If you’ve tried to make an appointment with a primary care doctor recently, the challenge will make you understand why I was leaning on the two young women I was working with at the Moss Clinic. Why I was trying to persuade them to be primary care doctors themselves.
One a foreign medical graduate from Turkey, shadowing me while she applies to residency programs. The other, a premed’ student working as a scribe, who has just been accepted to VCU.
The Crisis in Primary Care
“The physician shortage that we have long feared . . . . is already here” notes AMA President Jesse M. Ehrenfeld, MD, MPH - and it’s going to get worse with an estimated shortfall of 86,000 doctors by 2036.
This shortage is of all doctors but is particularly acute in primary care.
A significant factor was a gross miscalculation in the 1980’s, when a government report concluded medical schools were producing too many doctors - a calculation that failed to account for the growth and ageing of the population.
This meant a shortage of medical school places, making medical school insanely competitive – it never ceases to amaze me to see these would be doctors that volunteer at the clinic having to not just be tops in academics, but buff their resume by volunteering in medical facilities, the rescue squad and do all kinds of other projects to “demonstrate interest and commitment to community services and leadership.” Or others doing a whole year of extra study in some related science.
We have had several at the clinic, potentially great doctors, but who couldn’t get into medical school.
Post graduate training is another bottle neck with there being an average of 60 applicants for each place in residency programs.
It is marginally less difficult to get into a residency for primary care because two thirds of medical school graduates want to specialize – a significant incentive being that primary care doctors earn on average $250,000 a year compared with specialties like orthopedics, dermatology, interventional radiology, who earn some $400-500,000 a year – and most students have huge debt. The average medical student is reported to have a debt of $202,453 by the time of graduation.
Doctors Are Getting Out
Not only is the country not minting enough new doctors, but there is a marked attrition of those already in practice.
It is an almost universal complaint among primary care doctors especially that the burden of things like catching up on patients notes, documenting quality of patient care; keeping up with coding changes and insurance company formularies; preauthorizing treatments and tests; figuring out different insurance companies billing systems; recording ever increasing amounts of data required by insurance companies, as well as keeping up on continuing medical education to maintain ones license all add up, causing widespread burn out – or worse. Suicide among doctors is twice as prevalent as with the general population.
All aggravated by computerized electronic health records, which, because they are focused on billing and documentation rather than ease of patient management, slows everything down so it is reported that doctors spend 2 hours doing busy-work (often in the evenings) for every hour seeing patients.
Also, doctors are ageing with half of all practicing physicians over 55 and many looking to take early retirement.
Or another change that makes things worse is the growth of “concierge” practices - where usually some 80 percent of patients cannot pay the annual fee (which is usually several thousand dollars) that is needed to stay as a patient with that doctor, so are cut loose to join the scramble to find a new primary care doctor.
Loss of autonomy and control of one’s practice is yet another cause of discontent.
When I joined The Pratt Medical Center in 1986 all governance decisions were made by we owner/doctors. Now, like so many other practices, it has been bought out by a large hospital corporation (Hospital Corporation of America). Many others have been taken over by Mary Washington Healthcare.
Nationwide, 80 percent of doctors now are employees. The complaint is practices are run like widget factories with productivity and earnings being the priority rather than patient care – one consequence is that consultations seem to last in the order of nano-seconds.
A Fascinating “Specialty”
Working with these two potential primary care doctors, we saw a positive cornucopia of illnesses in just one afternoon - sciatica, headaches, a spermatocele, mold allergy, Barrette’s esophagitis, questionable urine infection, trigger finger, vitamin D deficiency. All in addition to the basic hypertension, diabetes, high cholesterol, depression and other chronic diseases they were there to follow up on.
My question to these two was “isn’t the fascination of a job where you get to see such a wide swath of pathologies sufficient reward, that you don’t need the big bucks that specialist make?”
I’m not sure my argument cut it. It was a bit of a hard sell.
Bottom line is, if there is not a major shakeup in work culture and remuneration in primary care, things are only going to get worse.
