Primary Care Doctor Shortage Set To Get Worse, USA

Boosting primary care does not guarantee better outcomes

Researchers from the Dartmouth Atlas Project explained in 2010 that a nation's primary care needs is not just a question of numbers . Better outcomes cannot necessarily be guaranteed by increasing the number of primary care physicians, having more primary care services, or improving access to primary care, the authors wrote.

Lead author and co-principal investigator for the Dartmouth Atlas Project, David C. Goodman, M.D., M.S., said "Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage. Policy should also focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals."

Good morning Chloe,

As RL stated, this has been a problem for a very long time. I believe that another thing that is going to add to the problem, is GP's not accepting medicaid or medicare. My GP will no longer accept new medicare patients, he will still see his existing medicare patients. He will not see any medicaid patients at all. So it seems that we will not have enough GP's, and those that we have will cut back on the patients that they see, (medicaid and medicare)adding to a growing problem ofnot enoughGP's.

As many people know, I am a medical student. I'm just starting my 4th year and beginning the match process - which means that I'm selecting the area of medicine I will be going into.

I can tell you this, I will NOT be doing family medicine. For multiple reasons, in no particular order - relatively low reimbursement, few procedures (I love surgery), you deal with a lot of insurance crap (more so than specialists do, not saying that specialists don't deal with it - just less so than family practice does), the things you see are just simply not all that intellectually stimulating for the most part (a lot of strep throat, flu, viral infections, routine medical management), among many other reasons. Quite honestly, it's rather mindnumbing and dull, imo.

I am trying to decide whether to do internal medicine, and then be a hospitalist; or do gen surg. As I said, I LOVE surgery - I love the idea of going in a 'fixing' what is wrong, then moving on. I love the procedures, the environment of the OR. Once out of residency, surgery has a pretty good lifestyle - unless you take trauma call. You are in charge in a way unlike any other physician - I mean you are the f*in' surgeon. However, the residency is pretty horrific - 5 years of just being torn apart and treated like crap. Also, as more and more minimally invasive procedures become more prevalent, surgery has less and less procedures to do - may of the specialists are doing them. For example - a cardiothoracic surgeon doesn't do stenting of coronary vessels - that's the invasive cadiologists. A cardiothoracic surgeon still does the CABG procedures, but these are getting less common as coronary artery disease is being caught earlier and there are better minimally invasive procedures that can treat the disease sooner.

As for doing IM and being a hospitalist - it's a 3 year residency, that, compared to surgery is a "kinder" residency (all of them are pretty tough). You still get to do some procedures - usually less invasive. The reimbursement for hospitalists is better (in many areas) than general surgery to start out (I have a friend that just graduated from residency - starting as a hospitalist making $400,000/year). The lifestyle is even better - there is no call since most places that have hospitalists have several of them and they each just cover their own shift (days or nights, etc.). Also, you are taking care of truly sick patients - which is meaningful to me. The patients have a variety of illnesses, so there is often puzzles to solve, figure out what is wrong and then help them get better.

Let's be honest for a minute - those of us that go into medicine (for the most part) don't initially go into it for the money. However, after accumulating $300,000 in student loan debt and learning more about the costs of being a physician (liability, loss of free time, etc., etc.) - finances, unfortunately, do matter. We, just like anyone else, want to live a comfortable life, in an area that appeals to us; we've also worked hard to get to this position. We've sacrificed a lot just to get into medical school; we've sacrificed a lot during medical school. A family practice doctor has the same amount of debt as a specialist does - but they make a very small fraction comparatively. Many people find the board, but basic, nature of family practice unfulfilling intellectually, then you add the financial incentives to specialize or do a hospitalist and the much more interesting nature of these positions - it's not surprising that there is a shortage of general practitioners.

BadFish, that's exactly what I was thinking.

In my part of the country, there are an increasing number of "immediate care" offices, mostly manned by DOs, which is one step below MDs. They take care of everything, short of what you'd need at the hospital, which is where they tell you to go if they can't help you.

If NPs can do that, I suppose that would be good enough...

Haha - yeah craniectomies on politicians might just increase their intelligence

When I was in undergrad I was trying to decide if I would get my PhD (and do research) or go to medical school. Medical school won because as much as I like research, I don't have the patience to spend years on something that may or may not work in the end and because I wanted to directly help people rather than use researchers research to help people.

DOs are NOT one step below MDs. DOs have the EXACT same practice rights as MDs, just as much training, they can do every single specialty there is. In fact, DOs actually take a couple of extra classes that MDs don't take. MDs take the USMLE for boards, DOs take the COMLEX for boards - research has shown that the two exams are equivalent in comparing MDs and DOs.

Traditionally, DOs were focused more on primary care, while MDs were more focused on specialty medicine. However, this has changed - DOs are doing more and more specialties and MDs are doing more and more family practice.

As far as NPs go - they are valuable in patient care and should be used appropriately - within the scope of their training. Different NPs have different training - there really isn't uniform education for NPs at this time (though they are working toward changing thins). Also, there have been studies done where NPs take the USMLE and COMLEX to see if they are truly approaching things in the same way a MD or DO would - there is about a 90% failure rate for NPs taking either of these examx (even when given a month to prepare for them, which is the same as MDs/DOs take to prepare for them). MDs/DOs fail these exams at a rate of less than 10%. That tells me that there is a difference in education - which leads to a different approach in patient care.

