Focus On Family Physician Shortage Sharpened
If America is to right the ship of health care and turn it toward a system of higher quality, improved efficiency, better outcomes, less cost, and decreased geographic and ethnic disparity, it must increase the number of primary care physicians. We cannot meet that goal without dramatically changing the policies that affect our medical education system, graduate medical education and the incentives that draw students to careers in primary care.
Results from the 2009 Match of graduating medical students to specialty training programs indicate our nation has done too little to reverse these policies. This year, family medicine saw the number of residency positions offered to graduating medical students fall by 99. We saw the total number of positions filled drop by 75. We saw the number of U.S. seniors choosing family medicine as a career fall by 89.
This decline has nothing to do with the value of primary care and everything to do with a system that claims to support primary care but fails to actually act on its pronouncements. Most young people who are interested in medicine will tell you their vision of becoming a physician began with a goal of providing the kind of care that is the hallmark of primary care.
And yet, as they apply to medical school, they see a system that values test scores over pragmatic, critical thinking. As they make their way through medical school, they learn in academic health centers that – due to inadequate state and federal funding for their educational mission – must rely on income generated by highly paid subspecialties and, that therefore give preference to training those subspecialties. As they investigate career choices, they see a payment system that overvalues post-disease interventions at the expense of the medical expertise that prevents the need for hospitalizations and procedures.
Research has demonstrated unequivocally that the world’s successful health care systems depend on primary care. With a ratio of 70 percent subspecialists to 30 percent primary care physicians, the American health care system is upside down. No health care reform can succeed unless we bring both financial and actual access to the primary care physicians that provide more than 80 percent of all health care services Americans need.
This is not to say that we do not need and value the expertise of subspecialists, whose focus on specific organ systems and diseases is indispensable for treating specific organ-limited illness. But research consistently shows that access to high quality primary medical care can prevent or ameliorate many of the conditions that – left unattended – eventually require subspecialist attention.
The fact is, having 100,000 anesthesiologists, radiologists, dermatologists or any other subspecialist group will not ensure that babies get their immunizations; that pregnant women get needed prenatal care; that people with diabetes, asthma and arthritis receive chronic care management; or that anyone with hypertension will receive the outpatient diagnosis and treatment that prevent chronic heart and kidney disease. This requires an adequate number of family physicians and their primary care colleagues to provide comprehensive, whole-person care that all Americans need. The Association of American Medical Colleges recently called for a 30 percent expansion of medical school graduates. If America’s medical schools continue to generate a physician workforce that is going into subspecialties, we are not meeting the needs of America’s communities. America’s medical schools then become part of the problem and not part of the solution of meeting America’s workforce needs.
Physician workforce studies have consistently pointed to a worsening primary care physician shortage. In 2006, when the nation had 100,431 family physicians, the AAFP workforce report indicated the United States would need 139,531 family physicians by 2020 to meet the need for primary medical care. That means we must graduate 4,439 family physicians each year. In our current environment, the nation is attracting only half the number of future family physicians that we will need.
The numbers are clear – the American people and our health care system are increasingly in desperate need for primary care physicians. Under the current environment of undervaluing the vital role of primary care in our health care system, of failing to recruit students most likely to choose primary care careers, and of defaulting on appropriate support for primary care graduate medical education, the American people can look forward to an increasing crisis in their access to basic health care.
We cannot implement health care reform, we cannot provide financial access to health care for all Americans unless we can keep the second half of that promise – that Americans will have an accessible doctor to care for them when they need it.