(Jonnie Miles/Getty Images)In today’s Doctor and Patient column, Dr. Pauline Chen explores a looming public health crisis: the doctor shortage.
Already experts are predicting a shortage of primary care doctors of 35,000 to 44,000 by the year 2025. Given population estimates that means “either primary care doctors will be seeing many more patients than they do now, or several million people will be without a primary care doctor, no matter how accessible health care might be for the rest,” she writes.
So while president-elect Obama is struggling for ways to give everybody access to health care, a more pressing problem may be getting ignored.
“We may find ways to give patients access to the waiting room,” writes Dr. Chen. “But what if there’s no doctor on the other side of the door? ”
Read the full column, “Where Have All the Doctors Gone?” and then please join the discussion below.
Healthy living doesn't happen at the doctor's office. The road to better health is paved with the small decisions we make every day. It's about the choices we make when we buy groceries, drive our cars and hang out with our kids. Join columnist Tara Parker-Pope as she sifts through medical research and expert opinions for practical advice to help readers take control of their health and live well every day. You can reach Ms. Parker-Pope at 
The easiest and most pleasurable way to eat well is to cook. Recipes for Health offers recipes with an eye towards empowering you to cook healthy meals every day. 
From 1 to 25 of 219 Comments
This whole issue breaks my heart, as I want nothing more than to care for the underserved, but cannot get into medical school. Because of the restriction on the number of spaces in medical school classes, the future generation will miss out on quality medical care.
— Katy GleditschCould the paperwork problem be mitigated by having people whose job it is to handle it so the doc doesn’t have to? That seems too easy?
— ChrisAgree there is a primary care crisis
But a much larger crisis is to not have economic incentives in place for primary care docs to do more preventive medicine.
Also we MUST rebuild our nation’s public health infrastructure which will reduce demand for all types of Doctors
— Dr. Rick LippinDr. Chen is correct in her assessment of primary care. However she neglected to mention the plight of the emergency physicians who hold the nations safety in their hands net when it comes to health care, and this net is capturing more and more of the patients that cannot get primary care. The state of Emergency Care in the United States is in “critical condition” according the report card issued a few days ago by the American College of Emergency Physicians. The nation can rest assured that emergency physicians will continue to treat anyone that presents to their door regardless of their lack of insurance, regardless of time of day or the scope of their ailment, but as the report stresses, increased pressures on this safety net will continue to impact waiting times and threaten the care and safety of patients that come to the emergency department.
— Selim SunerI have been a practicing family physician since 1989.
My job is much less satisfying than it was then. The average patient has gotten older and sicker in the past two decades, and there is much more to be done for patients. Doing more for patients (if it is effective)is of course good, but it increases our direct clinical workload as well as the time it takes to keep up with new developments. The administrative burdens are much worse now than they were when I started. The paperwork is simply unimaginable to someone not in primary care medicine. Pay has not kept up with inflation. My hourly salary is 22% lower now than it was in 1996.
Medical students are avoiding primary care. They see the difficult practice environment and want little part of it. But the main reason many of us will be unable to find a doctor in the coming years is the salary discrepancies between primary care and subspecialty medicine.
A realistic numerical example will suffice.Suppose a family doctor earns $150,000 per year for 30 years for a total of $4,500,000. Now suppose a subspecialist earns $250,000 per year for 27 years (he or she finishes training 3 years after the family doctor). His total lifetime earnings are $6,750,000. This works out to $750,000 for each extra year of training– and often, and easier job at the end of training. Medical students, who choose their specialty in the last year of med school, can do this simple analysis, and they understand that, from a lifestyle viewpoint and a strictly financial viewpoint, primary care makes no sense.
Fine words about the importance of primary care, positive role models, loan repayment schemes and scholarships for primary care all well and good, but they don’t change the fundamental incentives facing medical students when they make their specialty decision.
