It’s time for a primary care workforce surge

Primary care residency numbers didn’t change much this year. Depending upon your vantage point, that’s either a good or bad thing. For those who were hoping that the numbers would continue that 2-year steady climb out of the dumps, the 1% increase in FM positions seemed to be a disappointment. But for many of us who work day to day to revitalize the primary care pipeline, we breathed a sigh of relief that the numbers managed to hold steady.

Now don’t get me wrong.  There are many pessimists out there who don’t have faith in our primary care health system.  I’m not one of them. I have firsthand experience to know that change is afoot all around us in the primary care landscape.  I spend most of my time meeting people who are on the cutting edge of the revitalization of the primary care pipeline; people like Dr. Mike Magill of the University of Utah, where they have developed the Care by DesignTM model of primary care. Not only are these primary care heroes reinventing how primary care is delivered, but they’re excited to share this vision for a new, more patient-centered and innovative primary care future with our trainees- to offer them a glimpse of a multitude of new models of primary care delivery that are better serving both patients and providers alike. And many of these leaders, like Mike, aren’t just getting trainees exposed to these new models; they’re getting them involved as well. By doing so, they’re not just helping them see a future for themselves in primary care within these revitalized models, but they’re starting to get these trainees marinating in a new approach to care delivery, getting them familiar with those skills and competencies of team-based care that are almost completely absent from traditional models of medical education and training. And it’s making a profound difference.

The problem in primary care is not a lack of innovation in the field.  It’s that forward-thinking programs and efforts are the exception, and not the rule, in academic settings.  As Donald Berwick says, every system is perfectly designed to produce the results that it gets. And the honest truth is that our medical education system is just not designed to get trainees excited about careers in primary care.

The vast majority of medical trainees have no exposure to these exciting new models of primary care delivery like the patient-centered medical home. Instead, the overwhelming majority of their rotations, clinical experiences and electives occur within traditional academic practices, which are notorious for utilizing antiquated models of care that serve neither patient nor provider, and turn off medical students in droves.

I recently spoke with an internal medicine resident at a training program in the Midwest. She had entered the program planning on pursuing a primary care career. “There’s no friggin’ way,” she replied when I asked her if she was still planning on pursuing a career in primary care. Clearly, the discrepancies in salaries between primary care providers and specialists was playing a role in her thinking. But when I pressed her, she admitted that it was mostly the models of care she had been exposed to, and forced to practice in, that had dissuaded her from taking the leap. To her, the Patient Centered Medical Home, and other promising, alternate models of care delivery were a fantasy, almost like Willy Wonka land. It was something she had vaguely heard about, maybe even read about, but certainly had no firsthand knowledge of. Instead, she made her career plans based upon her own experience, and that experience had her working in a clinic, “that almost seemed like it had been designed to destroy my interest in a primary care career,” she told me. That’s too bad– for her, for the people of her state who need access to primary care, and for our healthcare system as a whole. What’s worse is that it could have been prevented.

The day prior to meeting this resident I had met with a clinician innovator in her community who had transformed his primary care practice into a patient-centered medical home and was having fantastic results in terms of care quality, overall spending, and both patient and provider satisfaction. What would have happened if our resident colleague had met him and rotated through his practice, if only for a few days?

What would happen if more and more trainees were exposed to the best and most exciting of what’s happening in primary care, as opposed to the most antiquated and overwhelmed? What would happen if more of them didn’t just shadow in these new innovative practices, but actually rolled up their sleeves and became key members of the team transforming a practice?

I bet our primary care match numbers would change. Big time.

I challenge us to find out.  Let’s make a commitment over the next year to take a look at every academic medical community in the country and identify the most exciting leaders and innovators in primary care.  Let’s recruit them if we have to.  But let’s make a better effort at getting trainees exposed to primary care clinical innovation and the inspiring folks on the front lines of these efforts.

Maybe then, we’ll no longer have to hold our collective breath every match day, hoping (praying!) that our low primary care match numbers “hold steady.”

