Should doctors give up on primary care?


Ten years ago, I wrote an essay on the primary care shortage.  I argued that more money and better working conditions would help decrease the shortage.  Unfortunately, things have worsened over the last decade.  The AAMC now predicts a shortage of between about 15,000 and 50,000 primary care doctors in 2030.

The gap between generalists’ and specialists’ incomes is still huge.  The average family doctor earns about half of what an orthopedist earns and earns much less than even a dermatologist.  In 2009 I advised a 50 percent to 70 percent income increase for primary care doctors.  We have seen nothing like that in terms of inflation-indexed salary increases.

I also argued for better working conditions, but things have worsened.  The amount of paperwork, much of it pointless, expected of us would stun those not in medicine. Our patients are now older and sicker, but the time we have to care for them has not increased. The adoption of poor electronic health records has destroyed what joy that was left in the field. The patient-centered medical home (PCMH) has been a bust for physicians, as many of us predicted it would be.

Many decision-makers and patients think we are no better at primary care than nurse practitioners and physician assistants.  Employed physicians are subjected to control and humiliation on a routine basis.

It is past time to face facts: Doctors should give up on primary care.  The United States, by its actions, is telling medical students to do something else.  We should turn the field over to those nurse practitioners and physician assistants who will take it.

Doctors should focus on specialty and referral care.  Perhaps there is room for some “consultant” primary care doctors, those who work outside the traditional insurance and hospital systems for patients willing to pay extra. Hospital work is a possible avenue of escape for others who can no longer stand outpatient primary care.

This solution is not optimal for Americans’ health, but not listening to what the society is telling you is ultimately self-defeating. And all is not lost: Specialists help people greatly and will be needed to take care of patients that a smaller primary care system will no longer be able to manage.

John Horstkamp is a family physician. 

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