Doctor Shortage Looms as Primary Care Loses Its Pull

Aug. 18, 2009 -- Family medicine is what Doug Dreffer has wanted to practice ever since he was a second-year medical student 14 years ago at Ohio State. He listened to a different drummer from the majority of doctors entering a workforce in which subspecialties generally are considered more glamorous — and lucrative.

"All the sexy shows on TV are about ER work or surgeons," Dreffer says. "Grey's Anatomy. ER. Whatever it may be. There is no Marcus Welby on TV — 'cause it's just not cool."

Television aside, medical specialists cite an array of reasons why more medical students aspire to be Grey's Anatomy's McDreamy neurosurgeon Derek Shepherd (Patrick Dempsey), than wise family practitioner Marcus Welby, played by Robert Young in the 1970s series.

Longer days, lower pay, less prestige and more administrative headaches have turned doctors away in droves from family medicine, presumed to be the frontline for wellness and preventive-care programs that can help reduce health care costs.

The number of U.S. medical school students going into primary care has dropped 51.8% since 1997, according to the American Academy of Family Physicians (AAFP).

Considering it takes 10 to 11 years to educate a doctor, the drying up of the pipeline is a big concern to health-care experts. The AAFP is predicting a shortage of 40,000 family physicians in 2020, when the demand is expected to spike. The U.S. health care system has about 100,000 family physicians and will need 139,531 in 10 years. The current environment is attracting only half the number needed to meet the demand.

At the heart of the rising demands on primary-care physicians will be the 78 million Baby Boomers born from 1946 to 1964, who begin to turn 65 in 2011 and will require increasing medical care, and the current group of underserved patients.

If Congress passes health care legislation that extends insurance coverage to a significant part of the 47 million Americans who lack insurance, the need for more doctors is going to escalate.

The primary-care doctor — a category that includes family physicians, general internists and general pediatricians — has been held up as the gatekeeper in keeping people out of emergency rooms and controlling health care costs. But medical analysts say giving this limited pool of doctors responsibility for millions more patients is problematic.

"That tsunami wave (of patients) is going to be huge," says Bruce Bates, interim dean at University of New England's college of osteopathic medicine in Biddeford, Maine.

Finding a doctor will get increasingly difficult, waits for appointments will grow longer, and more sick people will turn to crowded emergency rooms, says Ted Epperly, president of the AAFP, an association that represents more than 93,000 physicians. Or, if a patient goes to a doctor's office, he might not be treated by his doctor: One way overwhelmed family physicians have been dealing with patients is to have office visits overseen by a nurse practitioner or a physician's assistant, some of whom can dispense certain prescriptions and recommend specialists, Epperly says.

"At the time we need family-care physicians the most, we are producing the least," Epperly says. "The nation's medical schools are failing to produce a workforce that is essential to caring for America's communities."

How the gap is filled

In March 2009, U.S. medical school graduates filled only 42% (1,083) of the 2,555 resident positions for family medicine. More than 200 of the positions were left unfilled nationwide. The majority of other spots were filled by non-U.S. citizens educated internationally (20.7%), graduates of colleges of osteopathic medical schools (10.5%) and U.S. citizens educated internationally (18%).

Even the graduates of international medical schools and colleges of osteopathic medicine are showing signs of losing interest in primary care. Osteopathic training is nearly identical to traditional medicine but focuses more on the inner workings of the musculoskeletal system and puts a big emphasis on the importance of family care.

Bates says only 26% of the University of New England's grads chose family practice this year, compared with 40% "when I started this institution 20 years ago."

The shortage, which Epperly calls a "crisis," has gained the attention of the politicians looking at revamping the nation's health-care system.

"Patients with access to quality primary care are more likely to remain healthy and prevent costly and distressing chronic diseases, but the current shortage of primary-care doctors prevents too many Americans from getting the care they need, especially in rural areas," says Sen. Max Baucus, D-Mont., who plays a key role in Congress' health care debate as the chairman of the Senate Finance Committee.