Andrew Morris-Singer is an internal medicine physician and President and Co-Founder of Primary Care Progress.

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  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    Lots of talk. Worthless talk. The students aren’t stupid, and they are not going to risk their career, their future, their lives, on worthless talk. Even if the “medical home” garbage actually proves to be something worthwhile, and not just the next version of the “gatekeeper” of the 1990′s, the students are just as likely to say they went into medicine to be doctors, not a mid-level executive supervising midlevels in a healthcare delivery organization, and will still go into a specialty, where they actually get to practice medicine.

  • http://twitter.com/ykramerezha Bohdan

    The reality is that our system of health care will collapse for a variety of financial, organizational, and psychosocial reasons without a primary care foundation to our allegedly reformed health care system.

    But there is also no doubt that a primary care career is not a viable option for medical students.  That is the hard reality.  Medical students are motivated by survival.    

    The primary care deficit relates to lifetime income which is disproportionately affected by medical student debt, by professional status and structural issues within medicine, and by lifestyle issues.As a primary care doctor you have to confront all the inefficiencies and irrationalities of our health care system.  As a dermatologist, all you have to do is take a skin biopsy and deal with the surface of the system.  You do not have to provide service, just a cream. It takes as much effort to bill for a follow up visit as it does to bill for a much better remunerated procedure.  Primary care physicians also suffer the brunt of all the failed experiments in the reform of American medicine.  

    Then they have to undergo the moralizing from academic institutions which are essentially for expansion and profit.

    Finally, with the inefficiencies of health care finance, payment, multi-payer, etc. medicine is beleaguered by  high overhead which is greater than income.  This is particularly acute in primary care.  The system is geared against primary care.  The ACA only touched the surface when it came to primary care. 

    In effect, much of primary care delivery degenerates into a scheme to get reimbursed.  I witnessed this painful fact working in a FQHC, primary care center for thirteen years.   

    It is very easy for someone at Harvard, which through Partners has a remarkably sweet, if not corrupt, deal for reimbursement to preach optimism.  

    But that is not where we need primary care: Cambridge, Beacon Hill, or the Back Bay.  We need it in Detroit, Brooklyn, the Bronx, Oakland, Rosebud, and Hidalgo County Texas where Dr. Atul Gawande went to expose but not to reform the local practice of medicine.Bohdan A Oryshkevich, MD, MPH    

  • Anonymous

    “What would happen if more and more trainees were exposed to the best and most exciting of what’s happening in primary care, as opposed to the most antiquated and overwhelmed? What would happen if more of them didn’t just shadow in these new innovative practices, but actually rolled up their sleeves and became key members of the team transforming a practice?”
    Absolutely nothing, as long as you intentionally ignore the cause of all the problems in primary care: money.

    This is probably the most inane, clueless post I have ever read here.

  • Ragoza

    Wow, I’m surprised by the negativity of the earlier posters. I’m a medical student and I agree with what Dr. Morris-Singer is saying. I’m more turned off by “role model” providers who hate their jobs (maybe like the previous posters) than I am about the money situation. But maybe I’m different in that I know what I’m getting into money-wise.

    • Anonymous

      Don’t be surprised. The main disparities Primary Care physicians encounter have only a little to do with money in their pocket. As you say, I knew what I was getting into as well. It’s the caste system that gets people jaded. It’s the running full speed on a treadmill and having that still not be good enough to cover overhead that starts to erode at your optimism. It’s being told in medical school: You are wasting your time going into Primary Care. Once you get out, that message is reinforced by insurance companies, hospital executives and so called “colleagues” who would gladly replace you with a midlevel provider, as it would increase referrals. As the author suggests, other models would be great. And I agree with you that positive role models are in high demand. Unfortunately, we do not have a system that encourages that. Even if models like the PCMH hold promise (and I don’t think that they do), unless the payment system is revised, the model will deteriorate back into exactly what you see now. 