I'm not saying that NPs are bad, I don't think that at all - I think they have a particular place in patient care, and we should use them in this place. However, they cannot replace an MD or a DO.

I did not know that DOs were equivalent to MDs. That's good info to know. Thank you.

From a personal standpoint, I'd like to go somewhere once a year to make sure that everything is working as is should. I'd also like to go somewhere when I don't feel good, so that I can be treated properly. If that's not the same place, I think it would be unfortunate, as I'd have to develop some kind of care relationship with two doctors at 2 different facilities. It is always in my best interest to have multiple car dealerships, electronic stores and Italian restaurants to patronize so that I'm sure I'm getting the best car, TV or eggplant parmigiana. I think I'd be more comfortable just seeing one physician who knows my history and situation.

No problem - not knowing DOs and MDs are the same is a common misunderstanding. I actually chose to go to a DO school over and MD school (though I was accepted to both) because I liked the environment of the school I ended up at better. I liked the curriculum of the DO school better also. I can honestly say, that since being on rotations and having rotated with both DO and MD students - those from my school consistently outperform most of the other students, including the MD students. I'm at one of the top ranked DO schools in the country (in fact, it is ranked higher than Harvard and Yale for primary care - I just don't want to do primary care).

I also agree - see one practitioner for routine health maintenance and when you don't feel well. You'll get better care because they know you and your history better. Just an example, but my mom has a lot of chronic, serious illnesses. She has a PCP that oversees and coordinates her care. She sees him for routine health maintenance and when she gets a bug (which is frequent because she is on immune suppressants). However, she sees a gastroenterologist for her Crohn's and motility issues; a neurologist for her epilepsy and MS, and an rheumatologist for her Lupus. She would not be a good candidate for an NP as her PCP because she has a very complicated medical history and a lot of things going on all the time. My dad, on the other hand, is a very healthy man - he sees the same PCP, but more times than not, the PCP is overbooked, so he sees the NP. Since the NP and PCP work together in the same office and he's pretty straight forward (no chronic medical conditions) - things run pretty smoothly for him.

Haha - I think they have a functioning brain stem only - that's why they keep breathing, it's reflexive.

so, if you increase demand, without increasing supply, it causes a shortage?

who knew?

Increasing supply isn't as easy as it sounds. Some people would think all you have to do is admit more people to medical school. However, this is short-sighted. There are limited residency slots - without completing a residency, the physician can't, essentially, practice.

Well, so you might say, well increase residency slots. Here's where it gets tricking. It has to do with residency funding. These positions are NOT paid for by the hospitals that have residency programs. They are, instead, paid for by Medicare. Cuts to medicare hurt not only the elderly or disabled that use medicare for health insurance, it also hurts everyone else because it reduces the number of residency slots -- resulting in the shortage that has been around for many years, but is just getting worse.

EI: I absolutely agree with you. I was just commenting on part of the problem, which many people aren't aware of, is that residency slots are paid for my medicare. Medicare provides about $100,000/year to the hospital for each resident -- residents salaries, educational fees, etc., etc. comes out of this. So, cuts to funding medicare not only mean less coverage for elderly and disabled, but it also means even less money to fund residency slots. If you can't fund the slot, then you can't have the residency position available. So, there is a limit on how many people can even be accepted to medical school - due to the limit on how many residency slots there can be, due to medicare funding.

You are right though when it comes to taking care of medicaid/medicare pts. Just an example, but if an ob/gyn sees medicaid patients, it actually COSTS the ob/gyn to provide care for those pts. The reason is that medicaid reimbursements are so low - low enough that they simply don't cover the costs of supplies used.

Very true.

That was pre-Scramble/SOAP. This is basically a second match that occurs after the primary match. Once the Scramble/SOAP is done, those spots are taken. The students that have to scramble/SOAP into a residency are generally less competitive, just as the spots are typically less competitive spots. Essentially - this occurs when students who are below average over shoot and only apply to residency slots that take more competitive students.

In the end, those spots don't sit empty.

but arent physicians part of the evil 1% "meritocracy"?

surely they should be dealt with as appropriate.

The average primary care physician is not in "1%" (the average family practice physician makes $187,000/year). In fact, many specialists aren't even in the "1%". Yes, there are physicians, especially in some specialties, that are in the 1%

Damn, got that right EI!

Once we start controlling cost in all phases of medicine, nothing will change.

I agree. Quality doesn't come with having 'more' of something; it comes with incentive to improve and do better, and that's usually the result of things costing more.

Hi Kav,

..is GP's not accepting medicaid or medicare. My GP will no longer accept new medicare patients, he will still see his existing medicare patients. He will not see any medicaid patients at all.

Excellent point that is contributing to this problem. We (Gov) can't cut one side, giving it to the other without the effects trickling down to everyone involved. This scenario will in effect mean that sub-par caregivers might be all that is left for medicare/caid patients.

I would hope that you will start conducting craniectamies on the demographic group known as politicians.

LOL! ...Removing their defective brains would seem to be an improvement, for sure. I suggest replacing it with two round sponges. Then we can imbibe them with all of our goodness and the world's problems will be solved.