We are spending billions to train the wrong kind of doctors

Earlier this year, the physicians at my academic family medicine practice met with two senior officials from our parent health care organization to be oriented to its new initiatives and projects. Their presentation documented the organization’s ongoing investments of many millions of dollars into renovating subspecialty care suites and purchasing new radiology equipment that was likely to be highly profitable, but provide dubious benefits to patients.

Two of my colleagues asked why, given the expected influx of millions of newly insured patients into primary care starting in 2014, and an estimated shortfall of more than 50,000 primary care physicians by 2025, the organization had not identified expansion of primary care training as a financial priority. Where exactly did they expect to find family physicians to staff all of the new community offices they planned to open? An awkward silence ensued, followed by some polite hemming and hawing about how this was a complicated issue, and that supporting generalist training would likely require additional funding that was perhaps beyond the organization’s limited resources.

Additional funding required? How about $9.5 billion? That’s the approximate amount that that Medicare spends each year, with no strings attached, to subsidize the cost of training physicians in U.S. residency programs. Noting that the federal government doles out these dollars without requiring any particular outcomes from the institutions that benefit from them, some have called for Medicare to hold institutions more accountable for meeting America’s physician workforce needs.

If we have a surplus of radiologists and a shortage of general surgeons, why not tie funding to training more of the latter and fewer of the former? Given the decentralized nature of the U.S. health system, though, that has been easier said than done. In particular, it is challenging to follow the money trail and determine which institutions end up producing which types of doctors.

new study in Academic Medicine by health services researchers at George Washington University and the Robert Graham Center fills this information gap. Painstakingly assembling and cross-checking data from several sources on actively practicing physicians who completed their residency training from 2006 to 2008, they were able to identify residency-sponsoring institutions that were top producers of primary care physicians, that produced lower proportions relative to all physicians, and that produced none at all.

Notably, they conclusively disproved “The Dean’s Lie” that counts all internal medicine residents as going into primary care (when only 1 in 5 actually plan to do so), demonstrating that at some institutions fewer than 1 in 10 internists become primary care physicians. They also identified a large funding discrepancy between the top and bottom primary care producers.

The top 20 primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates (41.0%) and received $292.1 million in total Medicare GME payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates (6.3%) and received $842.4 million.

In short, where physician production is concerned, you get what you pay for. In this case, Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, even in specialties where supplies are plentiful, at the expense of training sorely needed family physicians and other generalists whose presence has been shown time and again to deliver better health outcomes.

That’s the big picture. Since all politics is local, policymakers who want to know what types of physicians their teaching hospital or health system is training can use the Graham Center’s free GME Outcomes Mapper tool to find out. And if enough of them do so, maybe we can all have a serious national conversation about moving beyond guaranteed health insurance coverage to ensuring that the care (and the workforce) that coverage is paying for will actually help us to live longer or better.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • JD

    I think it is important to remember that all medical and pediatric subspecialties (infectious disease, rheumatology, cardiology, etc) require full training in primary care, general internal medicine/pediatrics BEFORE subspecialty training. In other words, medical and pediatric sub specialists are trained to provide primary care, if needed. The problem is not whether we are training enough primary care physicians. It is a matter of whether we can make it more appealing to go into primary care.

    • ErnieG

      About subspecialists trained to provide medical care–That’s BS. Primary care is as much a specialty as ID, rheum, cards, etc– and this is coming from a rheum. Like anything you do, the more you do, the better you get at it, and the less you do, the less better you get. While specialists go through generalists training, it does not mean that you can be a practicing generalist. Out of training, you get a set a skills that must be honed and practiced, and that gets better and better the more you use them. As a specialist, I don’t seem myself as above or beyond general medical care, but rather in addition to it for patients that require help with conditions I know how to treat well.

      • JD

        Your argument is completely lacking in logic. Suppose you have person “A” who has just completed a pediatrics residency. Now consider person “B” who has just completed a both a pediatrics residency and a peds rheum fellowship.

        How can you possibly argue that “A” is more qualified than “B” to practice in primary care? Yes, the more you do, the better you get at it. But medicine is a lifelong learning process, and we all need to start somewhere. I know many medical/pediatric subspecialists who stopped practicing in their subspecialty and became excellent primary care providers. Some even put their subspecialty training to good use in their primary care practice.

        My point – the shortage of primary care providers is not because we are under training them. It is because too many internal medicine and pediatrics residency graduates, who ARE trained to be primary care providers, want to continue on to subspecialty training instead of becoming primary care providers.

        The solution is not to train “more generalists”. It is to get them to STAY generalists.

        The solution, therefore, is to create an environment where being a PCP is more lucrative and respected….this is something I wholeheartedly support.

