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Shortage of General Practitioners

Created April 24, 2015 by Brian Wu
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One perennial problem that has plagued the medical community for years and led pundits in the field to issue dire warnings for the future of healthcare in America is the current shortage of general practice physicians. In the United States today, there are approximately 210,000 practicing primary care physicians, but many experts predict that in order to keep up with healthcare demands, the medical community will need to add around 52,000 by 2025.

In current circumstances, it seems unlikely that this goal will be met. As of this year, it is estimated that there is a shortage of some 9,000 primary care physicians across the country. However, between the aging baby boomers and an influx of new patients who have been newly insured under the Affordable Care Act, this situation is predicted to get worse. In the next fifteen years, many experts predict that the United States alone could wind up with a shortfall of a whopping 65,000 general practice physicians.

This shortfall, of course, is not evenly distributed across the country. Poorer urban areas and rural areas are being hit the hardest and in many such areas, even finding a primary care physician within a reasonable geographical distance is becoming more and more challenging. For example, one rural area in southern Washington State reported that they now have approximately 5.9 primary care physicians per 10,000 people, and numbers are similar in many other areas.

The need for general practice physicians is obvious: these primary care doctors, general internists, geriatric doctors and general pediatricians are on the front lines of the healthcare community: they are the ones who help patients manage their day-to-day health, diagnosing new conditions and treating many chronic or ongoing ones, as well as education patients in the importance of preventative health care measures. Their clinics are cornerstones in many of the communities in which they work. Because of their importance, the repercussions from this shortfall will be felt throughout all aspects of the medical community and could have serious human consequences as well.

What is Causing the Shortage?

There are a number of reasons for this shortfall.

One of the causative factors is the lack of interest in general practice among students now in medical school. In fact, it is estimated that only roughly 2% of medical students have aspirations to go into general practice, and of that 2%, around half will change their minds at some point in their academic career and opt for a specialty instead. The result is that in the United States today, only about 30% of all doctors practice primary care (this number is around 70% in other developed countries and also was true for the United States itself fifty years ago).

Financial concerns play an enormous role in this lack of interest. As of 2013, it is estimated that the average cost nationwide for eight years of medical school is $169,901, meaning that medical students are saddled with debt at the very beginning of their careers and a higher income gives them the chance to pay that debt off more quickly. Unfortunately, this has the effect of making primary care practice unattractive to many students, as it has some of the lowest reimbursement rates and while a primary care doctor’s average salary is around $200,000 a year, specialists can make anywhere from $200,000 to $400,000. It’s easy to do the math.

There are other, less tangible reasons for this mass exodus away from primary care. Generally, primary care doctors will have a heavier patient workload than their specialist counterparts, work longer hours and have to deal more frequently with administrative issues like insurance company reimbursement and paperwork for Medicare or Medicaid. The result is that even when medical schools do graduate primary care physicians, they are much more likely to burn out and quit practice than those who specialize.

This is not only a problem for the individual patients who are increasingly unable to find a physician to take care of them. It also does not bode well financially for the entire healthcare system, since there is much evidence to suggest that a primary care-based model is linked to increased cost management (and improved patient outcomes) as opposed to the specialist-based approach currently in practice today.

Possible Solutions

Much discussion and debate has taken place in regards to possible solutions to this problem. While many have suggested that opening more medical schools to increase the overall number of practicing doctors has merit, many have pointed out that, because of the lack of interest in primary care, this might well simply churn out more specialists and not solve the problem. However, in southwest Washington State (which suffers from a very high primary care physician-to-patient ratio, mentioned previously in this article), the Pacific Northwest University of Health Sciences has opened, the first in this region to do so in the over 60 years. Since it opened in 2008, this university has, ironically, specialized in the training only of primary care physicians who are interested in rural practice and now over 60% of their graduates go to work in rural communities in Washington and neighboring states. Already, a difference has been seen in this region in regards to accessibility of primary health services.

Others have suggested making primary care practice more financially attractive to new graduates. There are a number of ways to making this possible. One is to improve reimbursement to primary care physicians from Medicare, Medicaid and private insurance companies so that pay will be more equitable (in many countries in Europe, for instance, there is not a substantial difference between the incomes of general practitioners and those of specialists). Another way to accomplish this is through student loan forgiveness for medical students who, after graduation, will practice in primary care for 5-10 years, especially if they choose a rural or other underserviced community. In short, making it more economically feasible for physicians to practice in primary care could well help ameliorate this problem.

The above suggestions, while extremely worthwhile, do not go into the issue of addressing physician burnout in primary practice. Many in the medical field have suggested that relieving physicians of much of the administrative and clerical burden and turning this work over to other trained healthcare professionals would increase access to healthcare by freeing the physician to do what he/she does best: that is, practice medicine and spend time with patients rather than with paperwork. Others have also suggested a change in health-care delivery to emphasize a more team-based approach which makes use of medical assistants and health coaches to assist with patient education and preventative health coaching to also reduce the physician load. This reallocation of the physician’s time, giving him or her more patient time with less clerical responsibility, has the potential to not only increase access to health care, but to greatly improve both its quality and efficiency.

Unsurprisingly, much mention has been made by doctors and others in the medical community of increasing the already strong presence of the 200,000 advanced nurse practitioners and 100,000 physicians’ assistants now in practice across the United States. Already, in many clinics around the nation, these highly trained practitioners outnumber doctors and this number is likely to grow to meet the increased patient demand. Currently, 19 states and the District of Columbia allow PA’s and APN’s full scope of practice, but increasing this role in other states has been suggested to help cover the shortage of general practitioners. There is strong evidence to show that care delivered by these professionals is cost effective and linked to positive patient outcomes, so quality care need not be sacrificed.

Technology, too, will likely play a role in helping to alleviate the issue of these shortages. One possibility is increasing the use of telemedicine, especially in remote or underserviced communities to help reduce disparities and to bring high-quality healthcare to those who might not otherwise receive it. Many such programs around the country has met with positive reviews both in regards to quality of care and to patient and physician satisfaction. Many doctors also point out that increased use of electronic health records can also help increase healthcare access while at the same time improve the efficiency with which the care is delivered by allowing for faster and more accurate communication between physicians, different healthcare institutions and various members of the healthcare team.

Concluding Thoughts

The problem of general practitioner shortage in the American medical community it certainly nothing new, but nonetheless this problem is worsening and the demands of an ageing population and newly insured patients is going to ensure that, if nothing is done to stop it, the problem will only get worse. Because the problem is complex, the solution will likely be correspondingly so and in all likelihood, a combination of many of the solutions suggested above will need to be utilized to stem this rising tide. If not, the cost to underserved patients, to overworked and burned out physicians and to the healthcare system as a whole will be tremendous, both in terms of human and financial cost.

Sources

The New York Times www.nytimes.com

The Wall Street Journal www.wsj.com

Med Pages Today www.medpages.com

The Daily News www.tdn.com

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