  • Anonymous

    true, enough, re: the money. primary care docs need to get paid more. but how long do you think it’s going to take for that to happen? a matter of months? even a few years? GET REAL. the RUC has 20-something specialists on it, and less than 4 primary care providers. those huge gaps in salaries are here to stay for a bit. so what do you expect us to do? just sit there and wait around for payment to change, crying that life’s unfair, while millions of our fellow citizens go without primary care, and the primary care that most folks do get is relatively low quality? as a primary care resident I tell you there is excitement and hope for some of these new models of care.  in the medical school affiliated with our program, i’m seeing the PCMH jazzing up more medical students. and it’s effecting our decisions about jobs too. there’s no way i’m going to take a job on the hamster wheel. i’m only applying to jobs at patient centered medical homes.

    • Anonymous

      For the reality of the PCMH when not subsidized by a medical school, check out last week’s Wall Street Journal article: hamster wheel spinning faster than ever + out of control overhead + lower revenues due to crippling administrative burden = continually decreasing income. Not a pretty picture.

      I love primary care, and will continue to practice as long as I can, but I’m incredibly frustrated/ angry about our refusal to fix what we know is broken.  We don’t have to reinvent the wheel: we know from the work of Dr. Starfield and others (and from the example of other countries), that strong, healthy primary care practices are the backbone of an effective health care system.  

      There were some good features in the original medical home model, but it has quickly been co-opted by the large insurers as a way to produce low cost, assembly-line care delivered by NPs, PAs, and various other members of the “team.” The long term relationship developed over time between physician and patient is considered to be meaningless.

      • Anonymous

        What was the wsj article?  Thanks. 

        • southerndoc1

          The entire article can be found at:

          http://www.eyedrd.org/2012/03/wsj-why-americas-doctors-are-struggling-to-make-ends-meet.html

          Unbelievably, this very same practice was featured in an AAFP propaganda piece only six months ago as an example of a successful PCMH that was thriving financially! In the real world, heads would roll for printing such blatant lies, but in the AAFP/Transformed fantasy land . . .

          It was obvious from the beginning that the PCMH financial “model” was a bad joke: make a huge investment of time and money in equipment, staff and other overhead; give away your product for free for years; and hope/pray that some kind insurer will eventually decide to start paying you for all the work you’ve done. The result in what we see in this article, doctors selling supplements and holding golf tournaments to help make payroll. 

          I learned very early that the number one rule for success in family medicine is to ignore everything that the AAFP recommends, and it’s worked well for me. These poor doctors are ultimately responsible for the very bad business decisions they have made. But, in a decent world, stories like this would lead to some serious self-analysis on the part of those who have so mislead their fellow physicians.

  • http://twitter.com/ykramerezha Bohdan

    There will always will be heroes and saints who will go against the current.  But that will not provide a comprehensive, effective, and efficient primary care infrastructure for the country.  That will not provide doctors to such communities as Indian Reservations, inner cities, remote rural areas, rust belt cities, etc.  

    The heroes will stay in Boulder, Cambridge, Ann Arbor, etc.   

    It is not just the money.  It is the job description as such that is the problem. 
    There is no respect for cognitive medicine in the USA.  That holds true for fields such as internal medicine, psychiatry, pediatric, family practice, etc.  This dehumanizes medicine.  Patients come to a doctor for advice and answers not procedures.   Primary care is fundamentally different in other countries.  

    Other countries have fundamentally simpler reimbursement systems.  

    There is much more mutual respect between patients and doctors.  There is a social contract.   

    The ancillary staff is more professional and better paid in other countries. 

    There is less emphasis on technology and esoteric specialties.  The limits are put on esoteric specialty practices rather than on primary care.In England the primary care physician is put at the center of care.  The converse is true here. The reimbursement practices are fundamentally different.  Fee for service is widespread.  In this country, many specialists own the technology necessary for the practice of high technology procedure oriented medicine: CT scans, MRIs, Stress Labs, laboratories.  This all weighs against primary care. 