        • ErnieG

          I agree that the problem is not undertraining for primary care. I also agree that the problem is that primary care “sucks”– i.e. few want to go into it. I will also tell you most IM programs are not designed to produce primary care physicians- most of the care is inpatient hospital training. IM programs are best at making hospitalist and specialist- training for primary care as an outpatient chronic longitudinal care is poor. Nevertheless, I mistook your comment to mean that specialists can become generalist, because they too were generalists once. I think that the more you are a specialist, the harder it gets to be a generalist. I am sure both agree that there is a real, tangible value to generalist, and that there should be more of them.

      • Suzi Q 38

        I so agree with you.
        Unfortunately, I have had experience with what you are talking about.
        For this reason, I am very nice to my PCP.

        • Alice Robertson

          That’s very wise because research shows if a doctor likes you then you get better treatment. And that’s just basic, good common sense. If they don’t like you a few will play games….like holding off on refills for pain meds, etc. Thankfully, most do their jobs well without an emotional back rub:)

    • Suzi Q 38

      What I have found though, that some specialists have lost their “general practice” skills.
      For Example, I complained about my nerve sensations after a hysterectomy. This scared my doctor so much that he didn’t want to treat me. He “ran” from me, instead of insuring that I had the right care.
      I had to demand care and a neurology consult.
      I surmised that he was afraid it was his surgery.
      I am not sure that it ever was.

      This whole experience taught me that the specialists are “specialists” with their own areas of expertise.

      Asking them to become a PCP is just too stressful and difficult.

      They need to be more and more aware of the fact that the human body is a lot more complex than just their area of expertise.

    • Dr. Drake Ramoray

      “In other words, medical and pediatric sub specialists are trained to provide primary care, if needed.”

      That is quite the assumption that you are making there. It undercuts the continuing education and experience that a good primary physician has incorporated through years of practicing medicine. Yes, at one time I received the same training as a primary care physician prior to an Endocrinology fellowship. However, I have not provided primary care services in almost a decade. I am in no way as qualified to perform as a primary care physician as someone who has been doing so over the last decade. It’s this sort of thinking, like when my former practice was bought by the hospital and they wanted me to do inpatient primary care duties, that makes me consider not recertifying in internal medicine. I can just say I’m not board certified in IM, and can’t help you there. This is of course until it’s mandatory to pass the IM boards to sit for specialty boards.

      There are exceptions, but most specialists I know have no desire, and are no longer really qualified to be primary care physicians. The above assumption also doesn’t take into account quality initiatives through EMR data dredging. IF I assume the primary care duties of some of my patient’s then the data would have to be teased out on who I am and am not providing primary care services otherwise I will get dinged for the absence of mammograms, DEXA, and lipid testing on patient’s who I only see for their thyroid cancer. At this point, I just become a primary physician who also provided Endocrinology services. That’s great except there aren’t enough Endocrinologists either.

      If you want to talk about a shortage of physicians , how about only 6000 Endocrinologists in the whole country. We already see patient’s from 2-3 hrs away because there is no other Endo closer.

      I agree that it needs to be made more appealing to go into primary care, but medicine is moving in the opposite direction, regardless of pay scaling as a factor.

      • JD

        “Yes, at one time I received the same training as a primary care physician prior to an Endocrinology fellowship. However, I have not provided primary care services in almost a decade.”


        You just proved the only point I was trying to make. The problem is not with undertraining primary care physicians. The problem is that primary care is not appealing enough to keep primary care trained physicians to stay in primary care. As result, they go on to subspecialty training and practice.

        I never said that as a subspecialist, you would be able to become a primary care doc at the drop of a hat. It would take time, and you would need to adjust. However, what is stopping you is not a lack of training, but a lack of desire and incentive. Hence, the premise of the original article is wrong.

        • Dr. Drake Ramoray

          As others have, I mistook your comment to mean that specialists can become generalist, because they too were generalists once. This is a situation I have encountered before, and was actually one of the deciding factors to leave a job. It is not just about money or reimbursement as I actually don’t have much of a pay difference in choosing to be an Endocrinologist (which is also one of the reasons why there aren’t many Endocrinologists.)

          My issues was not with your conclusion and I pointed out that there is little incentive to be a primary care physician. There isn’t much incentive to be an Endocrinologist for most doctors either (at least 50% of any private practice will be diabetes, most of whom are referred because they are non-compliant) but it is what I enjoy doing.

          Primary care has turned into a life of being the insurance companies and Medicare’s scut monkey scribe. Prior authorizations, meaningful use, mandates, red tape. I have considerably less red tape to deal with and generally speaking have one problem or related problems to deal with at a single visit. I still feel that I have enough time to spend with my patients (for the most part).

          I don’t care how much I would get paid as a primary physician, I still wouldn’t do it. The day I was told I was going to be expected to do primary care was the day I started looking for a new job. IF on a national level I’m going to be asked to do primary care “if need be” is the day I start looking for a new career.

