Reform medical education to fix the primary care shortage

When I was in medical school in the 1990s, students were given a bleak picture of the life of a subspecialist. We were told that there would be few job opportunities and that the only way to ensure a job was to pursue a career in primary care. Many of my classmates did go into primary care but the majority of us accepted residency positions in surgery, neurosurgery and other medical subspecialties. As we completed our training, we found that there were actually plenty of job opportunities for subspecialists.

In fact, other than in underserved areas, shortly after my graduation from medical school primary care doctors were abundant. However, times are now much different. As discussed in the New York Times, it is becoming more and more difficult for patients to find primary care doctors. In a very short time, there will be more than 40 million newly insured patients that flood the system. All of these patients will need primary care providers.

Today’s medical students are saddled with enormous debt. The average cost for a medical education at a public university is $29k per year for four years; the median cost at a private school is nearly $50k per year for four years. Many students leave medical school and enter residency training programs with between $200 to $300k in debt. The cost of a medical education has risen almost 300% over the last 20 years. Now, particularly in primary care, salaries and reimbursements are significantly lower than in previous decades.

Add to that the ever-increasing burden of paperwork and administrative duties that are required of primary care physicians and it becomes obvious why there is a shortage of newly trained primary care practitioners. Many students pursue a medical education to make a difference and to help people–many enter school wanting to be primary care providers and work in underserved areas. However, the financial realities of debt often force students to change their minds and seek residencies in subspecialties that hold the promise of better financial return.

Healthcare reform is important. We must focus on providing quality care to patients who need it in the US today. However, we must also reform the medical education system. No longer can we continue to allow the costs of tuition to rise to astronomical levels and at the same time lower the potential earnings for medical school graduates. If we continue on the current path, we will make a medical education an “upside down” investment.

Moreover, allowing the tuition of medical schools to soar will make it more difficult for bright students with limited financial means to attend. We will, in fact, self-select medical school classes of the financially privileged and prevent other very talented less affluent students from attending. Although I was fortunate enough to receive an academic scholarship to medical school, I often ate macaroni and cheese and ramen noodles for weeks at a time in order to make ends meet. I had a job moonlighting as an MCAT preparatory course instructor.

But, I did have access to an excellent medical education. In addition to containing the cost of a medical education, we must also address the issue of the investment of time–is it really necessary for physicians to attend four years of undergraduate work and then four years of medical school? In many countries in Europe, a combined track of 6 years produces well trained physicians that do very well in US residency training programs. Many students do not begin their careers until their early 30s due to the combination of undergraduate and graduate degrees coupled with prolonged fellowship training programs.

The US offers some of the very best training for physicians in the world. We are fortunate to have some of the finest institutions with cutting edge technology. Our students are able to be trained in the most sophisticated medical procedures and are able to participate in research that makes a difference in the lives of many patients. However, the medical education system in the US is currently broken and something must be done to fix it quickly if we are going to keep up with demand. No longer can we squeeze the young physician at both ends–astronomical educational costs, prolonged times to acquire both undergraduate and graduate degrees must be addressed as salaries and earning potentials continue to be regulated, lowered and limited.

Primary care doctors are essential. They are the entry point for patients and the stewards of our healthcare. Yes, there is a shortage of primary care physicians today and even greater shortages loom ahead. In order to fix this problem, we must closely examine the system and make changes that allow for access for all qualified students with a more reasonable time investment. In the end, our goal should be to produce the best physicians in the world, who are motivated to care for the patients who desperately need them today and in the future.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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  • Earl Smith

    Primary Care residencies also need to made less awful. At the school I attended, the IM residents were profoundly exhausted and depressed. Three years of unhappiness was the primary reason I decided against a Primary Care residency.

    • Kristy Sokoloski

      As for making Primary Care residencies need to be made less awful, how do you suggest that be done? The reason I ask is because a number of the patients seen by the Primary Care physicians have multiple chronic health problems. And unfortunately that can take many hours of work (and yes that includes the discussion time that goes on in the actual appts with each patient) to try and help these patients become stable. Part of being stable may mean helping the patients get to needed specialists for further care of those problems.

      Something that the clinic where I go for Primary Care needs has done is to not only have an MA to help with the back office stuff, but having an administrative assistant for each doctor. That administrative assistant will be working on calling about getting lab results for tests ordered as well as some other administrative responsibilities. They are calling this concept a Pod. I am going to be interested to see how this works out but I think it’s a good idea.

      I had a relative spend some time in the hospital in the middle of Jan. And during that time I got to see the other aspect of the job that her Primary Care Physician had with regard to caring for her. And one of the days I was there he looked especially tired because of how hard he had been working all day. This experience caused me to have even more empathy for just how hard the Primary Care Physicians work. Unfortunately, if there are not enough Primary Care Physicians to go around the burden of caring for these patients then falls to the specialists. Many specialists don’t want to be involved in Primary Care because of the fact that they are a specialist. So, if there are not enough Primary Care Physicians to go around and the specialists tell the patient that they don’t get involved in Primary Care what is a patient to do? Where do they go? Everyone talks about having NPs and PAs help with some of this shortage as we have seen in other articles through this site. That’s great for those that don’t have alot of health problems or complicated medical history. For those that have a complicated health history they have good reason to be very concerned about what’s coming.

      • buzzkillerjsmith

        Yesterday I saw a new pt with postconcussive syndrome, new onset nocturnal enuresis, PTSD, chronic pain on opioids, and history of repeated head trauma. No heart failure, thank goodness. But still those fifteen minutes were not enjoyable.

    • buzzkillerjsmith

      I don’t miss those days at all. Up 30 hours and trying to listen to a litany of complex complaints in post-call afternoon clinic from a pt that has waited a long time to get an appointment. A nasty experience indeed, and a common one.