— vberingKaty — Go to PA school or become an LPN. It takes less time and they can do many of the same things as MDs. They get paid very well and have nice schedules. Plus then you get to avoid the joys of medical school and residency. I have to say, if I were planning on going into primary care, there is NO WAY I’d do it via med school.
— SOne way of increasing the availability of primary care is to beef up training and expand the legal scope of practice of those healthcare practitioners who are already serving their patients as primary care providers such as licensed acupuncturist, chiropractors or naturopaths. Naturally, this would also require parity in regard to insurance reimbursement.
— Christiane Siebert, L.Ac.This is not really news. This trend has been reported for a couple of decades that I can recall. A number of years ago, the prognosis was that this downward availability trend would continue, because the specialties pay so much better than general practice.
Is this still the general consensus?
— CBAs the number of primary care physicians dwindles, the number of physician assistants desiring to practice medicine in the area of primary care is increasing. I believe that soon the profession of physician assistant (PA)will aquire a new name, perhaps physician associate, which will more clearly resonate with patients the abilities and capabilities of this highly trained/skilled medical clinician. The typical PA program of today is rigorous 2-3 year master’s level program, with stout prerequisites. Furthermore, there appears to be plans to initiate doctoral level programs in the near future. Since the PA is trained in the medical model, the physician / PA team is a benefit to patients since the PA always has a physician with whom to confer regarding patient care - a built in second opinion, so to speak. The medical school students who choose to practice medicine in primary care are to be commended.
— Elizabeth W.Primary care involves professional nursing, as well. I wrote an idea on the Obama Transition Team’s Change.org site which proposes primary/public/preventive universal healthcare reform more prominently featuring professional nursing.
The idea is skeletal because the ideas submission form allows for a max of 2000 characters, but it’s fleshed out with references on my accompanying blog post.
The Change.org site is open to everyone. It would be great is the NYT Health page would provide a prominent link to it, because the healthcare section is very active and is totally unrestricted in participation eligibility. (I have no affiliation with it or anyone on the Obama transition team.)
http://www.change.org/ideas/view/universal_healthcare_reform_-_primarypublicpreventive
http://www.change.org/ideas/view/universal_healthcare_reform_-_primarypublicpreventive
— Annie, MassachusettsMedical school is expensive. I hope these new incentives makes it more affordable.
— ThomasMedical Education in this country is a very long and very expensive path that is only so wide (~15,000 spots/year in MD schools and ~4,000 in DO schools). As a medical student (I am a second year student in New York), I spend every day memorizing a huge amount of information. Some of this information is useless, but the vast majority (as much as I hate to admit it) really needs to be learned. That said, any honest physician will tell you that they have forgotten almost everything they learned that doesn’t apply to their specialty and practice (more or less) the medicine they learned as a resident.
— LVSDue to the length and expense of medical education, we (as physicians and as a society) should seriously investigate pathways whereby routine primary care (and preventative medicine/risk assessments) is provided by non MDs (whether by NPs, PAs, or someone else) that have received training sufficient to manage routine chronic conditions and to identify when the progressions of a disease necessitates consulting a specialist. This will mean that the AMA will have to be a little less protectionist (not its strong suit) and that we as citizens will have to become comfortable having sprained ankles treated by our general internist and not an orthopedist.
Interestingly, this idea was first suggested to me by a good friend and classmate who wants to go into primary care. She correctly realized that she is, in many ways, over-qualified for the field she hopes to enter. By the time she is a residency trained physician she will have gone to four years of college, four of medical school and three years of residency. Compare that to the training program for a PA (4 years of undergrad, two of PA school, and maybe an 18 month training program; 3.5 years saved) or an NP (4 years of undergrad, 1 of RN/BSN school, and 2 of NP school; 4 years saved). It just doesn’t make sense to spend so much time, money, and training on a series of evaluations that can be handled with less. As a nation, as we seek to decrease the cost of medicine, we should seriously look at taking the MDs out of primary care and putting them into acute care (where the extra training really does matter).
