How to meet the primary care demand in the next decade

by Travis G. Bias, DO

Throughout my involvement in organized medicine, I’ve met friends who I hold in high regard, and colleagues for whom I hope to one day work.  One of my favorites, a neurosurgery resident buddy of mine, claims specialists should be paid more than primary care physicians.  But, I am a third-year family medicine resident, preparing to enter the practicing world.  And thus, it is with great respect that I offer this counterargument.

The primary care physician is the quarterback.  In more ways than one.  The primary care physician shoulders the responsibility of making numerous initial diagnoses, treating and managing all cardiac risk factors, and ensuring patients are directed towards the right levels of care.  We are also the center of chronic disease management, the source of 75% of health expenditures in the U.S.  Primary care visits save money by preventing poor outcomes and maintaining health.

For this very reason, we need more primary care physicians in the face of a 45,000 physician shortfall anticipated nationwide by 2020.

How do we meet this demand?  It’s very simple.  Pay primary care physicians more.

The first argument against this is that specialists undergo longer, more extensive training.  I absolutely agree that a physician whose residency is longer should be paid more.  Hands down.  My friend the neurosurgery resident will train for 7+ years after medical school, compared to my three.  He trains an additional four years that he can’t be making significant strides towards paying off his educational debt.  He is the king of delayed gratification, more so than the rest of us.

But how much more should he make?

Currently, he will make at least four times as much.

His training also may be more difficult at times, but all residents undergo the same stressors.  We experience stress on our relationships, both romantic and with our family.  We undergo sleep deprivation.  We miss friends’ weddings.  The life stress is comparable.

The next argument is that subspecialists are subject to greater risk.  Currently, physicians are reimbursed for procedures.  Procedures inherently carry with them a great malpractice burden – if the surgeon’s technical skills aren’t up to speed, or his/her judgment is flawed, life-threatening mistakes can be made.  But how does this compare to the missed or delayed diagnosis, the cause of many primary care lawsuits?  Or how does this compare to not adequately covering every single medical problem for the patient with an extensive medical history?  Even when a patient is referred to a specialist, they are generally referred back for the primary care doc to manage the treatment or monitor its effect.

Not only does a primary care practice not generate revenue from a high number of procedures, but we are not paid a dime for the skills we are trained to do best – think, communicate with patients, communicate difficult diagnoses, communicate with difficult patients, e-mail patients, call patients – you get the point.  None of the aforementioned skills are reimbursed by insurance companies, and the only one you might make an argument for is “thinking,” yet this is at a far inferior rate than that of a procedure.  I get paid much more for taking off a mole than just talking to my patient.

When in medical school, most of us just see the family physician as the one dealing with coughs and colds, and the one referring out to specialists for the real treatment.  But only deep into family medicine residency and practice does the family doc appreciate the depth of care delivered in the primary care setting.  We manage COPD, diabetes and other cardiac risk factors.  We deliver babies, give flu shots, do pap smears, and help our patients to quit smoking.  We remove suspicious moles, evaluate knee pain, and manage anxiety.

And most importantly we take the time to listen to our patients to get to the root of the problem.  Treating abdominal pain with expensive CT scans, antibiotics, and hospitalizations does no good if the patient is simply depressed.  Simply knowing your patients can save money and maintain a high level of quality.  My parents’ family doc of over 30 years knew them, and thus instead of the hospitalist admitting my father to the hospital one Thanksgiving Day, we simply called his family physician on his cell phone and, the following week, commenced the appropriate work-up in the appropriate setting – outpatient, and not in the hospital over the weekend.

Properly reimbursing primary care physicians for their coordination, communication, and quarterbacking skills will in turn incentivize medical students to enter the field of primary care.  This is how we will appropriately meet the primary care demand and shortage in the next decade.  It’s that easy.

Travis G. Bias is a family physician who blogs at Life’s Residency.

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