    The negative primary care role models in the USA are reflecting the reality.  The reality has to be changed.  Otherwise our health care system will drive us into bankruptcy. With no change, primary care will remain in the realm of the self sacrificing hero.

    I tried to warn the medical establishment at Harvard Medical School of the impending decline in cognitive specialties and primary care.  That was in 1981 to 1983.  That fell on deaf ears.    

    The current system comes as the result of decades of neglect.  The dysfunctional system has become entrenched.  

    In order to reduce the income gap between primary care and specialty care, one can introduce universal public financing of medical education.  If medical students graduate with no debt, they will be able to choose lower income specialties without personal harm.  This will automatically make primary care more attractive.  It will also make specialists less procedure driven.  They will not be trying to climb out of debt.This can take place without any change in reimbursement and without any input of practicing physicians.  It can be done in a budget neutral manner.    Of course we can afford to publicly finance medical education.  According to numerous forums held at Harvard Med School and elsewhere, we are wasting one trillion dollars in our health care system per year.  Just do the math of what it would take.   This is simple math.  In the 1970s and 1980s medical schools wanted to drive medical students into debt.  This would make them entrepreneurial and hungry.  They would do more and hospitals and medical schools would benefit from having more economically driven and ambitious medical doctors.  It was seen as a win win proposition.Now our society is paying for these decisions.  

    Bohdan A Oryshkevich, MD, MPH

  • Anonymous

    Medical students applying for primary care residency programs are focused on the altruistic and rewarding traits of a primary medicine career. Most have trudged through medical school living the student life, and the practical realities of life haven’t yet hit home. It is during the end of residency training do we realize how soon we’ll have to pay our student loans, expect the “big rewards” from our delayed gratification mentalities, and see just how crazily busy life can be as a PCP. It is at the end of residency when we’re ready to begin “life.” Except that life has a salary potential half that of a specialist’s combined with an imbalanced lifestyle reminiscent of the residency rigors we thought one day would come to an end.

    It has been demonstrated that while decreased income plays a big role repelling student doctors away from primary care, an imbalanced life is an even bigger reason primary care turns off medical graduates. After all, who wants to work 12 hour shifts and miss out on life? Now there are family, vacations (hopefully), and possibly non-medical interests that seem inviting, but limited reimbursements limit time that can be spent enjoying these things. It is no wonder almost 50% of PCPs in private practice are truly burned out.

    MedLion Direct Primary Care helps graduating residents find the joy in private practice again by helping them start from scratch, providing student loan reimbursements, promising specialist incomes, and most of all, a balanced lifestyle where these new PCPs see half the numbers of patients as their senior, traditional counterparts. MedLion is truly helping to resuscitate primary care private practice.

  • Mystery Medic

    Primary healthcare givers are as crucial as any other player in the healthcare system. It is unfortunate that their roles aren’t as glorified as others which makes it less alluring to prospective students. Apart from that we also have to deal with the negative attitude towards primary healthcare as a career choice, only then will they be respected and paid more for the service they provide.
    Mystery medic

  • Mystery Medic

    Primary healthcare givers are as crucial as any other player in the healthcare system. It is unfortunate that their roles aren’t as glorified as others which makes it less alluring to prospective students. Apart from that we also have to deal with the negative attitude towards primary healthcare as a career choice, only then will they be respected and paid more for the service they provide.
    Mystery Medic

  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    Primary care will never be desirable until the money goes up plain and simple. I have to see 40 patients a day to cover costs, I can’t afford to give raises to good people, or increase my part time MD’s work hours because of the awful reimbursement. If you hire a primary care doctor who mainly codes 99213 and sees 20 patients a day(otherwise known as a busy workload for a specialist) they don’t come close to covering a 160,000 dollar salary that they probably feel they deserve. In competitive markets where there is no anti-trust laws against managed care corps but plenty against MD’s the rates are set so low that the entire field is completely marginalized by prospective students. There is no joy to be had with filling out 30 page disability forms, getting yelled at by patients being told to come in for explaining lab tests. I’ve had people demand medrol dose packs from my staff, tie up the phones for 20 minutes and refuse to come in, so much primary care is unreimbursed. We are giving all the responsibility with none of the reimbursement or respect from patients, other physicians and insurance companies. There is a pro-primary care movement now but so far i have yet reap any benefit from it

