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Primary Concern?

REVIEWING THE PRIMARY CARE DEBATE AND EFFORTS AT REFORM

The New Physician November 2004
In 2004, when a medical student—the son of an ophthalmologist—bursts into his mentor’s office, wildly proclaiming his love for family medicine, she may spin around and check the calendar to be sure she hasn’t awakened in the early 1990s. Nowadays, family medicine’s low pay, long hours and perceived lack of prestige all make enthusiasm for the field an unlikely circumstance. But it was just last summer that Dr. Holly Cronau, assistant professor of clinical family medicine at Ohio State University College of Medicine and Public Health, experienced this scenario after one of her students spent six weeks in a family medicine externship program (see “Shoring Up Family Medicine,” p. 13), watching a preceptor in private practice introduce patients as “so-and-so’s neighbor or cousin.”


“He loved the continuity; he loved the aspect of someone just being so intimate with their patients,” Cronau says. “He told me that he didn’t realize there was this whole other world out there.”


Depending on whom you ask, that world is either richly in trouble or naturally diminishing with little cause for concern. If National Resident Matching Program numbers are to be given crystal-ball weight, primary care is becoming an oxymoronic term. In general, the numbers of U.S. medical graduates entering primary care fields have declined for the past five years. In this year’s Match, while internal medicine and pediatrics, including their subspecialties, saw modest increases—1.3 percent and 1.2 percent, respectively—family medicine and its subspecialty numbers declined 2.9 percent. While these percentages don’t take into account whether or not the 2004 Match offered fewer residencies in these fields, many primary care experts see trouble on the horizon. The bottom line: U.S. allopathic medical schools are training fewer primary care physicians.


But is the problem as bad as it seems? Dr. Michael Fleming, president of the American Academy of Family Physicians (AAFP), argues that the country’s ability to provide health care to its citizens will be sacrificed if more action isn’t taken to shore up primary care. Citing an April study published online in Health Affairs, Fleming points out that, among Medicare patients, those who saw more specialists spent more money and had worse outcomes than those who mainly saw primary care physicians.


According to research cited in the AAFP’s report, “The Future of Family Medicine,” which was published in the March/April Annals of Family Medicine, one in four office visits annually are with family medicine practitioners, and about half of all office visits annually are with primary care physicians. The report also cites a 2002 study from the Journal of the American Medical Association that concludes if family practice physicians were to become extinct, 58 percent of all U.S. counties would be federally classified primary care Health Professional Shortage Areas.


“There is a great deal of data now that shows that the only countries that have health-care systems that truly work—that not only have the economy of care but also the quality—are health systems that are based on a primary care model,” Fleming says. “We’re going in exactly the wrong direction, then. Primary care is, in fact, the closest thing to a savior for the system that there is.”


Some future physicians who have chosen primary care share this view. “The lack of students going into primary care is a huge problem,” says Margo Jenkins, a third-year at Xavier University School of Medicine in the Netherlands Antilles. Jenkins is one of a growing number of foreign medical school students who plan to pick up the U.S. primary care residency slots left vacant by U.S. medical graduates. “Most health-care issues can be solved at the grass-roots level of health care, saving time and money for patients, improving their health and decreasing their frustration with the system,” she says.


The problem, say Fleming and others, is getting the academic medicine community and its students to recognize the importance of primary care. “One of the biggest issues we’ve had is that within academic medical centers, [students] are discouraged,” Fleming says. “And they’re discouraged for a lot of reasons. One of them is money.”


Indeed, with U.S. medical school graduates carrying an average debt load of more than $100,000 and with the rising costs in medical liability insurance, making around $150,000 annually as a primary care physician can seem unwise to students when some specialties bring in nearly $400,000. When you add to this the controlled hours of a career in radiology, for example, it’s no surprise that future physicians—often spurred by their educators—reject primary care.


Just as damaging, students say, are the seemingly widespread assaults on the capabilities of primary care physicians—especially in regard to family practitioners. Kohar Jones, a fourth-year at Yale University School of Medicine—one of a handful of schools without a family medicine department—says instructors told her it was “a waste of a medical education to do primary care” and that she was both “too smart for that” and not smart enough. “There’s way too much to know. Don’t you want to know what you’re talking about?” she says instructors say.


