Why the primary care physician shortage is overblown

Are there really too few primary care physicians? And if so, what can we do to solve the PCP shortage? The standard answer to the first question is “yes, we have too few PCPs.” And the standard solution is to train more such docs, or allow more foreign-trained primary care docs into the country or, better yet, simply pay PCPs more money, so that graduating medical students will be more likely to pursue such careers.

I have a different set of answers. To the first question, of whether we have a PCP shortage, my answer is: “Maybe yes, but very possibly no.”

Keep in mind, before you rush to judge my answer, that I am a proud primary care physician, trained in general internal medicine. Coming out of residency, I was happy to achieve lower pay than my subspecialty colleagues in order to experience the pleasures of taking care of “the whole patient.”   I also finished medical school all the way back in 1988, when the expense of such schooling (especially a state university like the one I attended) didn’t burden me with six figure debt.

Keep in mind, also, that I think primary care is crucial to offering high quality, affordable medical services to people. I’m a HUGE fan of primary care. And I think way too few patients in the U.S. have access to good primary care.

So how could my answer to whether we have a PCP shortage be “very possibly no”?

Because of that last “P” in “PCP”—the P for “physician”. We need to think more clearly about whether it is more primary care physicians that we need or, instead, more primary care clinicians: nurse practitioners, physician assistants and the like.

Take the growing gap between medical school graduation numbers and residency slots, as captured in this picture from Sarah Kliff at the Washington Post:

Why the primary care physician shortage is overblown

Medical school graduates call this gap the “jaws of death.” The problem it highlights is that hospitals have not grown residency positions as quickly as they have grown medical school slots. In part, this is because the federal government funds many residency positions, and such funding has stagnated.

To address this gap, the Affordable Care Act (aka “Obamacare”) put $167 million toward funding new residency slots under its Primary Care Residency Expansion program. (Sarah Kliff writes more about that here; she is a MUST read for anyone interested in US healthcare policy.)

I’m happy about this funding, and think it will help address these two problems, of primary care shortages and the jaws of death.

But it won’t solve either problem. And that is why, to help promote primary care, I’d love to see more PCPs adopt an anesthesiology model of practice. Here is what I mean by such a model.

In many operating rooms today, the majority of anesthesia will be handled by a nurse anesthetist, under the supervision of an anesthesiologist.  In some cases, that will mean that one physician anesthesiologist will be “running” 2, 3, maybe even 4 operating rooms at a time. The anesthesiologist will have devised the anesthesia protocol for each patient. The anesthesiologist will be there for the trickier parts of the operation: the induction of anesthesia, for example, or any part of the operation where the patient’s vital signs fluctuate.  But given that most patients, especially those with low risk operations, fly through anesthesia without any complications, nurse anesthetists are able to handle most of the care without a hitch. Meanwhile, the anesthesiologists make a very nice living, since they are able to take responsibility (and therefore bill) for more patients.

Many primary care clinics already weave together physicians, physician assistants, nurse practitioners and registered nurses. I am just raising the possibility that if we do more such weaving, we can reduce the primary care gap.  Linda Green made a related argument in a recent Health Affairs paper.

I think this model could be a much more attractive way for physicians to practice primary care.  First, it would mean that many more routine visits would be handled by non-physicians. And for all of the joys of practicing primary care medicine, you have to realize—it can get routine. Most primary care physicians would probably be happy to spend a higher percentage of their working time taking care of more complex primary care needs than adjusting blood pressure medicines and treating colds.

Second, this model could increase primary care physician pay. By seeing more patients per hour, such doctors would be able to bill for more patient visits.

Third, it means getting more trained primary care clinicians, of all varieties, in front of needy patients. It reminds us that it is primary care that is in shortage, not necessarily primary care physicians.

When I practiced in the VA setting, I had the great pleasure of working closely with many excellent nurses, nurse practitioners and physician assistants. Together, we were able to offer a standard of care that experts say matches or beats the care most Americans receive.  If primary care practices more aggressively adopt an anesthesia model, we might simultaneously expand access to primary care while improving the quality of the care we provide.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

Comments are moderated before they are published. Please read the comment policy.

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    ” this model could increase primary care physician pay. By seeing more patients per hour, such doctors would be able to bill for more patient visits”

    see more patients an hour? get visits down to even less time? spend even
    less time actually in front of my patients?? and this increases the quality of primary care how??

    no thanks.

    • http://www.facebook.com/drmcompton Michael Compton

      I respectfully disagree, and feel that the AMA has had a strangle hold on the healthcare industry for far too long. We need competition in the systme, from NPs, PAs, and even Chiropractors as each of these disciplines serve their roles and are greatly underused. I also feel that these profession need to step up there training to be better fit for a specific area of practice, as what the nursing profession is doing with their change to DNP, and fellowship training. Training more Medical Doctors will help, but we have answers right now to advance the scope of the aforementioned professions, as long as the providers are meeting board qualification in the newly proposed expansions.

      • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

        Ummm…. nurses dont take the board certification exams that doctors take. I’ve seen their “exams” and they are a joke.

        A board certified physician >>>>> “board certified” nurse

        • ProudOkie

          Please excuse Jason……forgot to take his meds today. Please review some of his old posts. Very vile and denigrating.

          • Suzi Q 38

            O.K.
            Maybe David Behar can chime in soon. I miss his posts.

      • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

        You do realize that chiropractors have almost no medical training outside of the musculoskeletal system. Including no pharmacy training. They already operate outside their scope of practice.

        I love PA’s and NP’s. Very useful and many make good providers, however, they simple fact is they have A LOT less education and A LOT less training. If they want independent practice licenses then they need to go to medical school and complete a residency. If they want to provide great care under the supervision of a physician than they should be a PA (Physician ASSISTANT) or an NP (NURSE practitioner).

        In my previous job I reviewed the care of all the providers at my clinic on a semi-regular basis. I routinely saw more mismanagement by the NP’s and PA’s then anyone else. I feel the reason was lack of enough experience and lack of actual physician oversite (which I was trying to correct). Sadly I found a lot of NP’s resistant to correction or re-education. Our PA’s often were much more approachable.

        • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

          “Sadly I found a lot of NPs resistant to correction or re-education. Our PAs often were much more approachable.” Would this have anything to do with the fact that the PAs are taught according to the Medical model and not the Nursing model?
          I also agree with about that if they want to have an independent license then they need to go to Medical School and complete a residency. And then if they want to provide great care under the supervision of a physician to be either an NP or a PA. When patients come to the clinic for care the majority of them prefer to work with their doctor especially when if they have complicated medical histories due to multiple chronic medical problems.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      Agreed Brian. I had a long discussion with a few colleagues this weekend and we all agreed that optimal primary care is 16-18 patients per day. Sadly most of us are seeing 20-26 per day.

      I have no interest in seeing more patients.

  • southerndoc1

    All offices running on this plan should have a large sign in the waiting room: “If you are a simple patient with a simple problem, you will not be allowed to see your doctor.” That’ll be a real practice builder.

    “And for all of the joys of practicing primary care medicine, you have to realize—it can get routine”
    But supervising NPs and Pas seeing routine cases, that’s an intellectual thrill.

    “Most primary care physicians would probably be happy to spend a higher percentage of their working time taking care of more complex primary care”
    Complex is a euphemism for demented 92 year old nursing home resident on 18 meds and with 5 new problems, including social issues. Yes, a full schedule of 20 patients per day like that is just what every primary care doc wants.
    You have no understanding of what physicians and patients want in primary care: a long term relationship based on mutual trust, respect, and a shared background of knowledge. Seeing patients only when they are “complex” absolutely destroys that relationship.

    • N N

      The reason Peter Ubel fails to understand what physicians want in primary care is because Ubel is an ivory tower academic. Go to his blog where he has posted his CV. He’s now a professor with NO clinical (meaning actually seing patients) responsibility currently. I love the ivory tower academics who don’t have any skin in the game dictating how primary care should run for those of us in the trenches. What he fails to mention, or most likely just doesn’t know, is that CRNAs are fighting at the state level for independent practice rights just as PAs and Nurse Practioners are doing the same.

      • ProudOkie

        Thank you for mentioning that. If you think NPs are going to lay down and accept their lot in life, think again. You think I’m going to just close my private clinic and take a monstrous pay cut? If I ever worked in this Ponzi scheme everything would be complex and get referred to the “captain of the ship” and I would collect my check and go to the lake. Period.

        • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

          You already “laid down” when you became a NURSE AND YOU’LL NEVER BE ANYTHING MORE THAN A NURSE. YOU ARE NOT A REAL DOCTOR, YOU GOT YOUR TRAINING OUT OF A CRACKER JACK BOX! NOW GO EMPTY MY BEDPAN!

          • ProudOkie

            For all to see….and you wonder why. Please don’t remove this comment moderator. It is the epitome of why NPs are so successful. Thank you Jason for posting that.

          • innocent bystander

            If I were an NP in private practice, @ProudOkie:disqus , I’d be thanking my lucky stars that Mr. ANGRY SHOUTY ALLCAPS has effectively made the decision to self-select out of my pool of potential patients. ;-)

          • buzzkillerjsmith

            NPs and PAs help a lot of people in this country, dude. You’re way out of line

          • Suzi Q 38

            Very funny. Quit shouting.
            Are you really a doctor, Jason?
            Anger must come from fear in your case.

