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.

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