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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  • buzzkillersmith

    Prediction FWIW: Med students are not dumb and no amount of cajoling and “choosing the right people” is going to get them to go into PC in anything close to required numbers. Physicians will continue to do what they have always done with lousy jobs–have the nurses do it. A lot of nurses want to be midlevels, at least for now, because of the nightmare of hospital and nursing home work for a lot of them. At least that’s what my NP says.
    The primary care system is to be nurse-dominated, physicians having chosen subspecialties and hospital work. The world will not end, just primary care done by docs will end. Sure, maybe they” ll be a few dinosaurs (like me!) left in PC, but we will die out eventually. I say none of this with glee, but at some point you have to admit the battle is lost.

    • rswmd

      I think your analysis is correct. And the PCMH is the Trojan horse that is being used to quickly kill physician-delivered primary care. That our professional societies (and the author of this article) can’t see this is truly incomprehensible. Signed, Cassandra

  • Shelagh Lowe

    The delivery of health care services is a team effort. The medical profession is key to the delivery of primary care services. However they do not work in isolation. Expecting them to work in isolation puts the entire responsibility and onus of health care on them, leading to stress and burn out. The recognition that primary care is best delivered by a team of people working together to achieve the best outcomes for the patient is a way to ensure increasing satisfaction for being a general physician. Members of the health care team include the allied health professions and nursing professionals. Patients with chronic complex care conditions require access to the team…doctor, physical therapist, dietitian, psychologist, optometrist, podiatrist, pharmacist, social worker, occupational therapist, speech and language therapist, diabetes education, etc – in order to receive best practice in health care. No doctor should be expected to deliver primary care in isolation. It is time to focus on team based care and ensure that physicians are supported in their delivery of health care.

    • buzzkillersmith

      Sorry, but team care won’t make it. Most med students have no interest in being on this particular team, given the hassles and, especially, the lower income. Pray tell, whom will those other team members be bombarding with extra work when things go wrong, as they do all day every day? You know. And to whom will the Team doc be answering? Perhaps the Team’s evil MBA and the Team’s shareholders. 11 years post-high-school education and 200k in debt for this! Can’t we hit rewind? No, better to get traded from that team post haste, or not sign up in the first place. Better to be on Team Derm or Team Ent or Team Rads or Team GI or Team Cards or just about any team except Team Left Holding The Bag. Most med students aren’t dumb (although, curiously, I was dumb enough to go into primary care) and know a sucker’s game when they see one. It’s gonna be turned over to the midlevels and those with chronic complex care conditions will be left to fend mostly for themselves, as is often the case already.

      • southerndoc1

        The physician is a vital part of The Team: who else is going to accept the legal liability for everyone’s actions?

  • Steven Reznick

    This article is right on. Academic physicians show nothing but disdain for community based primary care physicians. They are the ” local medical doctors” they talk down all the time.Well trained generalists who complete training move out into practice and are immediately economically credentialled by hospital medical staffs and prevented from performing activiites and procedures they have documented that they are trained to perform. In rural and physician poor areas they may get to practice what they were trained to do but not elsewhere. The pay discrepancy over a lifetime is a major issue. It remains to be seen whether the Patient Centered Medical Home is the answer. Who in fact is going to pay for the nonphysician ” team members?” The goal seems to be to make all future PCP’s employees of large health systems where they lose a good deal of their independence, the very ingredient that made them special in the first place. Federal financing of medical school education must discriminate in favor of primary care training and against those specialty areas that have adequate or excessive numbers of practitioners. A new reimbursement system for primary care must be developed and may include educational loan reduction and forgiveness, economic allowances for outpatient office development and cost and some overhead and med malpractice insurance assistance. Re emphasizing the role of generalists as the family doctor of adults who coordinates care and provides advice and guidance needs to begin in medical school training and continue throughout residency training. I have advocated a year of national health service in a new NHS program in which all physicians must perform a year of outpatient generalist service before they can move onto their specialty training. It would at least give all young doctors in training an appreciation of the challenges of general primary care

    • Lucy Hornstein

      Re emphasizing the role of generalists as the family doctor of adults …

      Excuse me: Family Medicine includes pediatrics. No need to segregate primary care by age. We have been trained to care for all patients from cradle to grave.

  • LeoHolmMD

    I see a lot of wishful thinking about the PCMH. Unless this model has some new sources of funding for Primary Care, it will degenerate into exactly what you see right now: the hamster wheel.

    • rswmd

      The basic theory behind the PCMH is for the doc to do lots of data collection and administrative chores for free that benefit the insurer while still being paid at inadequate fee-for-service rates.

      A full-blown disaster that is obvious to everyone except those who keep their heads where the sun never shines (i.e., the leadership of the primary care societies).

    • buzzkillersmith

      I’ve been doing this a long time, and I have encountered only one “innovation” in medicine that has made my job better: The ability to work part-time and so limit the toxicity. I suspect you’re right about the PCMH: Perhaps improvement for a short time and then inexorable rehamsterwheelification. Oh, and how about docs being employed by hospitals and HC systems? Like Faust selling his soul to Mephistopheles. The screws are tightened in due time.

  • doc99

    Paying PCPs for their time, not CPT codes would be truly disruptive.

    • Jeffrey Mendenhall

      Disruptive to whom? The third-party payers (insurance corporations) which literally suck out billions of dollars in profits every single month? Not income; profits! CPT codes do not in any way reflect the enormous variations among patients who present with/for the same condition or procedure. We assess and treat persons, not conditions. In reality our so-called health care system is based upon reimbursing providers and purveyors of pharmaceuticals, medical devices, and so on. We simply can no longer ignore the ever-widening gap between the obscenely increasing costs and declining quality of care provided in the US. Access, or the lack thereof certainly is part of our incredibly poor measures of quality, ranging from infant mortality to prevalence of preventable chronic diseases. Primary care encompasses far greater challenges to medical knowledge, and emotional and spiritual “fitness” on a daily basis than most specialists and sub-specialists encounter in months, if not years of their narrowed practice parameters. Failure in primary care will further cripple our capacity to provide the quality health care that I believe is a basic human right.

  • Jeffrey Mendenhall

    I write as a nurse specialist with more than 15 years of practice and management in hospice and palliative care. I am now an accredited writer of CME items for a peer-reviewed journal in family medicine. Family medicine, OB/GYN, pediatrics, internal medicine, and geriatrics treat whole PERSONS across significant parts of the lifespan. I have written and published evidence- based items in a variety of areas beginning with end of life care, pain management, geriatrics, ethics, alcohol screening and family support, psychiatry, and even suicide risk. The breadth and depth of expertise required of all primary care physicians should, in a world in which human values were paramount, be rewarded not only financially, but in professional respect/standing.
    I wholeheartedly agree that nothing short of a multifaceted, coordinated approach implementing the value and evidence-based changes in our broken or actually non-existent systems could restore primary care to its proper, and historic place at the foundation of comprehensive care of people — not conditions. We do not need more research, or more committees. Pockets of high quality-low cost health care across the US already demonstrate the necessary elements: true patient-centered systems with integrated EHR (far beyond the baby-step “meaningful use” requirements in PPACA) — including point of care decision support for physicians, continuity of care across all settings, and data sharing between other provider systems, e.g., VA outpatient clinic with private physicians. This is happening. It can happen elsewhere — it is a matter of will, commitment, shared core values, and where necessary, education/training.

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