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We’re all about to feel the pain of the primary-care shortage

REUTERS/Jim Young
In its current state, our primary-care system is not only dysfunctional for patients but also unappealing for most medical students trying to decide on a specialty.

Primary-care shortage is a symptom of a broken delivery system.

Photo by Brandon Werth

Peter Meyers

Let’s look at “Mary” (she’s a composite, but closer to reality than most would like to think). Mary went to the emergency room 68 times in 2013 despite the fact that she didn’t have 68 emergencies. She also had four hospitalizations, most of which could have been prevented. She suffers from insulin-dependent diabetes, chronic pain, depression, and PTSD. Mary is 34 years old and has health insurance, but the system is clearly not working for her. 

As a medical student interested in primary care, I’ve met a few people like Mary. She suffers from multiple chronic diseases and faces several social barriers to proper health care. The heartbreaking reality is that she does not fit into the traditional paradigm of clinical care in the United States. And Mary is not alone.

According to the Agency for Healthcare Research and Quality, 1% of the population accounted for 22% of overall health-care spending in 2008. In Minnesota, this would represent roughly 53,000 individuals accounting for $5.7 billion in health-care expenditures in 2013 (or about $107,000 per patient per year).

People like Mary shine a light on the shortage of primary-care physicians and the dysfunction of our current system. Mary and her physician require time together to build their relationship and determine the best plan for Mary’s health. But because of her multiple chronic conditions Mary also needs more convenient transportation, a care coordinator, a social worker, a mental health team, and health educators. As baby boomers age and the Affordable Care Act expands coverage, others will need the same services. As a result, we will all start to feel the impact of this shortage immediately.

In its current state, our primary-care system is not only dysfunctional for patients but also unappealing for most medical students trying to decide on a specialty.

A 2010 national report recommended that at least 40 percent of graduating medical students enter primary care in order to improve in our provider shortage. Unfortunately, the rate of students entering primary care has been stuck at a shocking 12 percent for the past five years. Students considering primary care are concerned about the infuriatingly short visits with patients, the burdensome paperwork and insurance regulations, payment systems that heavily favor specialists, and the extremely high rates of burnout for primary-care physicians.

More hands bailing water

A current and central strategy to alleviate this shortage has been to incentivize primary-care training programs with targeted student loan forgiveness. While commendable, this strategy essentially amounts to more hands bailing water from the sinking Titanic.

If we want to address this workforce shortage, we need to redesign the entire delivery system. (A “delivery system” is the combination of insurance companies, employer groups, providers, and agencies that work together to provide health care.)

We have the best-trained health-care workforce in the world, but many Minnesotans experience a Third World delivery system. They pay for their medical care out-of-pocket or refuse to see a provider because it is unaffordable. The basics for real reform must include aggressive dedication to preventive medicine and patient empowerment, affordable access for patients, team-based coordination, community engagement, and, perhaps most important, more time for provider-patient visits.

A bleak scenario

I want to be a primary-care doctor in Minnesota. My family is here, my wife’s family is here, and we’re excited about a future in Minnesota (despite this legendary winter). But my current career landscape includes a mountain of debt and a future of stress associated with cramming in an endless number of short patient visits to keep up with insurance company regulations.

Currently, primary care resembles a demanding assembly line, underutilizing the training of health-care professionals. This results in dissatisfaction, burnout or resentment toward coworkers and patients. I don’t want to be associated with a field like that. I want to be able to talk to patients for longer than 10 minutes, to work in a team-based environment that prioritizes preventive medicine, to offer my skills to help improve people’s health, and to connect with my community to contribute to a healthy neighborhood and society. Studies have shown that patients of satisfied doctors are more likely to adhere to treatment protocols, while dissatisfied physicians report more difficulty caring for patients.

What’s the cure?

In order to make transformative change, I urge passage of pending legislation to create a Minnesota Legislative Health Care Workforce Commission, and urge its would-be members to study models of care around the country that prioritize comprehensive, team-based medicine that keeps patients truly at the center.

