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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