Real health reform cannot happen without a primary care foundation

Annie Lowrey’s July 28 article “Doctor shortage likely to worsen with health law” in the New York Times noted the growing shortage of primary care doctors particularly in economically disadvantaged communities, both in rural and inner-city America. This problem will likely  get worse before it gets better as more Americans gain coverage and seek a regular source of care. As the article suggests, training more doctors and incentivizing them to pursue careers in primary care will be a key part of the solution. And it will require a multipronged campaign, using both some of the traditional strategies for workforce renewal and a few unique tactics not typically deployed in efforts to fix health care.

The primary care workforce pipeline had dried up before the Affordable Care Act was passed. Currently, one out of every five Americans lacks access to primary care. As a result, up to 75% of the care delivered in emergency departments these days is primary care. This overcrowds and overburdens EDs, raises costs, and limits EDs’ ability to do what they were designed to do: provide acute, emergency care that makes the difference between life and death. So the primary care shortage threatens our access not only to primary care but also to emergency care.

How did we get here? Many are quick to point to primary care doctors’ low salaries compared to those of their sub-specialist colleagues. Indeed, choosing a career in primary care rather than a sub-specialty means walking away from 3.5 million dollars of additional lifetime earnings. That’s tough to do when you’re looking at $150-200,000 of debt, which is the average debt of an American medical student at graduation. But the crisis in our primary care pipeline goes far beyond the money.

Medical schools aren’t recruiting enough of the right people in the first place. Numerous studies show that people from rural and lower SES communities are more likely not only to pursue primary care careers but also to return to those disadvantaged communities to practice. Unfortunately, medical schools’ acceptance of applicants from these communities has declined substantially in recent years. Instead, medical school admissions criteria favor more affluent applicants who are ultimately more likely to pursue sub-specialty careers.

Further, these same medical schools have been actively discouraging primary care careers for decades. This is due partly to cultural biases that place super-specialized medicine on a pedestal over generalism, which is due in part to how NIH research dollars flow, predominantly supporting cutting edge biomedical/technological research usually advanced by sub-specialists. The result is that primary-care-oriented trainees face four long years of admonishments against primary care careers – a hidden curriculum in which generalists are portrayed as nothing more than referral centers and lectures from so-called primary care mentors warn trainees against primary care careers at all costs. It’s no wonder fewer than 20% of American medical school graduates are choosing to go into primary care today. We’ve all but legally barred them from doing so.

If that weren’t enough, in their rotations, trainees see the most dysfunctional, antiquated and frustrating approaches to primary care delivery that exist in our health care system. The combination of a sicker, more-complex-than-average patient population, inadequate funding and support for improvement efforts, and predominantly part-time faculty who are frequently not available for teaching or improvement activities has created a toxic milieu. I can’t tell you how many primary care students and residents have noted that it feels like their clinics were specifically designed to destroy their interest in primary care.

Trainees need exposure to the existing models of care delivery that are transforming primary care to work better for patients, providers and payers. Patient-centered medical home (PCMH) practices, which use highly-coordinated, enhanced access, team-based care, are showing exciting results: higher quality of care, decreased ED visits and hospitalizations, happier patients, and lower overall spending. And it seems that exposure to this new model of care is one of the best ways to help trainees see a future for themselves in primary care. The problem is, only a tiny group of trainees are exposed to these types of clinics due to poor penetration of this model in the academic environment. This is something that needs to be remedied.

Revitalizing the primary care pipeline is going to require a multipronged campaign, with the greatest thrust being a change in the way we pay physicians in order to create greater equity between sub-specialist and generalist salaries. If we really value primary care as the foundation of our health care system, purchasers must invest in it and give clinicians the financial support they need to do their job well. We must also expand the definition of a ‘primary care provider’ to include Nurse Practitioners and Physician Assistants, two critical members of the primary care team who can immediately expand access to high value primary care services in communities across America.

As the patient-centered medical home model spreads across the country, academic leaders must ensure it also takes root in our medical school practices, where trainees are both learning what it means to deliver high-value care and making career decisions. We’re increasingly realizing that trainees not only have much to gain from these experiences, but they have much to give. And the sooner we get medical students involved in inter-professional training opportunities with nursing students, social work students, etc, the better. ‘Learners learning together’ is a critical first step to get trainees used to practicing as a team – which is one of the key ingredients of high value primary care delivery.

American medical schools must be held accountable for producing the primary care providers this country needs. This means not only reinvigorating primary care programming and developing new approaches to recruitment and retention of those individuals most predisposed to primary care careers, but also teaching the actual patient-centered, team-based skills that providers need in order to deliver high-value care today. The public cannot afford to wait for medical schools to do the right thing. We must leverage our collective power as purchasers and consumers to demand that these institutions break from their “business as usual,” specialty-focused approach to training. Maybe it’s time for a national campaign to publicly call on all American medical schools to step up to the plate and start revitalizing the primary care pipeline.

Finally, we – from academic faculty to laypeople – must all recognize the role we play in perpetuating the bias in America that being a primary care provider just isn’t good enough. Whether it’s through our questions to family members in medical school about what “specialty” they’re going to pursue, or our negative responses to their explicit intentions to practice primary care, we make clear that we wish they’d do anything but go into primary care. I implore all of us to face up to our responsibility to remedy and reverse these biases. So, next time a student tells you he or she is planning to pursue a primary care career, do yourself, your country and the future generations of Americans – who are currently on target to not have access to their own primary care provider – a favor and thank that student for doing the right thing.

We’ll never achieve real health care reform without a foundation of robust primary care in this country. However, fixing the pipeline is no small undertaking. It will require a multifaceted approach to remedy the financial, academic, cultural and political challenges that have plagued the primary care pipeline for years. It will also require us thinking more expansively and inclusively about the definition of a primary care provider. But to increase the primary care physician supply, our course is clear: we must come together now, as a nation, and both collectively demand more from our medical schools while also providing that system with the support it needs to change. Without that, it will be next to impossible to help our academic medical machine break free from it’s specialty-centric approach to workforce creation.

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

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