          • http://twitter.com/Meryl333 Meryl at Beanstalk

            Ii understand your frustration. The system is wearing good doctors and nurses down. Still, Your reply is abusive. If you are feeling that angry, try going to your nearest mindfulness training workshop, sit quiet and get a grip on what is going on in your mind. When every we get triggered like that, it’s not the trigger causing that kind of response. Hope you get some mental and physical rest. Mostly that’s what we all need. Then we will ask the right questions and find solutions to health care. Right now we have attack medicine. We attack symptoms. We can do better.

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    Unfortunately, for people who have a complicated medical history thanks to multiple chronic medical problems there is no such thing as a “routine” visit. I have a couple of friends who because of their complicated medical history had a hard time finding a Primary Care Physician who could take care of them, and coordinate the care they need when it comes to the specialists that need to be brought in for additional care as one example.
    I am with Dr. Brian about the seeing even more patients per hour. This is already a big problem where in some practices the doctors are already seeing like 35-45 patients in a day. Some of those that are primary care physicians are no longer able to see their own patients in the hospital when the patient must be admitted to the hospital. Having them see even more patients in the office will cause the rate of physician burnout to be even higher than the statistics we hear about now.

    • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

      If you work in primary care and your doctors are seeing 35-45 patients a day they are looking to get sued for malpractice and coding fraud. 8 hour work day, that would be 6-7 patients an hour. You can’t educate a patient about their condition, medications, or follow through in that amount of time. Its the equivalent of a medical puppy mill.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Dr. Beau,
        I have to agree with you about the issue of looking to get sued for malpractice and coding fraud. Unfortunately, in the clinic where I go there was a doctor that was seeing that many patients a day or close to it based on what the MA told me at that time. This was some time ago that I was told this, so I don’t know what the situation is like now. I do know that I was thinking “oh my goodness, that’s not enough time to have important discussions” such as on the things you just mentioned. Interesting analogy to likening it to a puppy mill. I have heard others describe it as like herding cattle. Thanks for your input on this.

  • Hunter

    Who would pay the salaries of all these physician assistants? If it comes out of the physicians pay then there wouldn’t necessarily be a pay increase.

    • buzzkillerjsmith

      Corpmed, employer of both doc and midlevel, will do it. Of course then Corpmed decides who gets hired, and the doctor gets no say over things. Drones don’t hire the other drones.
      Primary care docs don’t have the resources to practice primary care medicine how it should be practiced and with a reasonable income. And employed PCPs, in time, get to hate their jobs because of disrespect and lack of control. Ergo, med students who go into primary care are fools.

    • Suzi Q 38

      Wouldn’t the added patients that could be seen pay for the salary of the PA or NP?

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        Suzi Q, I am sure that the added patients that could be seen would pay for the salary of the NPs and PAs but then there would be a lot of problems with burnout among them. Some PAs already have this problem now. I used to know a PA that worked at the clinic where I go for Primary Care, and when I went back to them almost 5 years ago I found out she was gone. She had gotten burned out. So the issue of adding more patients would affect the PAs and NPs also. I don’t know what the current stats are on the rate of burnout among them, but if it’s low right now it would be much higher then just like what would happen with physicians as I stated above.

        • kjindal

          Where I work (large nursing home) there is MUCH higher turnover among the NPs than MDs. Maybe this is because their training is much shorter, so less vested interest in making a situation work out? Not sure but in terms of roles/responsibilities/pay, they are surely not getting a bad deal (probably around $120k/yr plus benefits and stock options from their employer, who is a large insurance company).

  • buzzkillerjsmith

    Ubel’s post is sheer idiocy. As southerdoc said, taking care of one brutally complicated pt after another while simultaneously supervising the midlevels is no joy. Med students would be aghast. They already are. Add to that the fact that your employer, Corpmed, would replace you by those same midlevels in a heartbeat, and you begin to get the picture.
    Ubel’s model is unstable because its analysis of the incentives that primary care physicians and their employers face is naive and foolish.

    • southerndoc1

      “Ubel’s post is sheer idiocy . . . its analysis of the incentives that primary care physicians and their employers face is naive and foolish”
      The amazing thing is that the AAFP and ACP are pushing the exact same BS.

      • LeoHolmMD

        Right. The biggest pushers of fracturing care into a shattered mess…the so called “patient centered medical home”. Does anyone really think that patients want to fight their way through some video game inspired pyramid scheme to get comprehensive care?

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

    I like the name though. Anesthesia model. Very apt.

