Annie Lowrey’s July 28 article “Doctor shortage likely to worsen with health law” in the New York Times noted the growing shortage of primary care doctors particularly in economically disadvantaged communities, both in rural and inner-city America. This problem will likely get worse before it gets better as more Americans gain coverage and seek a regular source of care. As the article suggests, training more doctors and incentivizing them to pursue careers in primary care will be a key part of the solution. And it will require a multipronged campaign, using both some of the traditional strategies for workforce renewal and a few unique tactics not typically deployed in efforts to fix health care.

The primary care workforce pipeline had dried up before the Affordable Care Act was passed. Currently, one out of every five Americans lacks access to primary care. As a result, up to 75% of the care delivered in emergency departments these days is primary care . This overcrowds and overburdens EDs, raises costs, and limits EDs’ ability to do what they were designed to do: provide acute, emergency care that makes the difference between life and death. So the primary care shortage threatens our access not only to primary care but also to emergency care.

How did we get here? Many are quick to point to primary care doctors’ low salaries compared to those of their sub-specialist colleagues. Indeed, choosing a career in primary care rather than a sub-specialty means walking away from 3.5 million dollars of additional lifetime earnings.That’s tough to do when you’re looking at $150-200,000 of debt, which is the average debt of an American medical student at graduation.But the crisis in our primary care pipeline goes far beyond the money.

Medical schools aren’t recruiting enough of the right people in the first place. Numerous studies show that people from rural and lower SES communities are more likely not only to pursue primary care careers but also to return to those disadvantaged communities to practice. Unfortunately, medical schools’ acceptance of applicants from these communities has declined substantially in recent years. Instead, medical school admissions criteria favor more affluent applicants who are ultimately more likely to pursue sub-specialty careers.

Further, these same medical schools have been actively discouraging primary care careers for decades. This is due partly to cultural biases that place super-specialized medicine on a pedestal over generalism, which is due in part to how NIH research dollars flow, predominantly supporting cutting edge biomedical/technological research usually advanced by sub-specialists. The result is that primary-care-oriented trainees face four long years of admonishments against primary care careers – a hidden curriculum in which generalists are portrayed as nothing more than referral centers and lectures from so-called primary care mentors warn trainees against primary care careers at all costs. It’s no wonder fewer than 20% of Americanmedical school graduates are choosing to go into primary care today. We’ve all but legally barred them from doing so.

If that weren’t enough, in their rotations, trainees see the most dysfunctional, antiquated and frustrating approaches to primary care delivery that exist in our health care system. The combination of a sicker, more-complex-than-average patient population, inadequate funding and support for improvement efforts, and predominantly part-time faculty who are frequently not available for teaching or improvement activities has created a toxic milieu. I can’t tell you how many primary care students and residents have noted that it feels like their clinics were specifically designed to destroy their interest in primary care.

Trainees need exposure to the existing models of care delivery that are transforming primary care to work better for patients, providers and payers. Patient-centered medical home (PCMH) practices, which use highly-coordinated, enhanced access, team-based care, are showing exciting results : higher quality of care, decreased ED visits and hospitalizations, happier patients, and lower overall spending. And it seems that exposure to this new model of care is one of the best ways to help trainees see a future for themselves in primary care. The problem is, only a tiny group of trainees are exposed to these types of clinics due to poor penetration of this model in the academic environment . This is something that needs to be remedied.

Revitalizing the primary care pipeline is going to require a multipronged campaign, with the greatest thrust being a change in the way we pay physicians in order to create greater equity between sub-specialist and generalist salaries. If we really value primary care as the foundation of our health care system, purchasers must invest in it and give clinicians the financial support they need to do their job well. We must also expand the definition of a ‘primary care provider’ to include Nurse Practitioners and Physician Assistants, two critical members of the primary care team who can immediately expand access to high value primary care services in communities across America.