      • Shirie Leng

        No kidding. I started out in internal medicine, but those post-call clinics killed it for me.

  • buzzkillerjsmith

    It’s not medical education itself that is the main problem. It’s the effort/reward ratio in practice. It’s the money. I write this as a family physician of 23 years who precepts and has extensive clinical and medico-philosophical conversations with first-year University of Washington medical students. I put a positive spin on it, and the youngsters mostly buy it, or at least they pretend they do, a very polite lot. That will change for most of them.

    Primary care is interesting. It’s a people field, but it also involves the process of differential diagnosis. DD is intellectually challenging and a heck of a lot of fun. It helps people. Lemierre’s disease, malaria, myelodysplasia, ITP, pulmonary aspergillosis–all relatively recent outpatient cases. Appendicitis on a routine basis. But here’s the thing: in order to do this cool stuff, we all give up $150k or more per year. We are in a lower socioeconomic class than we would be in had we sub-specialized.

    This might not have been the case when I started out. I’m not sure. But a quick Google search now shows the incomes of various specialties. The med students have noticed. They’re young and they think that more money will make them happier. They might be right. They’re a new generation and do not have the martyrdom needs that we oldsters seem to have. Good on them. It’s about time.

    Certainly the chaotic nature of primary care will also give them pause. And more income would allow hiring more help and perhaps shorter hours. It can directly translate into a better quality of life, at least in primary care.

    And you know and I know that subspecialization in available to almost every halfway decent student who graduates from a halfway decent American medical school. Maybe not in electrophysiology ( and I know you work your tail off and help people greatly), but in something.

    Cutting med school tuition. Sure, it will help a bit. But med students can do arithmetic. They know that an extra $150k/year will pay that debt off in no time. It’s the money.

    New patterns of practice? The PCMH is to be our savior. Doctors, NPs, PAs, nurses, MAs all working together to improve care and to save money. Everyone working “at the top of his or her license.” That sounds like a recipe for a lot more work for maybe a little more money to me and to many of the other experienced family docs I talk to. It smacks of desperation on the part of the IM and FM nomenklatura.

    Think of it this way. Thirty years ago it was decided that urban education was in crisis and that more and better teachers were required. Was more money forthcoming? Not really. But jawboning was.

    They even sent a teacher into space to show how important teachers are. But not much more money. Thirty years later we still have a shortage, or at least a revolving door. The effort/reward ratio.

    Will a lot more money be sufficient to attract the number of PCPs that pundits say this county needs? Your guess is as good as mine. But the prognosis is hopeless without it.

    • newheart807

      The issues outlined in your response are real “on the ground issues”; that said, until the way CMS pays for medical education is changed, very little else will change for family practice in the United States. In fact, a case can be made for it not only getting worse but being a victim of Creative Destruction.

      Yes, “it” is all about the dollars and cents; about that one should not be mistaken. Yet, it is also about the scope of family medicine, not in academia, but in the “real world”. The reality is that in the United States (as opposed to Great Britain, Canada, Germany…) that scope becomes more and more constricted as more and more medical information becomes available to be learned and technology imposes its inexorable demands and expectations upon our “system”.

      These facts, along with the expanding roles of physician extenders in coping with the beneficiaries of wealth transfer in healthcare further marginalize the family practitioner.

      To all the above add the myriad rules and regulations that need to be followed, the cost of incorporating EMRs, decreasing Medicare rates that ARE coming, the ever thundering avalanche of paperwork and now the new HIPPA regulations whereby, among other abusive regulations, we are now responsible for the activities of our vendors, the real question is “Can Family Medicine survive?”

      Likely not.

  • Margalit Gur-Arie

    Meh…. The business people solved the primary-care physician shortage problem through patient-centered diversion of patients to non-physicians and computer care. It’s really brilliant and applicable to all sorts of other things…. like when there is a shortage of bread, you can divert people to eating dirt…. should work perfectly.

    • buzzkillerjsmith

      Yep. The article is comical, really.

      The primary share shortage could also be solved by means of magic scanners that would cure also disease instantly. Ten bucks at Walmart.

      My inability to win an Olympic gold medal in sprinting could solved by switching bodies and minds with Usain Bolt.

      Energy shortages could be solved by perpetual motion machines….

  • Steven Reznick

    Its about the reimbursement and money in your pocket at the end of the day that drives students into non primary care areas of medicine.. We are dealing with older , more complex patients who need more time and concern and listening skills to care for them well. The time is not available in a traditional family practice or general internal medicine practice if the physician hopes to meet his/her overhead. Cutting the length of medical school and residency in a more complex, technical era leaves you with less well rounded physicians. Dividing medicine into outpatient clinic or office doctors and inpatient hospitalists asked to see obscenely large numbers of new more complex patients during a shift is not the answer either. The answer is to make general internal medicine and family practice compensation higher. The answer is to grant loan forgiveness to doctors who agree to go into primary care and stay there for 15 years post training. The answer is to offer primary care practices favored tax treatment and office overhead assistance. The answer may be to offer primary care doctors financial assistance for their growing young families future education at public institutions. These are the same incentives that government has used to attract industry and business to areas for generations but seems to be a blind spot in the eyes of our current political leaders at all levels of government. How about restricting the number of specialty fellowship slots to correspond with the nations actual future needs? There are plenty of answers but when the Medicare Payment Advisory Commission is made up of 19 procedural specialists and only 3 PCPs there is no interest or creativity in changing the system. Since private insurers work off the Medicare fees to determine their rates the PCP is never really compensated appropriately.

  • Social@ Intead

    Nice Information about medical education.Just i real below all comments.All are good.

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