Two examples of successful care models currently operating are the Nuka model for care in Alaska and the CareMore project in California. The hoped-for commission should consider incentivizing pilot projects in Minnesota that emulate these transformative practices.

If you design the delivery system to give providers enough time with patients and incentives to do their job well, more students will choose primary care and the shortage will disappear.

Peter Meyers is a fourth-year MD-MPH student at the University of Minnesota, and is planning to enter primary care. 

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Comments (8)

  1. Submitted by Steve Titterud on 04/04/2014 - 04:19 pm.

    It’s worse than you say.

    We can make inroads on the shortage, but it won’t disappear anytime soon, regardless.

    The economics driving medical school students out of primary care, which you refer to without specifics, is fleshed out a little in an article at http://www.aarp.org/health/medicare-insurance/info-03-2013/how-to-beat-doctor-shortage.html:

    “While students may enter medical school wanting to practice primary care medicine, they graduate saddled with heavy debt — $250,000 is not unusual — which prompts them to switch to a more lucrative specialty. The starting salary for a primary care physician is $150,000 to $170,000; a radiologist or gastroenterologist can make two to three times that.

    Only one in five graduating internal medicine residents plans to go into primary care medicine, the Journal of the American Medical Association reports.”

    Also, the current workforce is aging: “…nearly half the nation’s 830,000 physicians are over age 50…”. Hmmm. Didn’t know that.

    Then there’s the rate at which new physicians are graduating and entering family medicine, based upon 2012 data at http://www.stfm.org/fmhub/fm2013/October/Wendy642.pdf

    U.S. medical school graduates who were first year family medicine residents 1,451 of 16,224 graduates (2012). When you add in Osteopathy and International candidates, the number rises to 3,523.

    According to an article at http://health.usnews.com/health-news/news/articles/2012/12/04/study-foresees-shortage-of-primary-care-doctors:

    Dr. Colin West, an internist at the Mayo Clinic in Rochester, Minn., said, “In the next decade, we will be 50,000 primary-care physicians short for the needs of the country.”

    On top of all this, the ACA is going to bring a huge number of new patients seeking services, who usually refrain for the well-known reasons. This suggests a new complaint opponents of the ACA might howl about: too many people are being covered !!

    The role of primary care physician is going to have to be supplanted to some degree by Nurse Practitioners, and in some roles, by others with lesser training.

    We should all contact our legislators to support this bill !!

    • Submitted by Paul Brandon on 04/05/2014 - 05:15 pm.

      On your last point

      I believe that studies have shown that outcomes for patients treated by physicians assistants and nurse practitioners are as good as those treated by primary care physicians. In either situation, cases requiring specialized training are referred to specialists.
      Of course, the American Medical Association begs to differ.

      • Submitted by Steve Titterud on 04/05/2014 - 08:45 pm.

        Yes, there is resistance by some in the profession, but…

        …we are looking at an emergency situation, and soon. So it’s not the time to cater to those who resist building new treatment paradigms for broad societal benefit, especially when this resistance has a lot to do with the revenue streams of those doctors.

        There is no doubt that a skilled Nurse Practitioner can handle a great deal of routine office visits with no fall-off in quality of patient care. And they can be trained to clearly identify when deeper expertise is required.

        If we’re going to be short 50,000 primary care doctors in 10 years, I’d say we can make a big dent in the impact of this shortage with a goal of 30,000 – 40,000 new Nurse Practitioners during that time, and 10 years should be enough. There should be enhanced funding from the federal government to pay for the advanced training to deal with what amounts to a national emergency. The basic infrastructure to support the training already exists in the nursing programs around the U.S., it just needs more revenue to increase its output.

        One more thing. I should think the managed care organizations and insurance companies would be all over a plan like this, because, let’s be blunt – you can make more profit on lower paid personnel.

