Perhaps you’ve heard that there is a shortage of primary care physicians in the United States. In a country where only 25% of medical education graduates with M.D. and D.O. degrees enter primary care (75% become specialists, usually focusing on one body part or system), the growing demand on the front lines of health care is outstripping the supply of providers. Dr. Stephen C. Schimpff zooms in:
Estimates in the Annals of Family Medicine indicate that America, which today has about 210,000 primary care physicians in active practice, will need an additional 52,000 PCPs by 2025. Good luck. This is based on growth of the population (requiring 33,000 added PCPs), the aging of the population (10,000) and the added number of individuals that will have health insurance as a result of the Affordable Care Act (8000). The number needed almost undoubtedly is substantially higher. And if you accept my premise to be detailed in a later post that a primary care physician (or nurse practitioner or physician assistant) should be caring for only about 500-1000 individuals rather than the current typical 2,500+, then the need is truly much, much greater.
We’ve heard about the coming shortage for years now — way before the Affordable Care Act became law. And while it is not nearly enough, Gregory Twachtman says more post-graduate residency (training) programs are being offered than ever before:
Medical school seniors continue to show an increasing interest in primary care, according to the results of the 2015 Main Residency Match.
And for the third year in a row a record number of first- and second-year residency positions were offered – 30,212 positions, up from the 29,671 positions in 2014, according to the National Resident Matching Program (NRMP).
The number of residency positions available for primary care pediatrics increased in 2015 — by 28 spots. Of the 2,668 positions offered by pediatric residency programs around the country, only 14 spots went unfilled. While most pediatricians-in-training are U.S. graduates, the majority in other primary care fields (family medicine and internal medicine) attended foreign medical schools.
Residency programs are biased towards specialists because that’s where the money is. Primary care — and pediatrics specifically — does not generate much revenue for any hospital, especially teaching hospitals; specialty programs grab the most of federal Medicare dollars for training residents because they do generate big dollars. And the money brings prestige to the medical staffs of teaching hospitals and attracts grants to research centers.
Medical students are also biased towards specialty fields because of the large debt burden incurred by students seeking a medical education. USA Today reported last year:
For the class of 1992, the median education debt was $50,000. In 2012, it was $170,000, according to a 2012 Association of American Medical Colleges study. Gina Martin, who is finishing her primary care residency and plans to practice in rural Delta, Colo., says she faces $250,000 in medical school debt, which made her choice more difficult.
Dr. Schimpff zooms back out:
Primary care physicians earn about one half of what a specialist earns. Specialists are generally seen to have a higher level of prestige in the community — “I was sent to Dr Jones, the surgeon.” Most medical school graduates have large debt loads so earning more means paying it off sooner. And with a large debt, it is harder and scarier to take out a loan to start a practice that brings in fewer dollars. But the primary reason is that medical students realize that PCPs are in a non-sustainable business model, one in which they must see far too many patients per day, accept unpleasant burdens with insurers, be on call many hours and yet not be able to offer what they know would be better care. They see it as a no win situation and so avoid primary care even if that might otherwise be their preference.
Less prestige, high debt loads and a knowledge that PCPs work in a non-sustainable business model forcing them to see an excessive number of patients per day in order to meet overhead and still garner an income about one half that of the specialist is, combined, enough to discourage medical school graduates from selecting primary care as a career.
So how do we relieve the shortage of primary care practitioners? The influx of other providers — nurse practitioners and physician assistants — has been somewhat helpful. The best solution, in my view, would be for the government to subsidize a good part of the cost of medical education, getting in return a multi-year public service commitment from graduates to practice in poor and rural communities, where the shortage of primary care physicians is acutely felt. Instead of the wealthiest students, perhaps medicine will once again attract the best and brightest.