Congress is looking at bills that could help doctors who choose primary care with loan forgiveness or other debt relief and payment increases for their services.

Medical school tuition and expenses generally range from $140,000 to $200,000, according to Merritt Hawkins & Associates, a leader in recruiting and placing physicians. A primary-care doctor usually makes $120,000 to $190,000 a year, compared with $530,000 and higher for those in neurosurgery, according to the Merritt Hawkins salary survey from 2007.

Dreffer is still paying back his loans to Ohio State but says he made the right career choice.

"Absolutely. For me it's about why I came into family medicine," he says. "I consider it a privilege. I like people. I like relationships. That's what family medicine is about. It's not about doing procedures or a cool heart bypass. You get to be part of your patient's life story."

He has seen interest in family medicine change as the medical director of training programs at Family Health Centers in Concord, N.H., and Hillsboro-Deering, N.H.

"More than half of the spots filled are by non-U.S. medical graduates," Dreffer says. "Our pool used to be mostly U.S. medical graduates." One problem with using foreign students is the draining of talent from their home countries. Another is their English-speaking skills, which might make communication with patients more challenging. All are required to take stringent exams in the USA, however. An upside is their willingness to work in underserved areas often rejected by U.S. graduates, including rural areas and inner cities, according to studies done by the American Medical Association.

Part of the reason U.S. medical school graduates are rejecting primary care, Dreffer and Bates say, is because some U.S. schools promote subspecialties or research, higher-paying careers with more prestige.

"I would put a lot of weight on the culture of the school being a big influence," Bates says, adding that doctors pursuing family medicine often will hear, "you're too smart to be in primary care."

Eleven of the top allopathic (conventional medicine) medical schools, including Harvard and Johns Hopkins, have internal-medicine departments but lack separate family-medicine departments. Most internal-medicine doctors get out of primary care and go on to specialties within five years of leaving school, says AAFP's Perry Pugno, director of the division of medical education.

"I think the way you get exposure and cultivate it plays a role," he says. "In some of the bigger schools that generate more primary-care positions by percentage — some of the state schools and osteopathic schools — they have better mentorships and exposures early on."

A shift in training

Training of family-care physicians has been evolving as the supply of doctors decreases. The fictional Marcus Welby symbolized an era in which many doctors handled nearly all aspects of a patient's care. That is not always the case now.

Pippa Shulman, 35, completed two residencies at Dartmouth and begins her first year of family practice Sept. 1 in Massachusetts for Harvard Vanguard Medical Associates, where the team approach is practiced. She is a graduate of the UNE college of osteopathy.

Her residencies "tied into what is the hot topic now: the patient-centered medical home and really creating a primary-care home for patients," she says.

The medical home approach surfaced in the '90s and delivers service that is supposed to be better-coordinated, family-centered and more accessible with expanded hours. Nurse practitioners and physicians assistants play bigger roles in office visits and relieve physicians of other time-consuming tasks so they can focus on the continuity of quality care. "Home" implies continuous, preventive care rather than seeing the doctor only for acute problems.

Experts say getting more doctors to be generalists is an uphill climb in a health care system that rewards doctors based on the procedures they do.

"The biggest problem is the payment model," says Sameer Badlani, an instructor at the University of Chicago's school of medicine. "The more procedures you do, the more money you make. That is why, in a procedure-based specialty, a physician can make about four to five times the annual salary a primary-care physician can earn."

'There is hope'

And that's why specialists like Grey's Anatomy's McDreamy are envied and why fewer students will follow Shulman's path into family medicine, Epperly says.

"I really love being a generalist," Shulman says. "Primary care is fun. I always say I'm a generalist in a specialist's world."

Badlani urges students to consider primary care.

"I give a lecture to medical students basically on not letting debt affect your career choices," he says. "And my aim was just to convince one out of the 100 students who attend. That's where I set my benchmark. If I can convince just one person, I will have done my job.

"I have had three or four students come back to me and tell me they did not want to go into primary care but now they will rethink. There is hope."