        A modest dropoff in billings (but my guess is they may attempt to sustain the same billing rate for office visits even when staffed with N.P.s) will be more than compensated by a huge dropoff in pay between the M.D. and the N.P.. So revenue-wise, it will be a winner for these entities !!

  2. Submitted by Tom Anderson on 04/04/2014 - 11:06 pm.

    Another commission?

    Could we at least ax one and replace it with this new one?
    Interesting piece though it might be a generalization to say that the whole system is broken because “Mary” isn’t having a good outcome. Also not sure how the lower pay for primary care and thus less interested doctors is fixed either.
    The ACA opponents will howl that they were right about rationing and waiting, which is what will happen with fewer doctors and more patients.

    • Submitted by Miriam Segall on 04/05/2014 - 09:18 pm.

      Shortage of primary-care doctors

      I’m not sure whether Mr. Anderson is suggesting that “Mary” is so atypical that her situation is not worth worrying about, since there are many patients who get their primary care in the ER, and that situation isn’t good for the patient, for the system, or for the society at large. Yes, if the ACA brings a lot more patients into a situation where they can get decent medical care but the personnel and facilities aren’t there to care for them, the brokenness of our system will become so apparent that something will have to be done about it. I only hope the “something” isn’t an intensification of our current situation, say something like boutique medical care for those who can afford it and the back-of-my-hand to everybody else.

  3. Submitted by Miriam Segall on 04/05/2014 - 09:10 pm.

    Shortage of primary care doctors

    I am not a complicated patient, and I now see a nurse practitioner for my routine care; this has worked out very well. But the last time I was seen at another University clinic, the physician explained apologetically that he was required not to spend more than 15 minutes with each patient. I was astonished and, of course, not very happy, although I think I got what I needed. However, I’m sure this only works with patients who are known in the system and whose situations are uncomplicated.

  4. Submitted by Neal Gendler on 04/07/2014 - 02:32 pm.

    Absurd non-system

    We don’t have a medical system in this country (except maybe for the armed forces and the VA). What we have are physicians, clinics, dentists, hospitals and insurance companies that may or may not communicate with each other.

    I have learned the hard way about lack of coordination since a surgery left my wife with a disability. At the beginning, we had as many as six practitioners and no care coordinator but me — totally uneducated for the task. I remember one day when a clinic cancelled an appointment and after rescheduling it (the choices were limited), I spent the next two hours (!) working to reschedule other appointments to accommodate the change. Many times, I didn’t know which practitioner I should ask for help with a problem. Fortunately, a very patient practitioner at one of my wife’s specialty clinics realized my difficulty and advised me repeatedly by e-mail.

    If I had an idea of how to fix all this, I sure wouldn’t keep it a secret, but a single-payer system might be an improvement.

    And I certainly second Miriam’s unhappiness with what HMOs have done to primary-care physicians, who spend their days rushing from one exam room to another. (I once asked my primary care physician if this was how expected to be practicing medicine, and he said an emphatic “no!” He hated it, too.) Two physicians I valued most in recent decades were guys who said they always were in trouble with their HMOs because they spent too much time with their patients.

  5. Submitted by David Power on 04/11/2014 - 03:13 pm.

    Re-claim primary care

    Thankfully, despite the challenges, students like Peter are opting for careers in primary care. Currently, Family Medicine is the best pipeline into primary care with over 85% of graduates entering primary care practices.

    As a primary care physician myself, one of our necessary challenges in the US today is to re-claim the type of medical practice that we believe our patients need to get best care and that we personally find fulfilling. We’ve been a ‘catch-all’ for too long for too many miscellaneous health issues that no one else wants to take care of. Our leadership needs to support the necessity of defining appropriate primary care roles with adequate time allowed when needed for complex patients and refusing to allow us to get inundated with paperwork from insurance companies and other agencies. There definitely have been improvements in recent years but the challenges continue.

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