(Previous comment contained a url error)
Primary care involves professional nursing, as well. I wrote an idea on the Obama Transition Team’s Change.org site which proposes primary/public/preventive universal healthcare reform more prominently featuring professional nursing.
The idea is skeletal because the ideas submission form allows for a max of 2000 characters, but it’s fleshed out with references on my accompanying blog post.
The Change.org site is open to everyone. It would be great is the NYT Health page would provide a prominent link to it, because the healthcare section is very active and is totally unrestricted in participation eligibility. (I have no affiliation with it or anyone on the Obama transition team.)
http://www.change.org/ideas/view/universal_healthcare_reform_-_primarypublicpreventive
http://revolutionredux.wordpress.com/2008/12/10/share-and-vote-or-not/
— Annie, MassachusettsKaty (#1), have you looked into NP (Nurse Practicioner) programs? You should, we’re awesome! More info here (http://en.wikipedia.org/wiki/Certified_nurse_practitioner) and here (http://www.aanp.org/AANPCMS2)
— NP StudentGiven the overwhelming need for primary care, the time and expense of medical training, and the limited number of training spots, I think the answer is for primary care physicians to form small partner practices which work with a larger cadre of physician extenders-this will improve patient access, improve quality of care, improve quality of life for physicians, and preserve income (as opposed to simply increasing the number of PCPs, which will drive down reimbursement).
— MikeIn turn, the job of a PCP will once again become satisfying; interest in the specialty will increase, and the profession will continue to attract high quality candidates.
The loss of primary care physicians makes for good reading but is irrelevant. What we really need are more specialists. If you have a heart problem you probably want to be seen by and should be seen by a cardiologist, if your hand hurts get to an orthopedic surgeon and preferablely one who is fellowship trained in hand problems. She will order fewer tests and turn around your interaction with the health care system faster and less expensively than the primary care providers, with their comparitivily limited training and knowledge base.
Ms Chen, made an unfortunate choice of residency selection coming out of medical school, fortunately few are following in her footsteps and the health of the country will be better for it.
— Andrew ThomasI had a conversation with a cardiologist the other day who stated that within 5-10 years physicians will no longer be providing primary care. As the gap between what insurers and patients are able and willing to pay and physicians’ expectations of remuneration widens, the tipping point will be reached where primary care practice is not a financially viable career path. What made him so sure? Why has this happened? The medical establishment has brought it on itself. The AMA, domination by specialists, reimbursement schemes that favor procedural medicine, disorganized and disempowered public health systems, and the public’s ignorance and taste for platinum-level care have all contributed. The cost of medical education, setting up and running a practice, malpractice insurance - even for groups of physicians - make the opportunity cost impossibly high for those who would become primary care physicians. Rather than these systems changing to meet the need for primary care, tiers of providers at different income levels will continue to evolve to address primary care and chronic illness care. Extenders such as nurse practitioners and physician assistants will come in to fill this void while primary care physicians migrate to other fields which pay better. Mr. Obama’s healthcare plan will need to recognize this development and plan for the training and deployment of the professionals - not physicians - who will be the “new face” of primary care.
— DS BostonMassachusetts is experiencing a serious primary care shortage, as they transition to broader coverage. Or, put another way, patients in Massachusetts are having a very hard time finding a PCP.
Decreasing the administrative burden that currently plagues American health care will free up all physicians to concentrate on doctoring over filling out yet another form while on interminable hold with an insurer to get authorization. There will need to be student loan repayment programs, of the type that currently exist for some medical researchers, or other creative programs to encourage students to do heavy lifting of primary care over the better compensation, lifestyles (or both) of many (but not all) specialties.
— amygdala#16; DOCTOR Chen is a transplant surgeon, which may or may not be unfortunate, but is not the point you were hoping to make.
