By PAULINE W. CHEN, M.D.
More and more, my family and friends are asking for my help in finding a primary care doctor. That they would be having trouble finding one doesn’t surprise me. We’ve all been reading warnings about an impending doctor shortage for several years now.
What is alarming to me is that there are no sure-fire solutions in place that will bail us all out in time.
In the United States, we are now shortapproximately 9,000 primary care doctors. These are the general internists, family doctors, geriatricians and general pediatricians, the doctors responsible for diagnosing new illnesses, managing chronic ones, advocating preventive care and protecting wellness. And health care leaders predict that that deficit will worsen dramatically in the next 15 years. Specialties like general surgery, neurosurgery and emergency medicine will also become critically understaffed; but primary care will be hardest hit, with a shortfall of more than 65,000 doctors.
While the demands from a growing and aging population and an influx of 40 million patients newly covered by insurance are considered the main drivers of this crisis, there is no shortage of issues on the physician supply side.
For starters, only 2 percent of all medical students in a recent study expressed interest in practicing primary care as a general internist. Most continue to flock to subspecialty fields like dermatology, anesthesiology, radiology and ophthalmology.
And once trained, primary care practitioners are particularly vulnerable to burnout and more likely to leave clinical practice than doctors insubspecialties like cardiology or gastroenterology.
It’s like the patient is bleeding faster than we can transfuse.
Experts have proposed several solutions to the doctor shortage. But for many worried patients and doctors, the best answer is seemingly the most obvious one: churn out more young doctors and funnel them into residency programs that train for primary care.
Unfortunately, according to a new study published in The Journal of the American Medical Association, it’s not that obvious.
Researchers asked more than 50,000 doctors training in internal medicine about their career plans. As expected, the majority of these young doctors planned on becoming subspecialists.
What the researchers discovered, however, was that over the course of their training, almost half the young doctors who began wanting to become primary care doctors changed their minds, most deciding to pursue a subspecialty career instead. And by the time the three-year residency was finished, those numbers dwindled even further, with only one out of five indicating that they wanted to become primary care physicians.
Some of the young doctors surveyed were enrolled in a traditional training “track,” which centers on inpatient and subspecialty care. But even a majority of those who pursued a primary care track, developed in the 1970s to encourage more doctors to choose primary care and which concentrates on medical work done in outpatient clinics, doctors’ offices and other ambulatory settings, were planning to become subspecialists by the end of their training.
“The environment is such that even the primary care track training programs don’t have a fighting chance,” said lead author Dr. Colin P. West, an associate professor of medicine at the Mayo Clinic in Rochester, Minn., and associate program director of the internal medicine residency training program.
Much of the problem lies in what general practitioners have to look forward to. General practitioners work as many hours as, or more, than their subspecialty colleagues. Yet they have among the lowest reimbursement rates. They also shoulder disproportionate responsibility for thebureaucratic aspects of patient care, spending more time and money obtaining treatment authorization from insurance companies, navigating insurers’ ever changing drug formularies and filling out health and disability forms. “All the paperwork,” Dr. West said, “interferes with the patient-doctor relationship that drew them to general medicine in the first place and pushes trainees away from primary care unless they are remarkably committed to its goals.”
But it is this subset of committed young doctors — the one in five who still planned on a career in general medicine at the completion of their training — that may help to provide the answer to the current primary care shortage. In this study, most were female, enrolled in primary care track programs and graduates of American.medical schools. Dr. West believes that understanding more about what attracted them to primary care, and why they remained committed, could help “make the entire field more attractive to more young doctors,” he said.
“If we go with the simplistic view that opening more medical schools and more training slots will give us more primary care doctors, we may get a few more, but we’re mostly going to end up with more subspecialists,” Dr. West said. “And even the few additional primary care internal medicine doctors will not do much to address the shortage.”
“The residents are voting with their feet,” he added. “And they are telling us something really important.”