad that you have provided this place for us to rant and exchange experiences. I as a general internist in solo practice found many of the comments here something that I can relate to. From a day-to-day practice stand point, I see the pay/hazel ration to be the main obstacle to getting anyone interested in primary care, no matter how lofty one raises her/his rhetoric’s. Being a realist observing how our political system rewards the very financial institutions that have brought havoc to our financial future, I have very little hope that our political leaders and system would do the right thing for the welfare/health of our greater citizenry. The much advertised ACO and Patient-centered-Medical Home, (allow me to be suspicious), seem to be just mechanisms for the insurance and hospital interest to ultimately control what once was an cottage industry. Once we have all become a cog in this huge “Healthcare-Insurance-Pharmaceutical Industrial complex”, patients will have even less of a voice. Just like the tax payer in this financial upheaval we are now in.

  • Leo Holm MD

    You are not paranoid. No patient or physician ever asked for a largely centralized ACO or PCMH to get involved in healthcare. Go to the National Committee for Quality Assurance (, click on “sponsors”, then click “meet our sponsors”. Drug companies, insurance companies and large employers make up most of the list. (Along with a lot of medical societies…no surprise there). This organization decides who is and who isn’t a PCMH. Patient centered…really?

  • Marc Gorayeb, MD

    The big lie of Obamacare: “patient-centered.”

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