Laura Klatt, a fourth-year at the University of North Carolina at Chapel Hill School of Medicine, experienced similar discouragement. “Even in schools that push primary care, there is still the undercurrent of thought that you are not very intelligent if you choose primary care,” Klatt says. “This is especially true of family medicine. I have had dozens of people try to talk me out of family medicine because I am ‘too smart’ and my credentials are ‘too strong.’”


Fleming says that perception is “patently wrong.” In fact, he argues, incoming residents’ test and licensing board scores indicate family medicine attracts top-tier graduates. “It is a broad field, and there is a lot to know. But the fact is that we are the mind of medicine. We’re needed.”


Not everyone agrees with his assessment. Dr. Richard Cooper, professor of medicine and health policy and the director of the Health Policy Institute (HPI) at the Medical College of Wisconsin, says there will be significant physician shortages during the coming decades, but that those shortages will be in specialist disciplines, not primary care—and certainly not in family medicine.


“If you were to call the flight controller’s union, what do you think they’d tell you about the number of flight controllers in the country? This is kind of an old mantra,” says Cooper, who specialized in hematology-oncology after training in internal medicine and has led the HPI for the past 12 years.


He cites statistics from the health-care recruiting firm Merritt, Hawkins and Associates that indicate a higher demand for specialists. He says market forces indicate the country still only needs about 80 physicians per 100,000 people—the same as in 1950, and what we have now. There aren’t fewer primary care physicians than before, he says, just a greater percentage of specialists and a growing need for more of them.


“Yes, our system is organized around primary care. But with the growth in nurse practitioners, it’s not necessarily organized around primary care physicians. It’s organized around primary care teams,” he says.


Family practice is the best to take over rural medicine—but with less than 20 percent of U.S. residents living in nonmetropolitan counties, we won’t need more family physicians, he argues. And primary care physicians in more populated areas no longer handle surgeries or deliver babies as they once did, he adds.


“These are all very powerful spokespeople for a philosophic position that is simply contrary to the way the people want to experience medicine. Primary care doctors only get one vote on how it should be, just like patients. And patients vote with their feet. The first thing they want to do when they’re sick is see someone who really knows a lot about it—specialists,” he says.


Other work-force analysts take a more measured view of the health-care horizon. Edward Salsberg, director of the newly established Center for Workforce Studies at the Association of American Medical Colleges (AAMC), has spent 20 years working in and studying health care, and he doesn’t think primary care is in trouble.


“The marketplace is very sensitive to changes,” he says, citing published 1990s data on anesthesiology residents having difficulty finding jobs, which led to negative communication among schools and medical students, and a perception that the job market was tight. “The job market probably was tight for anesthesiology at that time. But the numbers of people going into the field then dropped in half over a five-year period because of that perception, which in turn led to a shortage. So slight surpluses and slight shortages can end up looking very big. There’s no reason to send out a call that the sky is falling.”


Salsberg agrees with Cooper that physician shortages are likely over the next two decades and that the hardest-hit areas will probably be specialties serving aging populations, such as cardiology, oncology and urology. The AAMC and Council on Graduate Medical Education have recommended increasing medical school capacity by 15 percent over the next decade to keep up with the demand, yet reject a previously suggested target that U.S. medicine should achieve a 50-50 generalist-to-specialist ratio.


“But I don’t think that means that we’re not going to need family physicians or internists or pediatricians, too,” Salsberg says. “If you’re a medical student now, you should be pretty comfortable that there are going to be many opportunities over the next 20 years in almost every specialty.”


So how does U.S. medicine know when to sound the primary care alarm bell? According to Salsberg, it’s when primary care physicians see a continued marked difference in salary relative to other specialties. “We shouldn’t ask our primary care physicians to sacrifice more financially than other physicians.”


Ultimately, says Dr. Mary Mebane, a first-year resident in rural family practice in Harpers Ferry, West Virginia, the demanding aspects of the primary care lifestyle are not going to be attractive to medical students seeking residency—and she doesn’t blame them. Mebane worked in finance for 15 years before a volunteer health position prompted a career change. She believes incentives are the key. “It’s the same as business. You have to reallocate your funds a little bit, and what you can’t afford to give them financially, you have to give them in insurance, better retirement packages, things they can fold into their income statements.


“Unfortunately,” she says, “when you go into medical school at 20, 21 years old, you want what everyone wants at that age. You want good money, but you don’t want to work your tail off to get it.”
Beth McNichol is a contributing editor with The New Physician and a freelance writer based in Durham, North Carolina. Direct comments about this article to tnp@amsa.org.