As the patient-centered medical home model spreads across the country, academic leaders must ensure it also takes root in our medical school practices, where trainees are both learning what it means to deliver high-value care and making career decisions. We’re increasingly realizing that trainees not only have much to gain from these experiences, but they have much to give. And the sooner we get medical students involved in inter-professional training opportunities with nursing students, social work students, etc, the better. ‘Learners learning together’ is a critical first step to get trainees used to practicing as a team – which is one of the key ingredients of high value primary care delivery.

American medical schools must be held accountable for producing the primary care providers this country needs. This means not only reinvigorating primary care programming and developing new approaches to recruitment and retention of those individuals most predisposed to primary care careers, but also teaching the actual patient-centered, team-based skills that providers need in order to deliver high-value care today. The public cannot afford to wait for medical schools to do the right thing. We must leverage our collective power as purchasers and consumers to demand that these institutions break from their “business as usual,” specialty-focused approach to training. Maybe it’s time for a national campaign to publicly call on all American medical schools to step up to the plate and start revitalizing the primary care pipeline.

Finally, we – from academic faculty to laypeople – must all recognize the role we play in perpetuating the bias in America that being a primary care provider just isn’t good enough. Whether it’s through our questions tofamily members in medical school about what “specialty” they’re going to pursue, or our negative responses to their explicit intentions to practice primary care, we make clear that we wish they’d do anything *but** *go into primary care. I implore all of us to face up to our responsibility to remedy and reverse these biases. So, next time a student tells you he or she is planning to pursue a primary care career, do yourself, your country and the future generations of Americans – who are currently on target to not have access to their own primary care provider – a favor and thank that student for doing the right thing.

We’ll never achieve real health care reform without a foundation of robust primary care in this country. However, fixing the pipeline is no small undertaking. It will require a multifaceted approach to remedy the financial, academic, cultural and political challenges that have plagued the primary care pipeline for years. It will also require us thinking more expansively and inclusively about the definition of a primary care provider. But to increase the primary care physician supply, our course is clear: we must come together now, as a nation, and both collectively demand more from our medical schools while also providing that system with the support it needs to change. Without that, it will be next to impossible to help our academic medical machine break free from it’s specialty-centric approach to workforce creation.

Andrew Morris-Singer, M.D., co-founded the precursor to Primary Care Progress to advocate for improved primary care programming at Harvard Medical School. He now serves as President of Primary Care Progress and speaks regularly on the topic of clinical innovation in primary care,primary care advocacy and trainees’ critical role in that process.

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27 Responses for “Reviving the Pipeline: A Call to Action For All”

  1. maggiemahar says:

    Andrew, you write:

    :”Medical schools aren’t recruiting enough of the right people in the first place. Numerous studies show that people from rural and lower SES communities are more likely not only to pursue primary care careers but also to return to those disadvantaged communities to practice. Unfortunately, medical schools’ acceptance of applicants from these communities has declined substantially in recent years. Instead, medical school admissions criteria favor more affluent applicants who are ultimately more likely to pursue sub-specialty careers”.

    “Further, these same medical schools have been actively discouraging primary care careers for decades.”

    This is so very true. Thank you for saying this.

    (If readers are interested in the topic,–, see what Dr. John Stobo and
    Dr. Robert Bowman have to say in this HealthBeat post.http://www.healthbeatblog.com/2009/05/reinventing-the-way-we-train-doctors-and-nurses/ (It’s a long
    post–just search their names.)

    I’ve also written about recruiting these students here: http://www.healthbeatblog.com/2011/03/primary-care-and-the-national-health-service-corps-finding-physicians-who-will-go-where-no-one-else/

    The only thing I would add is that we need many more nurse practioiners
    helping to deliver primary care.

    The ACA provides funding for scholarships for many more, and raises pay for nursing school teachers (which will lead to more teachers and more slots in
    nursing schools.)

    NPs and PCPs can work very successfully together. PCPs report that
    sometimes the NP is better at certain things than he or she is (for instance
    chronic disease managment– and teaching the patient how to help, without
    lecturing or shaming the patient. (Which just makes the patient avoid
    coming back.)