  • http://www.facebook.com/vikas.desai.92560 Vikas Desai

    basically a private doc who is willing to work hard can easily cover any shortages, but as long as it is economically not feasible for a private doctor to stay in business and big health orgs continue to chew up small practices and insurance companies continue to nickel and dime private docs but then give huge sums of money to hospitals and out of network providers this will continue. A private doc, will squeeze patients in, will do the occasional home visit, will call in that med because they know the patient works 60 hours a week and can’t come in. An employed doc/np basically waits till 5 and the goes home, knowing they can get a job anywhere else if their employer let’s them go.

  • Simon T.

    From a patient’s point of view, how will we avoid situations like, “I’ve been vomiting blood for three weeks but my insurance company will only let me see a chiropractor”? Or having an insurance company tell someone they’re only allowed to see a nurse or play-doctor for their abdominal bloating, and s/he prescribes diuretics or a low-salt diet for what later turns out to be ovarian cancer or some such? “What could go wrong?”

    Who is going to be the gate-keeper who decides whether a hapless patient is “deserving” of seeing a REAL doctor? If it’s the insurance company, then lookout for the almighty dollar. If it’s the play-doctor, then lookout for egos.

    If you have a lovely cherished BMW, whom do you want to fix it when you take it in for repairs: a trained & authorized BMW mechanic or some random high school “shop class” graduate?

    • ProudOkie

      They will make me your PCP. And I will introduce myself as play-doctor and you won’t have a choice. Pathetic. And you aren’t a typical patient.

      • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

        It is quite pathetic and so are you. By the way, you never told me the name of your “collaborating” physician so I could report him to the state medical board. All NPs in Oklahoma are required to have a “collaborating” or “supervising” MD.

        • ProudOkie

          And this the reason for the need to practice to the full extent of our authority. You utilize the law as power and intimidation.

    • Homeless

      Currently, the person who decides whether you have a problem worthy of a REAL doctor is the receptionist who answers the phone.

  • http://www.facebook.com/profile.php?id=1536833852 Rick Lundgren

    This is a better model rather than letting Naturopaths, Chiropractors, or Chinese medicine specialists taken on this role. That is the real danger, rather than an NP who can treat 80% of diagnoses that come in and could refer to a physician level GP anything outside their scope of practice.

    • N N

      What’s to stop Naturopaths, Chiropractors, or Chinese medicine specialists from doing the same? NPs are asking for INDEPENDENT and AUTONOMOUS practice. In other words, they want the full scope of general practice.

  • ninguem

    There is no primary care shortage.

    The people CLAIMING there is a “shortage” and a “crisis” have underlying agendas that have nothing to do with improving access.

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

      Nice!

      There is however a shortage of willingness to spend money to provide proper medical care to poor people that are going to be “covered” shortly. Hence all these harebrained models for make-believe health care. These things are just for poor people. Nobody that is suggesting this stuff is actually planning on receiving their own medical care from these places.

  • chachacha222

    This graph lacks a measurement of slots actually filled and how many unique applications were to each slot. It takes no consideration into the idea that 1 resident may apply to 20 spots.

    Lack of a very rudimentary consideration makes the data your conclusion is based off irrelevant

  • Diagnosus

    Anasthesia vs. primary care: Routine/impersonal vs. dynamic/personal. If primary care can be automated then it is only a matter of time that all primary care provider functions; visits, NP etc will be outsourced to a corporation opearting from say India. Insurence companies would love that. I go to my primary care physician for advice based on his understanding of my history and concerns which simply cannot be automated or cloned.

    • kjindal

      the trial lawyers (and thus the Obama/Sebelius machine etc.) will never let this happen. It would take away their gravy train of campaign contributors.

  • http://www.facebook.com/people/Judy-Pendergrass-Berger/1576932169 Judy Pendergrass Berger

    There may be “enough” docs but it seems like a majority want to live and work in upscale areas in cities or the ‘burbs. If they are unwilling to serve rural populations, Native American reservations, those who are on public assistance and the like then it is a problem of access. There are many counties in my state that don’t have an MD within their borders. Fortunately nurse practitioners often jump into the void and care for those that would have to travel great distances in order to receive basic care. These counties don’t have a hospital either, so patients can’t show up at the ER for care. At least not one that is nearby.

  • sdietrich17

    Dr. Ubel, I agree with you wholeheartedly, except for your statement that by leaving the mundane cases to NP’s or PA’s, and seeing the more challenging patients, we as physicians could see more patients and therefore make more money. It is exactly the opposite: when you see more complex patients you see fewer patients, because they are more COMPLEX, and though you may be able to charge a level 4 or 5, you cannot increase your volume of patients without working a few hours longer each day. This is the problem the Primary Care Practices are dealing with every day. And, you cannot bill for providing consultation for your NP’s and PA’s, at least in my state.