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A new day for primary care – Fall 2014

By Marcia Horn Noyes

Hope and Change – a recent political campaign slogan – are two words that could also be applied to the current state of primary care medicine. Hope for a future where all have access to basic healthcare, yet a need for change to better balance the limited supply of physicians entering primary care medicine with the growing U.S. population that outpaces the reservoir of those physicians.

The practice of family medicine is the hub of healthcare. However that hub has changed over the past five decades. Doctors, who were once the go-to source for small communities, are closing up shop in greater numbers and grafting their practices onto larger health care organizations just to survive. It’s a change that’s causing primary care physician shortages across the country, especially in rural and underserved areas.

A primary care primer
According to Paul Ogden, M.D., interim director of Texas A&M Health Science Center College of Medicine, the concept of family medicine blossomed during the 1960s. “Doctors then primarily consisted of those who gained experience by going to medical school followed by a rotating internship or military service.” Things shifted in the 70s, 80s and 90s when specialties began taking off. “Somewhere during the 70s or 80s, the general practitioner slowly disappeared and was never replaced,” explained Ogden.

Like the general practitioner of the 60s, primary care physicians have been slowly declining in numbers over the past several years. Ogden says several factors play a role in that decline:

  • Primary care interest from medical school students has gone down.
  • Demands of primary care physicians have gone up.
  • Relative pay of the job is less than other jobs physicians can choose.
  • Residencies have remained flat for almost 20 years while the overall population has increased.

Aaron King, M.D., family medicine physician with BHS Physicians Network, says he followed his heart into family medicine and the decision was a no-brainer. Known as a “jack of all trades” with a wide variety of interests, this San Antonio doctor says the profession fits him well. However, King says that choosing primary care, as a specialty, can be difficult. “It’s hard to choose a specialty that pays less, works as much or more, and has less respect within the physician community due to specialists being regarded as ‘smarter’ physicians.” Consequently, King says a natural tendency exists for the top students to go into specialties, curtailing the supply of primary care candidates.

Recruitment challenges in primary care
This shortage presents a dilemma for many physician recruiters. Even outside recruitment firms say the need for primary care and specialists has gotten more pronounced. Karen Zeller, president of RM Medical Search & Consulting in Denver, Colorado says, “Nearly every organization in the country is seeking to add primary care and hospitalists to meet the current and projected needs,” explains Zeller. “In our experience, it takes twice as long to fill primary care positions versus other specialties.”

While many in-house physician recruiters also struggle to fill primary care positions, others are fortunate to work for health systems with residency programs that feed their primary care needs. After working as a nurse recruiter for seven years, Mary Burns recently moved into an in-house physician recruiter position with Susquehanna Health Medical Group in Williamsport, Pa. “Presently, we have no openings for primary care physicians, but filling specialist positions is a different story,” Burns says.

Kelly Morgan, administrator of Physician Recruiting & Contracting for Centura Health Physician Group in Englewood, Colo. says their two residency programs also help with primary care physician recruitment. “We have more difficulty finding internal medicine candidates, because the majority of them want to be hospitalists due to attractive block shifts.”

Lack of residencies add to problem
Another factor in the primary care physician shortage is the lack of residencies. As Ogden points out, while the U.S. population steadily grew, residencies for primary care doctors basically flat lined. In 1983, the federal government began subsidizing teaching hospitals to help offset residency program costs. But in 1997, Medicare’s support for physician training was frozen. “With cuts to Medicare, the federal government decided not to fund more residencies, other than what we currently have,” explains Ogden.

According to the Association of American Medical Colleges, Congress must lift the freeze on Medicare-supported residency positions to help meet the projected physician shortfall of 65,800 primary care physicians by the end of the decade. Without these additional doctors, the ramifications will be far reaching, especially to the elderly.

Medical school approach to primary care shortfalls
To help combat the primary care physicians’ deficit, Ogden says medical schools are being creative, doing what they can. “Texas A&M College of Medicine has always been a primary care-oriented medical school. We seek out students that have a strong humanitarian bent, and we build upon that by giving students an opportunity to provide continuity of care,” he explains. “Our longitudinal curriculum allows students to do all their clinical courses at the same time, versus sequentially.”

Some medical school programs even offer three-year fast-track programs that may reduce the overall debt for students going into primary care. While helping negate some of the debt-to-income disparity between family medicine and specialties, these programs also hasten the numbers of doctors who can be trained for primary care.

Future of primary care
Fixing the problem of a physician shortage goes far beyond recruiting and training more primary care doctors. Ogden says the fix isn’t physician centric, mostly because medical schools can’t produce enough physicians to address the need. “We’ll have to come up with a new system that uses a combination of doctors, advanced practice providers and community health workers to manage the future health of populations of people.”

One Washington, D.C.-based healthcare innovation leader agrees with Ogden’s outlook, noting that when multidisciplinary team members are each working at the top of his or her license, healthcare is most efficient and effective. In his role as director for MedStar Health’s Institute for Innovation (MI2), Mark Smith, M.D. is focused on addressing the challenges in healthcare today by re-inventing the future. One MedStar team-based primary care model is now being studied closely for its success. “The Medical House Call Program is a great example of a physician-led, multidisciplinary team coordinating care for frail or homebound patients with complex needs that must be tightly managed,” Smith says. While receiving wide national recognition, support for the care model is also coming from individuals. “You know you are on to something when people come up and say, ‘I want that for my parent.’” Smith says.

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