I believe the projected shortage of physicians caused by  the Affordable Care Act will drive primary care into two opposite tracks. Each is a distinct and logical response to the patient overload and each points out gaping holes in our medical education that must be addressed.

The Association of American Medical Colleges  estimates that there will be a shortage of 63,000 doctors by 2015 and 130,600 by 2025 in the wake of the SCOTUS decision to let the Affordable Care Act stand. This tidal wave of newly insured patients has to be served somehow and medical schools and residency programs cannot supply anywhere near these numbers of new physicians in this short of a time frame.

How will healthcare markets respond – especially with regards to primary care?

I see two likely options.

1. Volume driven: Doctor as apex of a care pyramid. In the more traditional practice structure, the physician will be come the leader of a care team supervising a number of physician extenders who provide the majority of the hands on care. The skill and experience of the physician will be saved for the more complicated and severe cases seen that day. The majority of the doctor’s activity will be devoted to leading and coordinating the care provided by the pyramid of NPs and PAs who are their direct reports.

The challenge to this model is the complete absence of functional leadership skills training in most medical school and residency programs. 30 to 50% of these physicians’ time will likely be spend in leadership and management activities for which they are not prepared on graduation.

2. Service driven: Concierge/direct care model. As the typical patient begins to notice they are only seen by a physician on rare occasion, a certain percentage will become willing to pay for that privilege. I suspect this will quickly grow to a tidal wave of new demand for concierge medical services, where you pay a reasonable monthly fee to guarantee you are always seen by your doctor.

The surplus of patients means a shortage of doctors.  As the shortage worsens,  I believe a larger and larger segment of our population will become willing to pay to continue to see their doctor as they do today.

The huge popularity of this service will have another important driving force – the office duties of the physician are exactly the opposite of those in example #1 above. Here the physician is often seeing less than 15 patients a day, providing direct patient care and continuing to have meaningful personal relationships with their patients.

The challenge to this model is the absence of business training, specifically marketing training, in most medical education programs. The concierge model is inherently entrepreneurial and will always involve a fairly sophisticated marketing program to be successful.  This is not an insurmountable obstacle and I have yet to meet a newly board certified MD who understands the essentials of marketing.

So if you have 10 years or more of practice ahead of you, I suggest you look at these models and get ready to be met by a fork in the road. Will you choose to lead a team or build your cash/concierge practice? If you are leaning in one direction, I suggest you get started building your missing skill set — be that leadership or marketing. The wave of newly insured patients is coming.

Dike Drummond is a family physician and provides burnout prevention and treatment services for healthcare professionals at his site, The Happy MD.