  • Anonymous

    Dr. Morris-Singer sketches one possible optimistic future for primary care.  There are other possible futures that are not so rosy.  These include the following:
    1.  Worsened pay discrepancy compared with sub-specialists as a sub-specialty shortage takes hold.
    2.  Downward pressure on absolute pay because of competition from mid-levels.
    3.  The intensification of the current trend away from diagnosis and treatment towards managing populations and trying to keep them healthy without adequate resources and skills to do this. 
    4.  Overall increased work levels due to a primary care shortage.  
    5.  The failure of new practice models like the PCMH because of a doctor shortage, because of the failure of the PCMH to save money, or for other reasons, and then a subsequent intensified re-hampsterwheelification of primary care.
    6.  Increased paperwork and hassle as payers panic about inexorably rising health care costs. 
    7. Having to spend more time and energy interacting with persons with business training and orientation and having to listen to such persons use terms like “synergy,” “win-win,” and “opportunity” (this one might be the worst one for me).

    I’m sure you all can think of others, but you get the idea. A complete analysis of this would go over all the possible scenarios and assign a probability to each one.  An analysis that gives us one possibility is  inadequate. 

  • Anonymous

    It’s true that overhead is incredibly high, and help needs to come from various avenues, but with the right re-alignment of staff time and staff training, long term costs and administrative time can (and often do) decrease dramatically. The problem is that there is not enough sharing of ideas and best practices for implementation and many clinics are turning to expensive consultants to help conversion, which only adds to overhead. It’s a vicious cycle. But if training for coordinated care models occurred earlier on in med school and residency, and clinicians and their staff were given better exposure to these models, overhead would decrease over time and become more part of normal operations. Reimbursement does need to change and everyone- consumers, payers, insurers, providers and mass employers should come to the table (as they have in many communities) to re-align payment to reward episodes of care. Different per-member fees have been shown to help offset overhead costs and slow down the hamster wheel, while creating real shared savings. Unfortunately, these savings do not occur across the board in all communities. Exposure to best practices, continuous quality improvement methods, and community engagement deserve a fair shot in the system. In the least, exposure to models like the medical home provide a respite to disparaging rotations that trainees like the one in Dr. Morris-Singer’s article receive.

    • Anonymous

      “My conclusion from my own experience and from much observation of other businesses is that a good managerial record is far more a function of what business boat you get into than it is of how effectively you row….Should you find yourself in a chronically-leaking boat, energy devoted to changing vessels is likely to be more productive than energy devoted to patching leaks.”–Warren Buffett
      Family docs have watched our boat spring one leak after another for a very long time. We hear tell that the Coast Guard is coming to save us, even today from Dr. Morris-Singer, but we haven’t seen them yet, rhetoric notwithstanding.

    • http://twitter.com/ykramerezha Bohdan

      You cannot build a strategy on ifs.

      It will take more than that.

      There are also too many people, physicians included, who see health care as an area for profit.

      Addressing the primary care deficit is something that the whole society, our policy makers, and our medical establishment should be doing.

      But among other things, stem cells, endless medical advances, information overload, debt, lifestyle issues, status  and a million other things are in the way of developing a sound universal primary care based health care system that we need for this country.

      But as a first step we must admit and address the fact that our medical schools and our medical education are at the source of this problem.

      Above all positive PR for primary care is not going to solve our primary care deficit. 

      Bohdan A Oryshkevich, MD, MPH

  • Anonymous

    “As a dermatologist, all you have to do is take a skin biopsy and deal
    with the surface of the system.  You do not have to provide service,
    just a cream.” 