    See medica reserach comparing care by NPs and PCPs here http://www.healthbeatblog.com/2010/04/hey-nursie-the-battle-over-letting-nurse-practitioners-provide-primary-care/
    (Begin by seraching “Avorn”– that will take you to the part of the post where I discuss the reserach)

    Also seee what we know about NPs here
    http://www.healthbeatblog.com/2011/11/how-health-care-reform-can-create-jobs-and-cut-costs/#more-1286

    NPs also are willing to work on their own (and do) in many of those places
    where the majority of doctors will not go (poor rural areas, inner cities,
    particularly cities like Detroit.)

    More med students from low-income backgrounds who grew up in those places will help, but until we provide a better publlic school eductation for low-income kids, we’ll have a hard time finding enough who can get into med school—even if the med schools lower the test-score barrier a bit (which they shouldl)

    Reserach shows low-income kids will have lower tests scores entering, and aren’t as well-trained in test-taking as the kid who went to Yale, so they don’t do as well on tests in med school.

    But as clinicians they are just as good. And insofar as they are better at understanding their low-income and middle-income patients, they can be better.

    NPs will also play a major role in staffing community health cetners that will
    be providing primary care to many low-income families. The ACA provides
    funding to double the capcity of these health centers

    Finally,median salary for a PCP is now around $180,000.–half earn more.
    For a NP it’s about $100,000.
    If they’re doing more, they should earn more. But they’re not comparing their salaries to an orthopedists $450,000.(Money is so relative.)
    An NP is likely to be happy earning $120,000.
    Meanwhile some (far from all) PCP’s earning $220,00 are
    disgruntled that they not earning the $450,000– and definitely do not want to
    have to work with poor patients who are not compliant, lead chaotic lives, and have many emotional problems.

    As one of my doctor-readers once commented on HealthBeat:
    “If you want “comfort” find a nurse. I cure!”

    Many patients need both. And of course, sometimes “cure”isn’t possible.

    • rbaer says:

      Agree with most what MM said. And:
      -as often, it boils down to (or at least centers on) the medicare fee schedule overvaluing procedures, and yet there are few people talking about that
      -with regards to patients wanting “comfort” within the medical system, that’s a difficult problem. Anyone in the medical system keeping his/her eyes open knows that “comfort” does not stop at attention and hand holding but often includes unneeded tests, scans and hospitalizations.
      Moreover, the current trend to reimburse in part based on patient satisfaction will lead to provider cherrypicking – for instance, I see chronic pain patients who are known – on average – to be more demanding and harder to satisfy (in terms of time and effort). If the lower satisfaction scores from this patient group impact my reimbursement and reputation, why should I bother?

  2. Randall Oates, M.D. says:

    The more immediate solution to the lack of capacity in primary care is not via the pipeline but by removing the waste within the primary care process. Multiple studies have revealed that primary care clinicians are performing 2-3 hours daily of documentation and administrative tasks. This can almost all be removed with proper use of information technology and the care teams. Doing so would increase primary care capacity by 30% almost immediately.
    Sadly, the current approaches being commonly implemented at the point of care are not increasing primary care capacity, and commonly seem to either be attempting to turn doctors into data trolls or burn them out by robbing them of their free time having them clicking and typing for 2-3 hours daily. Some get an hour or two back by using templates to throw in globs of garbage that threatens the validity of the very data we need to collect to improve care.
    In 2014, when we have 34M or so newly covered patients, perhaps the sign on the clinic door or the message on the answering machine should say… “Sorry the doctor can’t see you now, the time he/she should be spending with you he/she is now spending clicking and typing on a computer.”

    • Peter1 says:

      “Multiple studies have revealed that primary care clinicians are performing 2-3 hours daily of documentation and administrative tasks.”

      Could it be private insurance hassles having to serve multiple providers and fight for reimbursement?