          We are in agreement that it stinks to be a PCP, we need more of them, and their needs to be more incentive for a physician to be a primary care doc. As it stands medicine is currently heading in the wrong direction except for some minor Medicare reimbursement tweaks. For me, it’s not about the money, it’s about the practice environment in primary care which is generally terrible unless you go concierge.

      • Alice Robertson

        This is understandable. Our ENT is the head of Otolaryngology of NE Ohio and we complained about sinus problems. He turned and shared, “What you really need is a good ENT!” I laughed and he explained that his skills with sinus problems are too rusty to treat well. Honestly, his answer was so refreshingly honest.

      • Bob

        Ah the good old days come back to haunt us. You might remember back in the 80′s when PC docs were told their job as “gatekeepers” in order to “screen” patients to send them on to the docs who were expert in the “age of specialization”. When they did so the patient and the physicians specializing in the field of medicine knowing more actually did a good job, until or unless the patient had another condition at which time the GP, whose job became an “anchor” as when treatments changed in the original condition, unless and until it flared up again the patient would never see the original specialists for continuing care.
        So today the GP’s are like home plate in baseball and must be touched at each point of care, which today are: prescriptions for existing drug refills, and/or referrals for tests and to specialists. A trip to the GP is usually only to get one of these 3 pieces of paper when the GP and the patient know what the purpose of the appointment is and that the GP isn’t a big part of it until the test come back requiring another visit to get a referral. So why use up GP time ordering refills when pharmacists are doctors too now, and why do we have to see GP’s to get routine tests from licensed facilities? And why aren’t patients with known health conditions assigned to specialists when their conditions will require patients see them routinely? Patients know and so do doctors who allow government to run their businesses regardless of who pays for it!

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

    I am certain that the “parent health care organization” will find “innovative” ways to staff all those “community” clinics, whose sole purpose is to generate and funnel referrals to lucrative specialty services, without wasting company funds on training family physicians.

    • buzzkillerjsmith

      Wow, are you cynical. And you know what they say: “No matter how cynical you get, it’s never enough to keep up.”

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

        I guess your enthusiasm is contagious… :-)

        • Alice Robertson

          I think the reason people like Buzzkiller’s posts is because of his honesty. And people are very suspect of organizations that exist solely for political reasons and post not out of altruism but wanting more gravy train and bureaucracy because like AARP they are out there shouting away while their very livelihood depends on their shouting. Not that doctors aren’t hypersensitive at times…..hey there’s enough cynicism to go around:)

  • http://glutathionepro.com/ Glutathione Pro

    The line right at the end of this article spoke volumes to me, “to actually help us live longer OR better”. I question the ethics and passion of some doctors, regardless of training it seems money is the deciding factor in which medical treatment they choose. Prescribing drugs like Statins on a scarily regular basis, a drug proven to deplete coq10 levels and leave patients even more vulnerable to heart complications. Yet finding a doctor who suggests a ubiquinol coq10 supplement is like finding a needle in a haystack.

    • southerndoc1

      How do doctors make money by writing a script for a statin?

      • ninguem

        More to the point southern, what’s “glutathione pro”? The domain is registered in Panama by a “whois” search. It was created last May. Try to find a real name and street address on the site.

        They’re hawking supplements. Southerndoc makes money with the patient visit and recommendation. Likely southern will recommend a generic statin for which he receives not one penny. If southern gets better data supporting something else, paid the same to recommend nutritional supplements or whatever is upported by best evidence.

        Same as my practice I’ll bet.

        “Glutathione Pro” really does make money selling their proprietary supplement.

        You “question” the ethics of some doctors?

        You wouldn’t know what ethics was if it bit you in the behind.

    • Suzi Q 38

      Thant’s why I take it on the “side,” but tell my gyn and PCP what I am doing. I dropped my statin.

  • Anthony D

    “How about $9.5 billion?”

    $9.5 billion? I wish I was that poor!

  • Anthony D

    If those that go into specialties that make more money and the doctors know they can to help repay their debt and other expenses quicker, then we should have known that we were going to have an imbalance of physicians in certain departments in medicine.

    With student debt rising, the standard of living decreasing and inflation climbing, etc. Is it any wonder your better being an Cardiology instead of GP at this moment?!

  • Steven Reznick

    If they wanted more generalists in primary care, Medicare and private entities could follow the ideas outlined by the author. Limiting funding for subspecialty training beyond what is needed and transferring it to primary care training makes sense.They could additionally pay for the education of clinicians who agreed to stay in primary care for 15 years post training. Without the huge education loans young physicians face today they might enter primary care to get loan repayment.

  • Liek Sari Handikin

    Dollars( money) do not (always) make people live longer and happier.

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