— noelleThe number of medical students should immediately be tripled with a special path being created for those students who want to become primary care physicians. This path would not necessarily entail all the years required of a specialist but would cover the fundamentals of medical education (at a level above a nurse or physician’s assistant) but with more emphasis on practical training. These doctors could then create practices where they supervise paraprofessionals such as nurses or physician assistants at a lower cost to the public. These practices would focus on preventative care and management of chronic diseases such as diabetes. Over the long run this would save the health care system a lot of money by slowing or reducing the progression of chronic diseases into acute situations.
— Lisa PorterAloha Dr. Chen,
I enjoyed your well written article, which covers the problem that my family’s life mission has been focused on solving for over 15 years. The one glaring error in your article highlights a real problem undiscussed, which is the ignorance of MD’s regarding mid level providers. I have never before seen “physicians’ assistances” in written form after over a decade of my wife being in that professional area.
A Physician Assistant, Physician Associate, or Physician Assistants or Associates, refer to the class of medical school graduates in PA programs who can accomplish master’s degrees in their programs. They provide unassisted patient care under the state defined supervision of an MD. PA’s are typically older and more experienced students going into medical school, and are trained in the medical model the same as doctors. PA’s cost about 26 cents for every dollar they bill for, and most PA schools that I am familiar with have focused on primary care in their training to meet this emerging need you have well defined in your article.
My wife has found extensive resistance here in Hawaii, which has an exceptional shortage of primary care providers, on the part of MD’s reluctant to hire PA’s and other mid level providers. I was told point blank on the phone by the provider manager of the largest local hospital’s outreach clinic that their policy was firmly against the hiring of PA’s.
I just read that Michelle Obama is, or was, a hospital administrator. I am pretty sure that she will figure out that the government has for decades been paying PA’s to help fill this shortage in primary care. You might find it entertaining to know that the director of the Hawaii State Health Department that certified that Barack Obama was indeed born in Hawaii, according to state records, was and is, unfamiliar with PA’s also, after my wife contacted her a year ago to offer primary care services. Small world, maybe.
Medically, PA’s have academic standards and REQUIRED board certification tests comparable to MD’s, and make substantial profit for the facilities that bill for their services. I am certain that some doctors find this regulated support, or perceived competition, intimidating, perhaps, as the many PA’s in our closer circles report the same ambivalence towards their employment by MD’s across the country.
Where have all the Doctors Gone?
Golfing in Hawaii, likely, but not practicing primary care here in sufficient numbers.
Probably they should go to their local Physician Assistant association website and make more money by hiring PA’s in their practice, while spending better quality time in patient care as a result of their reduced patient load. It just makes good sense for everybody, and only requires a short amount of CME time on the subject of Physician Assistants.
Physician Assistants work side by side with MD’s in providing quality primary care, while adding to the doctor’s, or facilities bottom line income. My wife’s MD employer, massively overwhelmed by patient demand, told her that the two of them together saw more patients last week than ever before in the history of his practice. And he works quite a few less hours per week than he used to. He also used to head an association of primary care doctors, and now sees a large and growing number of daily patients, as other doctors have left the islands.
There IS a way for primary care doctors to field the growing demand, and I agree, they should be better compensated for bearing the larger burden of responsibility and wider required range of expertise required of them when compared to specialists.
Barack Obama only needs a little effort on the part of primary care doctors in order to make things work better in America for everyone. Substantial online material exists about PA’s, feel free to look up the small web page I have posted on the subject.
Mahalo!
John Pratt
Married to the question, “What is a PA?”
PS Katy Gleditsch, submitting in this forum could look into PA school!
Two years and into the trenches….
From Pauline Chen: Thanks, John, for writing in about this important group
— John Prattof health care professionals. There is also excellent information on website
of the American Academy of Physician Assistants: http://www.aapa.org/
To Post #16:
The loss of PCPs is not irrelevant. If you think that it is a better use of resources for an otologist to take care of your ear infection rather than a general practitioner, then so be it.
But who is going to provide you the coninuity of care over the course of many years, to help you manage your chronic conditions (i.e. diabetes), to persuade you to quit smoking, to prevent you from acquiring age-related diseases, to pull the specialist treatments to create a holistic picture of your health?