  3. Vikram C says:

    Peter1, a very relevant comment and one of my railing point on inadequacy of statistics. Say, that insurance is just 15% odd of overall healthcare expense. That is expense on side of payors. It doesn’t include big billing group expenses on side of provider. Then is the question of value add coming from payors and the wonks note that it’s only now insurance is trying to focus on making people’s live’s healthier. I would like to ask these wonks to live uninsured for some time and haggle prices with doctors. Then argue about bills with provider billing group. Try getting global package deals. Check out that doctor is properly certified. Try to understand claims sent by providers and all the diagnosis and procedure codes. Count bills during maternity stay or any other in-hospital and make case by case decisions whether service is needed or not while even making sure that service offered is medically necessary. The physician-patient relationship is horribly lopsided and it is only insurance that has bought some parity into this relationship. Yet, I don’t see any appreciation for the value delivered by insurance. So when comparisons are made, I hope and wish that wonks look at scenario where the evaluated service is completely unavailable and also at collateral impact of services.

  4. maggiemahar says:

    On the paperwork–

    As more and more PCPs became part of larger organizations, they will
    have more help with all of the paperwork. One of the things many of today’s docotrs like about being on salary at such an organization is tgat the back office takes care of filing for payments. They practice medicine.

    At Mayo, doctrorsdon’t even know how much insurers pay for their services, or whether a patient has insurance. Not their problem.

    Finally, under reform, if doctors want to be paid extra for good outcomes. Medicare also will be asking for more information. And as Medicare increases efforts to reduce both fraud and overtreatment, it is bound to
    ask for informatoin.

    Whether this informaiton comes on paper,or via a computer, someone is
    going to have to provideit, though certainly good IT could make things more efficient.

  5. Randall Oates, M.D. says:

    The larger organizations have been able to afford to both take on some of the paperwork and subsidize primary care physicians (typically >$100k/annual) because the PCPs are feeders into their profit centers. With health reform, and the migration away from fee-for-services, it will become increasingly untenable to subsidize these feeder physicians into what will become cost centers. The need for more data at the point of care will only grow. For example, the back office is not going to be able to code to the specificity of ICD10 after the encounter. ICD10 and the data needed to measure/improve care have to be in real time and it is insanity to simply add this to the burden of the primary care clinicians which further reduces their capacity to manage a population of patients. The systems that use new technologies and workflows that create the coded data in real time for the physicians are going to thrive while those following the legacy approaches of doctor as distracted data trolls are going to suffer.

  6. southern doc says:

    Larger organizations can provide more paperwork support (and “pay for performance” data massaging) because they negociate fees that are 2-3x as much as what smaller groups are paid (with facility fees thrown in).

    I don’t think that gravy train is going to last.

  7. DeterminedMD says:

    Politicians are about micromanagement and cookie cutter applications to societal issues. PPACA had no interest to do otherwise. Yeah, let the uninvested MDs and non physicians like NPs blaze this trail. Good luck America, nah, scratch that, PPACA supporters, I look forward to your figurative iceberg collision by 2014!

  8. andymc says:

    If that weren’t enough, in their rotations, trainees see the most dysfunctional, antiquated and frustrating approaches to primary care delivery that exist in our health care system. The combination of a sicker, more-complex-than-average patient population, inadequate funding and support for improvement efforts, and predominantly part-time faculty who are frequently not available for teaching or improvement activities has created a toxic milieu. I can’t tell you how many primary care students and residents have noted that it feels like their clinics were specifically designed to destroy their interest in primary care”

    I work with medical students every day from one of the top ten largest schools in the country and this, in my opinion, is the main reason for students declining interest in primary care. Simply, their experience first hand with the clinics. They change rotations every 4-6 weeks and get to see first hand the trials of a primary care provider contrasted with the experience of a specialist
    But touting the PCMH is a part of the solution is dubious at best. One, didn’t the largest PCMH pilot project to date show an increase in burnout among clinic employees (MDs included)? Second , seeing more NPs and PAs practicing in primary care clinics (even with an MD as the team lead) has lead to a sentiment among some students that the PAs and NPs will be doing most all of the primary care in the next decade and why go into a specialty that might not even be around or will be dominated by non-MDs?

