Sunday, July 25, 2010

Shortage of Primary Care Physicians Persists: Causes and Solutions

For at least the last 20 years, graduates of U.S. medical schools have resisted pleas from organized and disorganized medicine to become primary care physicians (PCPs). Since there is already a severe shortage of PCPs, pundits are wondering who is going to take care of the hordes of newly insured by 2014. Many have speculated about the possible reasons for this dilemma such as the relatively paltry earning potential of PCPs, the amount of debt incurred by graduates of medical schools, the perceived lack of prestige of a PCP career etc.

I have some theories of my own. One, primary care is boring. It has been estimated that 90% of patients appearing in PCP offices have no treatable illnesses. This leads to another issue which is that a physician assistant or nurse practitioner can treat most of these patients, often without input from a physician. PCPs function as triage officers. If an interesting case should somehow happen along, the PCP refers the patient to a specialist who deals with the problem. Since the advent of hospitalists (physicians who restrict their practices to hospitalized patients only), PCPs are never seen in hospitals which almost guarantees that they will not be involved with anything interesting.

What is the solution? Bear with me. I will make a point eventually. About 15 years ago, medical schools in the New York City area were scrambling to climb aboard the family practice bandwagon. (Grant money was available for schools to establish departments of family practice.) This was a real problem for the schools since there were about as many family practitioners in metropolitan New York as there were blacksmiths. One school managed to set up a family practice department with a chairman who practiced in a town about 50 miles north of the city. Students were offered tuition forgiveness for the fourth year of medical school if they promised to do a family practice residency after graduation. Of some 12 initial enrollees in the program, a grand total of one ended up in family practice, proving one couldn’t even bribe students to become PCPs. I recall asking a few students why they thought the program did not work. The answer was that the new rotation in family practice was too realistic. It was as boring as actually being a family practitioner.

The solution to recruiting more students into family practice is to replicate the situation that exists in specialties the medical students highly desire like emergency medicine, anesthesiology and dermatology [the most competitive residency training program in all of medicine (see page 11)]. Most schools offer very little or no exposure to these disciplines in their curricula. Medical schools should disband their family practice departments. Thus, a mystique would be created and the students would be seduced. I believe this would work. If needed, I am available to chair a task force or blue ribbon panel on this issue.


plumtree said...

Love it! I've just returned to the US from a long stint in Australia. The GP shortage is acute there, and that is a place where general practice has always been the norm. I had to explain to people that in the US, in a big city one simply did not see any family practitioners.
In Aus, for various reasons I'd be happy to elaborate on, the number of medical students is disproportionately female. While medical school is not free in Australia, the cost is manageable (usually about $50-60,000 in total for a 6 year course). Many women see GP practice as a pleasant, well paid part-time job. It is quite common for a woman to enter GP practice, become pregnant, take six months off (probably not paid, depending on the state) and then return to practice for two half days a week. While most of them up their hours once children are school age, they still do not usually practice full time. The GP practice I attended there had 16 doctors in partnership; on any given day no more than 3 were in the office.
As a patient, I also wondered about the level of experience these doctors had. How can you build it up when you aren't there? My son was diagnosed with scarlet fever by a doctor who was about 30 and had never seen it before. She couldn't wipe the grin off her face as she told me it was scarlet fever, and had to pull a book off the shelf to answer my questions (eg, was the rash itchy). And, in case you haven't figured it out by deducing that it's normally the mother who takes a pre-schooler to the doctor, I am a woman!

Skeptical Scalpel said...

Sorry for the delay in responding. Great comments. You make an excellent point about the difficulty in gaining experience if one only works a few hours a week.

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