    Good to know.  I’ll keep that in mind the next time I’m starting a patient on biologics or immunosuppressants.  I should just forget about all that monitoring I do in order to check for systemic side effects and extracutaneous manifestations of inflammatory & connective tissue diseases.  According to my supposed colleagues in primary care, my job is to take biopsies and prescribe creams to “deal with the surface of the system.” 

    The amount of unfounded vitriol being hurled against specialists on this blog is truly unbelievable.  So much for fostering a collegial atmosphere.

    • Anonymous

      My wife, who is also a doctor, has a skin condition that would benefit from phototherapy.  Her dermatologist has not filled out the required paperwork for 2 months.  The derm office does not return phone calls and, according to my wife, has a waiting room filled with glamour magazines.  This “physician” has absolutely no interest in taking responsibility for her patient.  
      We’ve had similar experiences with the orthopedists, but, thankfully, not with the local general surgeons, who are real doctors.    
      Somederm, you might be a great doc, but some of your colleagues are business-school variants. 

      • Anonymous

         As long as we’re just sharing anecdotes, about ten minutes away from my office there’s a medispa run by two family practitioners.  You’ll find more glamor magazines, advertisements, and beauty products in one of their exam rooms than you’ll see in my entire clinic.  They spend their time supervising an army of midlevels, techs, and aestheticians, and then glibly refer all of their complications to myself and my colleagues. 

        Buzzkillersmith, you and your wife might be great docs, but some of your colleagues are business-school variants. 

        Am I going to argue now that all family practitioners “aren’t real doctors” and have absolutely no interest in taking responsibility for their patients?  Absolutely not.  My objection is to the vitriol being hurled at entire specialties here, which I find to be unprofessional and uncollegial.  

        • Anonymous

          Fair enough, plenty of blame to go around. 

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    The approach to primary care needs to change from medical school right through practice and payment methods. People who go into general medicine want to be hands on caregivers.They want to develop long term doctor patient relationships. They do not want to be the administrative leader of a care team where lower paid and lesser trained individuals provide the hands on care. It remains to be seen whether the ACO’s can economically allow a limited number of primary care physicians to do anything but be administrators of others. There also needs to be a greater respect for PCP’s within the profession allowing them to do what they are trained to do and demonstrate during training that they can do well. The idea of training residents to either be outpatient doctors or inpatient doctors creates a workforce that really doesnt know what the other clinician does. It is a recipe for dissatisfaction , poor communication and understanding and lack of ability to coordinate care. PCP’s have become  the guys who walk behind the elephants with a pail and broom to clean up the excrement for every other procedural specialty that no longer will do anything except perform procedures. This attitude within the profession plus the lack of comparable reimbursement for cognitive skills is what drives individuals away from primary care. It is hard to be the sole breadwinner in your family and be a PCP.  Generalists were supposed to be the professions clinical detectives and patient advocates. They have been economically credentialed out of that role by specialty control of the AMA and ACP. That is not to say that there are not some outstanding generalists in powerful positions in both of those organizations. They are just overwhelmed by the money and lobbies of the specialty interest groups and have bought into mega big groups of employed physicians who will get paid extra for achieving benchmarks that will be made more difficult to achieve from year to year.
    I hope there is a resurgence of primary care popularity and applications. It will not come until the Federal government reduces reimbursement for specialty procedural fellowship programs and departments and diverts that money to general medicine departments to train generalists who come out of training and stay in general care for a prescribed number of years.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      “People who go into general medicine want to be hands on caregivers.”

      I am not sure this will hold true for much longer. Reading this article leads me to think that there may very well be a new breed of general medicine graduates, that will have more closely aligned interests with what primary care is being driven into by politics & policy, i.e those “business-school variants” mentioned above.
      If academic institutions begin to subtly change curricula, we may start to see primary managers emerging to service the ACOs and the evolving two tier medicine created by these arrangements.

      • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

        Sadly Margalit I agree with you. Politically they will take idealistic young students who have no experience of what was or what can be and mold them in school and training for the dumbed down roles employers, insurers and government bureaucrats desire

      • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

         Fine.

        Just don’t call them physicians.

  • http://empoweredpractice.com/ Trista

    “But let’s make a better effort at getting trainees exposed to primary care clinical innovation and the inspiring folks on the front lines of these efforts.” Coming from a rural area I can see huge opportunity here. Students can only make decisions based on what they know, which the author hit on with the example student. There are so many things that factor into a student’s decision to continue or not with primary care. In order for long term gratification of their career choice, however, it is important for the student to consider their core values and beliefs behind the decision they make. If they truly chose to become a doctor to make a difference in people’s lives, than the decision to move on to a specialty based on money alone is only going to lead to short term gratification. I have made plenty of decisions based on money, but I have to admit that the choices I made putting money aside and focusing on what was really at my core are the decisions that are truly bringing me greater joy and happiness in my life. -Trista

    • http://twitter.com/ykramerezha Bohdan

      If medical school were financed in a strategically different way, medical schools would attract rural student applicants who are much more likely to practice in rural areas.

      High tuition fees and heavy medical student debt guarantees that the applicant profile at this time does not favor those who come from communities who need primary care and those who would eventually be interested in primary care.  In the current medical school application context, one has to make a financial calculation before applying to medical school.  It is quixotic to believe that an urban person is going to move to a remote rural area because of a good rural primary care experience.We have to publicly finance medical education so that we attract a genuine cross section of our population to apply to medical school.That is the only way that we will provide adequate numbers and quality of physicians for our rural areas. 

      • http://empoweredpractice.com/ Trista

        Coming from a rural community and having worked there as well, I feel there is great opportunity for doctors who are wanting to make a difference. I understand that the rural setting is not for everyone, but sometimes people don’t even consider those areas thinking there is little opportunity. I recently spoke with a clinic administrator who said the doctors are doing their best to get students in and mentor them in our area, but he wonders if it may be working against them because then they see just how much they have to know and don’t feel like they have the resources to help them as they would in the urban areas. He made a good point. I’m not sure what the students’ are thinking, but it would be beneficial for the clinic to do a followup or exit interview with the students to see what their thoughts and needs would be in order to consider coming back to the rural areas after graduation. That would allow the clinics to make changes if so desired. There is actually additional financial benefits for doctors and other health professionals who take jobs in such communities. In addition, I would assume with the growing demand and inability to recruit, the salaries should be competitive in these areas, especially when you look at the comparisons in cost of living. 
        Thank you for your response, 
        -Trista

        • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

           I practice in a rural area.

          Bad as primary care practice pays, you are paid even less to practice primary care in rural areas.

          Healthcare organizations are monopolistic in rural areas. If you do not fit in, Lord help you. I’ve seen doctors get their careers ruined when they don’t fit in. They move to a big city, they find their niche just fine, given the diversity of a bigger community.

          The patients themselves perceive the big city as better medicine, they self-select to the cities, travel for that healthcare………to be precise, ROUTINE healthcare.

          This leaves you with the Medicare, Medicaid, uninsured, the people the city places don’t want, for good reason……oh, and you get the emergencies when that person who perceives the big city to be better, but now there’s an emergency, a complication of treatment done elsewhere, then they deign to let Doctor Okie from Muscogie care for them……and the attitude shows.

          No thanks. Closing the rural practice after many years here. Not worth it.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      “…..Coming from a rural area I can see huge opportunity here…..”

      I practice in a rural area.

      They pay you less to practice in rural areas.

      Let us know when you get a clue.