  9. It’s the money.
    If we paid $200 for an average primary care office visit (instead of $60), there would be enough money to delegate the paperwork to the “team”, and there would be enough money to listen to patients, educate patients, “engage” patients, and “coordinate” care, and refer less, and there would be enough money to repay student loans and, yes, to change the image of “anybody can do primary care”.
    And there would be more than enough students wanting to practice this highly prized type of medicine instead of merely “cutting for stone”.

    • southern doc says:

      Exactly.

    • Peter1 says:

      “If we paid $200 for an average primary care office visit (instead of $60), there would be enough money”

      Enough money from whom? You can bet there would be NO reduction to specialist reimbursement. Where would the cost curve go then? “It’s the prices stupid”.

      • Enough money from nothing more than a rounding error in the total cost of care. There will be reduction in utilization of specialists and the associated, supposedly, excessive tests & procedures. The cost curve should slow its upwards growth over time. Hoping for more than that without purposefully skimping on quality is not realistic anyway. Yes, it is the prices, but not all of the prices.
        And since we seem hellbent on experimenting, why not try something like this in some enlightened State somewhere…. The only caveat I can see here is that the primary care docs MUST remain independent and beholden to no one but their patients.

        • DeterminedMD says:

          “And since we seem hellbent on experimenting, why not try something like this in some enlightened State somewhere…. The only caveat I can see here is that the primary care docs MUST remain independent and beholden to no one but their patients.”

          Isn’t that a tad incongruent with the terms of PPACA? IPAB for instance.

          Gotta hate those trivial truths, eh?

        • Peter1 says:

          “There will be reduction in utilization of specialists and the associated, supposedly, excessive tests & procedures.”

          Really, a reduction in income for specialists? Are you going to legislate PCPs as the gatekeepers to specialists?

          • No, I don’t want to legislate anything. I just want to pay primary care physicians enough to allow them to practice at the top of their license. I think that’s something they want and something they think will improve the quality of care and I am much more inclined to listen to docs when it comes to health care than any other learned experts.

            If we are really interested in quality patient-centered care, and if we really believe that such care is also more affordable, than we should at least try it out…..

    • BobbyG says:

      We’re paying $500 per hour for Outside Counsel for our HIE.

      Good physicians should make at least as much as attorneys. But, we don’t want to pay for it.

  10. mary says:

    Thank you. This is a well thought out and well written article. I believe you really want to be a PC doctor and I send kudos. I wish many more people would go for happiness and contentment instead of money and fame.
    Since the government is making us all buy insurance maybe they could help out too by making available grants to rural and middle/low income families if they sign to go to an area most in need. If they forfit, they repay the grant……makes sense?

  11. James Ripa says:

    I agree with everything in the article. If you are a physician practicing in a physician shortage area please make sure you are using modifier AQ on your claim submission. This will at least get you a higher visit reimbursement from Medicare.

  12. Peter1 says:

    “I just want to pay primary care physicians enough to allow them to practice at the top of their license.”

    Margalit, first I agree with PCPs as best defence and for good compensation, but why aren’t they “practicing at the top of their license” now? From posts this is not PCPs not doing their duty, but too little of them – for which higher pay is the “solution”. If patients are using PCPs as primary entrance then how are the specialists getting so much of patient care?

    • I think Peter that the two problems are intertwined. Because we pay them so little PCPs are forced to churn through patients quickly to make ends meet and in 10 minutes intervals it is almost impossible to do much more than refer people to specialists. This creates a distorted image of primary care (which really should be called general practice because primary implies that something secondary exists) and the appearance that other less qualified people can do this primary triage and refer everybody out as needed. I doubt this is an occupation that can appeal to a bright and bushy tail med student.
      I know some have said that even if you triple the PCP pay, the docs will still keep the same schedule and style and just triple their income. I don’t think so.
      But unlike the experts I don’t expect anyone to take my word for it. Let’s try it out – pick a couple hundred docs and run a 1 to 3 year “experiment”, like the ACOs or the dual eligibles managed care programs. I bet if fairly compensated and in full control of their practice, primary care docs will leave everything else in the dust, for a fraction of the price.

