How to increase primary care supply in the US: wishful thinking versus evidence-based interventions

We've all heard that there is a primary care physician shortage in the US.  This is troubling because more primary care results in better outcomes at lower total costs - a.k.a. "bending the cost curve."  The same is not true for any other medial specialty.

To address this primary care shortage current health reform legislation proposes to increase the number of training slots for primary care physicians.  This seemingly logical intervention flies in the face of facts.  While I'm not adverse to increasing the number of training slots, it's a bit like increasing the number of seats on the bus.  The problem is not that we have a crowd of medical students unable to ride, they're choosing to drive Hummers and the bus leaves the station unfilled.  

Karen Hauer and colleagues studied medical student avoidance of primary care.  Here are the findings:

• Medical students see current primary care physicians burning out at very high rates
• The current primary care work force loves taking care of patients but hate much of the rest of their work, and the non patient-care components are overwhelming the rest
• In general, primary care physicians work harder than and earn less than their specialty colleagues
• Primary care physicians are increasingly disillusioned and disgusted by being forced to do less than what is right for their patients

The primary care bus travels the road to perdition as we stop for lunch at the Hamster Wheel, have a snack at the Productivity Express, choke down meal at the Performance Report Card Cafe, all the while finding the toilets blocked up with prior authorization paperwork.

You want to drive a bigger bus and expect smart medical students to pony up for the ride?  Think again.

We increase the primary care pipeline when we make primary care an attractive career choice, when primary care physicians have the time and resources to engage in the full scope of their work.  I've been lucky to practice in a way that provides the time to truly engage in trusting relationships with my patients, that allows me the time to listen and understand why folks struggle with their health so that I can better guide their journey through complex conditions.

I broke out of the jail of status quo primary care and practiced on the lam.  I took the radical approach of starting it all over from scratch, building a practice from the idea that the relationship I have with my patients is the very foundation of what I do as a professional.

Don't get on that bus. It is possible to take a different path and achieve what we and our patients want and need.  Join those who eschew the status quo in favor of practicing at a more professional level.  When medical students see these docs they know the joy of a job well done, of retirement delayed, of primary care reinvigorated.

This is how we increase the ranks of primary care.

Comments

[Kristin]

Increasing interest in primary care is something that I've given some thought to and I appreciate this article because it provides insight as to some of the major obstacles. I wonder if there has been any effort in the medical community to create a program that would incentivize primary care in the way that Teach For America has incentivized teaching by making it an appealing and compelling option for the best and brightest college graduates from across the country. Although there are clearly many differences between the teaching and medical professions, I see some similarities. Top students often do not find a career in teaching appealing for some of the same reasons that top medical students to chose specialties over primary care: burn out rates, bureaucratic processes, and longer hours for less pay than peers. Teach For America has addressed these problems by establishing a network of passionate individuals, making teaching a financially viable option for students of all socioeconomic backgrounds, providing additional training and support, and perhaps most importantly, creating a platform for future education leaders to create new education policy and form start-up charter schools. These efforts tackle some of the core issues in education much like your "micropractice movement" has tackled some of the problems in primary care. If we could figure out a way to lead more medical students to your path through a centralized effort like Teach For America, I believe it would increase the interest in primary care.

Kristin

Full disclosure: Although I am not a teacher myself, I did work for Teach For America for a number of years. This comment is not meant, however, as a promotion of the program, but rather a suggestion of a model that could potentially be copied in the medical profession.

[Sandra Barton MD]

Lovin' your efforts, Dr Moore.