      • http://empoweredpractice.com/ Trista

        Opportunity goes beyond the paycheck. It’s how you choose to look at it. Everyone makes the best decisions they can given what resources they have at the time. It looks like you are making a decision based on your resource of experience to close up shop in the rural community. Your experience is true for you, but maybe not be true for another person. It is unfortunate for your community to be losing a doctor, but there comes a time you have to do what is best for you. It sounds like insurance is a huge stress for you and you are not alone. What can you and other doctors do as you move on to combat that? No matter where we choose to continue our efforts, there will always be challenges. We must decide how we can face them to best serve our needs and those of our patients. In the end we have to live a life that brings us joy and lets us share our gifts. 

        • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

           Oh, it will get fixed. The hospital is a monopoly in the area. They will open up a clinic, staff it with a nurse practitioner, charge twice my fee as a rural critical access clinic. They will hold their nurse out to the public as a physician. That nurse has an interest in cardiovascular disease. Fair enough. What is not fair is to call that nurse practitioner a “cardiologist” in news articles.

          Let’s just say someone dropped a dime to the medical association, with the news release clipping, the medical association in turn called the Medical Board “on behalf of a member”, to force a retraction in the news media.

          Don’t do such a thing directly, they can be very vindictive in small towns.

          My friends still call the nurse “doctor”.

          The hospital CEO makes $600,000 a year. The salary is a line item in the hospital’s IRS filing, which is a public document.

  • Anonymous

    i am going to boldly predict that there will be no primary care workforce surge.

    you get the behaviors you incentivize. and going into primary care is a behavior that is not incentivized.

    • http://twitter.com/ykramerezha Bohdan

      We desperately need a primary care workforce surge.  

      It can happen.  We have to align the incentives differently in American medicine.
      A successful primary care surge will provide better, more humane, and more sustainable health care.

      Dr. Morris-Singer has accomplished very much by co-founding Primary Care Progress.  We just have to roll up our sleeves and make a surge happen.Bohdan A Oryshkevich, MD, MPH 

  • Anonymous

    A harrowing article.  A couple months from bankruptcy.  Wow. Although I don’t have enough knowledge about the economics of the PCMH to make a final  decision, I would be very leery of that pig in a poke.  It is elementary business sense not to do something unless you are quite sure it will at least break even.  I don’t think I can say that about the PCMH.
    I agree that the AAFP has no business sense–or political sense.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

     “Unbelievably, this very same practice was featured in an AAFP propaganda
    piece only six months ago as an example of a successful PCMH that was
    thriving financially!”

    HAH…….I hadn’t noticed that little subtlety, thanks.

  • A Singhal

    There will always be shortage of physicians in general. Several senior physicians are leaving medicine due to complexity of regulations. Medical Boards discipline 5500 (about 1/3 of new doctors produced per year) doctors a year (majority of them for silly reasons which has nothing to do with competence) making it hard for them to get credentialed at hospitals and with insurance companies. Another 400 commit suicide each year bacause they can’t seek help for their stress because of stigma. Monopoly of hospitals in smaller communities is true. They can very easily destroy you and your career.

  • MaMD

    As someone who recently left primary care, I have many friends who are primary care doctors.  Some of them have changed over to hospitalist medicine, and others are thinking about leaving primary care.  I’ve always agreed with patient-centered care, however, a critical piece continues to go unrecognized.  That is, how can you expect to reverse the primary care shortage and encourage newly minted MDs to pursue primary care when all around them, they see primary care doctors working to the point of exhaustion, having to sacrifice valuable and rare family time in the name of their “calling?”   No primary care doctors go into it “for the money,” but this misplaced notion that since it is a “calling” everything else comes second is precisely what is driving people away. 

    Like it or not, if there was a well implemented system of job sharing then patients would get continuity of care (between a team of 2 or 3 doctors who know them well) AND doctors would not be burning out at such a high rate.  In order to solve the primary care problem, the root causes of physician burnout MUST be addressed.  Unfortunately, in our current system, hiring 2 or 3 doctors for the job of one goes against cost-cutting, which is a high priority for CEOs whose primary job is to bulk up the company shareholders’ pockets.