      • Peter1 says:

        “I know some have said that even if you triple the PCP pay, the docs will still keep the same schedule and style and just triple their income. I don’t think so.”

        That would be human nature and without some enforcement of time spent with patient I’m afraid most would add to bank account without better care.

  13. Bill Springer says:

    I’m afraid that I agree with those who point to higher costs as the most likely outcome of increasing what we pay PCP’s. It will take a number of years for the higher pay to translate into better working conditions and an influx of new freshly minted PCP’s. And if specialists respond by pushing their rates up, this latter benefit may not be realized.

  14. Craig "Quack" Vickstrom, M.D. says:

    You know, the more I look at the trends, the more I think if I want to stay in primary care, my best option would be to emigrate.

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  16. Lori Christensen MD MBA FACS says:

    There is no wonder that the primary care “pipeline” has dried up it has become almost impossible to stay in practice. I am one of those specialists that charge for procedures and would normally not rely on an office practice for income. However, I crossed over to the dark side twelve years ago and opened an Integrative Medicine Practice. Although I am not a primary care provider I have come to understand the untenable position my colleagues struggle with in providing primary care to patients. My practice based in functional medicine is centered on a significant amount of time with my patients to determine the best course of treatment. Our office is often the place of last resort having been told by multiple doctors that there is no further treatment available for their chronic disease. Because I still accept Medicare and the health plan of the local multi-hospital system I am fully involved in the insurance war faced by primary care doctors every day. I am sad to report that many of my colleagues are barely able to keep their offices open, resorting to borrowing money against their home to pay their bills.

    So looking forward to the full effect of the ACA, I am worried. In the broad picture of providing care to more people that is a positive. However, only the providers of this care will not see any improvement in their current dilemma. Medicare is to cut fees again and the uninsured that will be placed in the current Medicaid paradigm will overwhelm an already failing system. There are not enough providers that accept those covered by Medicaid. By vastly increasing the number of people in that pool, there will still not be enough providers to cover those patients. So how exactly, is that better than the system now?

    How can this healthcare be provided by doctors already under economic stress? There is a simple formula that providers use: Number of patients X Fees = Revenue. If the fees are continuously lowered, the number of patients must increase and therefore the amount of time spent with patients will also decrease. Many are choosing to leave their practices and pursue other career opportunities. Why is medicine the only profession that makes less money for providing the same service? When I ask the landlord and my vendors if they will take 25 cents on a dollar they all refuse, yet doctors receive fees that are often that. Does it disturb anyone that the cab driver that provides transportation to the doctor’s office makes a higher fee than the doctor who is caring for the patient?

    Most of us chose medicine because we wanted to care for people. Although morally the practice of medicine is a vocation, in reality it is a business. My office cannot stay open if I cannot pay my bills. As a small business I am responsible for all the costs of the office, liability, workman’s compensation fees, health insurance, rent, malpractice etc. Like it or not I must charge patients and be paid for my services to survive. I would love to be able to treat everyone who needs help, which I am able to do on my part time job as a Trauma Surgeon. But in my office where I spend quality time with my patient I have to be a business person or I cannot stay open. As many primary care providers have discovered in order to provide care to Medicaid and Medicare patients this must be balanced by fee for service cash pay or participation in multiple commercial insurance programs. There will not be enough primary care doctors to provide to the newly enrolled patients.

    Turning to alternatives to physician provision of primary care there is the resource of advanced independent practitioners. I have had the pleasure of working with many Physician Assistants and Advanced Nurse Practitioners. They provide excellent care but I feel if they are to practice without physician back up the education and clinical training must be expanded. This is especially true of Advanced Nurse Practitioners who are not provided with sufficient clinical time in school to feel confident until they acquire some experience dealing with patients independently. Quite honestly however, how many Nurse Practitioners can keep an office open only providing care to patients for which they receive a significantly reduced fee?

    Maybe the answer is that more practices will be hospital based where there is a dilution of costs allowing for care for more patients. Perhaps that was always the intention of the ACA to have more control over health care fees and performance that is not really possible with a free market system of privately owned practices.

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