If you think a specialist like a cardiologist or an otologist is going to do all this, then clearly you haven’t seen a doctor for awhile because what you imagine in your head is not reality,
— Going into Primary CareThe Patient Centered Primary Care Collaborative http://www.pcppp.net would agree with you. We are a Collaborative of over 400 organizations large employers physician groups like you’re the AAFP healthcare benefit companies and consumer groups and . Study after countless study shows that when a patient has a primary care physician that cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford. Let’s call that a Patient Centered Primary Care (PCPC) or Patient Centered Medical Home (PCMH).
But we the buyers large companies have been part of the problem (as Pogo said so long ago I see the enemy it is us) in not demanding systems of payment and practice organization that encourage and enable the comprehensive, patient-focused primary care we desire. There is no money paid for the necessary investments in teams and health information systems so essential to the delivery of comprehensive, cost-effective, patient-centered care. Current payment methods richly reward medical procedures and discourage spending time with patients in such essential activities as history taking, physical examination, diagnosis, planning treatment, counseling, coordination, and prevention. This must change. ,
When one compares the U.S. health care system with those of other industrialized countries, one is led to the more specific conclusion that the two major problems in U.S. health care are the way we 1) fail to deliver comprehensive primary care and 2) the way primary care is financed. Our premise is that primary care is the only natural locus of control of health care quality and costs. It is the only entity that is charged with the longitudinal care of the patient. It is the only entity whose job it is to consider the whole patient, the health of the whole person, including mental and physical.
For some reason, the healthcare industry and we as the buyer have demonstrated an inability to develop a sharp focus on solving core problems. We seem much more willing to create complicated responses to our problems than we are to fix the core problems of our delivery system. Again, disease management is a perfect example. If primary care is not delivering high quality care for those with chronic conditions, we can either find a way to work around primary care or we can find a way to fix it. Our willingness as large employers to “pay any price” for that episodic care which for example provides for a Diabetic amputation of a limb but our unwillingness to open our eyes and understand that the reason for the amputation was our failure to be willing to pay for the prevention and primary care.
Demand of ourselves as patients:
Comprehensive, continuous, patient centered, personal and holistic primary care which is based on strong relationships between patients and their physician — this is foundational to good health. Practice and payment reform are the prescriptions for achieving it.
— Paul GrundyFor now, the best way to go is to increase the number of PAs and NPs. Internists and FPs would be the next level up if help is needed, and then the specialists.
PAs and NPs would be much cheaper, since their level of training, time spent training, and educational expense is overall much cheaper than for a physician. And again, if they can’t handle it there would be sufficient backup in place.
The cost savings would be enormous, We simply do not need every sore throat and simple case of high blood pressure seen routinely by a physician. We do not need a pediatrician for well-baby visits (or even most ear infection visits), or an obstetrician for low-risk prenatal visits.
We can become cynical and indignant about the possibility of two-tiered systems and why it would not work, but we need to fix it NOW, and we have to start somewhere to address these cost and access issues.
— jackDr. Chen’s report on primary care shortages is accurate and the reasons are sound, however, her message in another recent article supporting longer residency hours seems to contradict part of her reasoning.
As stated in other comments here, a free market system in the medical industry is on the way out, and is non-existent for doctors-in-training. Hence, doctors are left with only one career ‘making or breaking’ decision to make - what field will satisfy the balance between work and home life, and at what financial cost. The rest of their career is at the mercy of reimbursements - not supply and demand.
It is unfortunate that we push our doctors-in-training through such a mangled system, depriving them of sleep, and paying them less than janitors on an hourly basis, while wasting away the fertile years of life when strong family ties should also be a priority. Why should we expect anyone to want to choose a field that gives them nothing in return for this journey- no time and little compensation?
Doctors are among the most intelligent and passionate people within our community. If we could only give them some breathing room and let the market help drive the supply of jobs, we would not be in such a quandary .
— Eric J