Meeting the new primary care physician is no easy task. Why? In many ways this person has yet to be identified. With the changes in federal healthcare laws coming in the next year, the current primary care physician shortage will reach crippling proportions. Consider that health insurance is set to cover approximately 34 million people in the U.S. with the passage of the Affordable Care Act (ACA). But the estimate of the number of new primary care physicians, in addition to those already going through residency, is in the region of 25,000.
With population growth, an aging population and expanded insurance coverage, it is anticipated that there will need to be an extra 62,000 primary care physicians by 2025. Medical schools are increasing the number of places open to med students in order to try and compensate for the shortage. But primary care is now the least popular branch of medicine—so there is no guarantee these vacancies will be filled.
My Life as a GP
I should point out that my own experience of primary care was as a general practitioner (GP) in the U.K. for 16 years from 1991 to 2007. Working within that much maligned (but quietly envied by many around the world) behemoth called the National Health Service (NHS), I experienced most of the problems and issues that will occur here in the U.S. over the next 10 years. My own practice went completely paperless in 1997 and, although beyond the scope of this document, the advantages of having electronic medical records alone were incalculable. A system in which the GP is the gatekeeper to all health services has some significant advantages—not least of which is job satisfaction for primary care physicians.
While well intentioned, the solution to the problem of physician scarcity will not be resolved by just increasing the number of places available at medical schools. From the time you increase the places, it will be eight to 10 years before those doctors leave residency and make up for the shortages in practicing primary care physicians.
The Law of Attraction
The main issue becomes what will attract young/new doctors to enter a profession in which their income is going to be insufficient to pay off the crippling debt that most newly qualified doctors find themselves owing after completing their undergraduate studies and medical school. A few years ago I had a frank discussion with a second-year medical student who had come to the realization that he would have a debt in excess of $275,000 by the time he left medical school and he wanted some advice on which specialty he should consider going into—primary care was not an option. Now five years later, as he enters his third year as an ENT (ear, nose and throat) resident, he is earning the equivalent of a paralegal and is not even able to keep up with the interest on his loans.
Paying to Help Others
A significant majority of doctors will spend half their careers paying off a debt that they incurred to be able to be in a position to help others. Entering medicine is a selfless life decision for most, and yet the society we live in considers doctors to be the elite few who should be obligated to pay for their chosen vocation.
Now, there is no empirical evidence that the choice of specialty is determined by the level of debt, but it is undeniable that this plays a significant role in that decision-making process. Over the course of their time in medical school, more than 50% of med students who started with the intention of going into primary care changed their mind by the time they were applying for residencies. Even after starting their residencies, significant numbers changed their minds and switched to a subspecialty rather than continue in primary care.
In a large recent study, only 2% of all medical students surveyed expressed an interest in practicing primary care as a general internist. The majority of students in this study intended to go into subspecialties such as dermatology, anesthesiology and radiology.
Worrying statistics suggest that primary care physicians are much more likely to leave clinical practice and suffer from burnout than cardiologists, gastroenterologists and other subspecialists. Job satisfaction is getting worse as the amount of time a doctor can spend with any individual patient declines. And despite this, patients are finding it harder to obtain an appointment within a reasonable time with their physician of choice.
The Prognosis for New Primary Care Physicians
So what lies in store for the young doctor entering into primary care? Primary care physicians (general internists, family doctors, geriatricians and general pediatricians) represent approximately 30% of all currently practicing physicians in the U.S., yet nearly 50% of all physician office visits are to primary care physicians. Primary care physicians work as many or more hours than their subspecialty colleagues, have some of the lowest reimbursement rates and spend more of their time and money obtaining treatment authorization for their patients. The non-conformity of drug formularies and the vast number of health and disability forms to be filled interfere with the delicate doctor-patient relationship and is another reason trainees opt out of a career in primary care.
Fortunately there is a small, and according to some recent studies, an increasing (albeit still small) number of committed young doctors who are planning a career in primary care after completing their training. And a slight majority of these appear to be female. Making primary care an attractive career choice is going to take some work and needs to be addressed from day one at medical school. The very curriculum at most medical schools has a tendency to push students towards a subspecialty career. The attraction of working for a large organization and all the benefits that go with it make a career in primary care look like a distant second choice.
Having spent the majority of my professional life in general practice I can extol the attractions of making that career choice. To this day I miss the patient contact and the satisfaction that goes with a job where the clinical variety is always a challenge; you treat the whole patient and develop long-term relationships with both patients and their families. A less publicized statistic is that primary care physicians are less likely to get sued. OB/GYNs and general surgeons are five times more likely to be sued than general pediatricians and family practitioners.
Change in Delivery
Still, most authorities think that the answer to the primary care physician shortage is to increase the number of doctors. What is needed, though, is a complete change in the approach to delivery of primary care and reduction of the 20% to 30% waste in the current healthcare system. A more organized system for delivery of care with patients triaged effectively and guided to the appropriate caregiver is a starting point. There are many conditions that do not need a doctor as the primary provider.
Getting back to the topic of meeting the new primary care physician, what is really needed is the old (as in past generation) primary care physician who was able to provide healthcare at the initial point of contact, who had a real relationship with patients and who really knew what his/her patients’ needs were.
The Team Approach
However, without a radical change in the healthcare delivery system the waste will continue to increase, the costs will rise exponentially and insurers and lawyers will increasingly dictate clinical decision-making. The primary care physician of the future will in all probability—out of necessity and lack of “man-power”—not be one person but one member of a well-organized primary care team in which the doctor is in the minority and manages/oversees a team of physician’s assistants, nurse practitioners and other healthcare providers.
I saw a quote in a recent online blog in which a young doctor asked about going into primary care. “The primary care physician is being picked to the bone; the facts speak for themselves. Once you experience it, go and decide on whether to become a dermatologist, radiologist or allergist…where the rewards are better and you are less likely to be in financial debt for the rest of your working life.”
Sidebar: The Doctor’s Take on the Sunshine Act
PM360 polled 30 U.S. general practice/family physicians using MedLIVE from WorldOne Interactive to see what they think about the Sunshine Act and how it will affect their practice now that reporting is finally underway. Here are the results:
50% are somewhat concerned about the Act, while 23% are very concerned and 27% are not at all concerned.
30% are afraid that erroneous data could be published about their involvement with the industry and made public before they are given proper time to review and dispute it.
30% said they will be forced to stop attending industry sponsored CME events or meeting with reps for more information about a drug just to avoid being perceived as biased.
60% feel that their time with reps will remain unchanged, while 37% said it will decrease and 3% said it will increase.
37% believe that accepting paid speaking engagement opportunities from the industry is the most likely interaction to cease now that reporting is underway, while 30% think this means the end for free lunches.
13% feel that the Sunshine Act will help limit the industry’s influence over doctors’ prescribing habits.
53% said the Act will hurt doctors in the long run.