January 2006 | Back to Table of Contents

Commentary

The Crisis in Primary Care

Are primary care physicians an endangered species?

By Judith A. Easley, M.D.

Is primary care medicine, as it is known in this country, at risk of extinction? Probably so, and perhaps that isn’t such a bad thing. The patients are dissatisfied, the doctors are discontented, the cost of care is too high, the amount of money wasted is obscene, and the quality of care is suboptimal.

By at least two measures, primary care appears to be in serious distress. First, fewer medical students are choosing primary care residencies. From 1997 to 2003, the number of graduating medical students choosing primary care residencies declined steadily.¹ In 2004, results of the National Residency Match showed a slight stabilization, according to the American Academy of Family Physicians (AAFP). But the 2005 match results again showed a decrease in interest in family medicine, general internal medicine, and general pediatrics among graduates from both medical and osteopathic schools in the United States.² Overall fill rates have improved slightly during the past two years because of a reduction in the number of positions and an increase in the percentage of positions being filled by international medical graduates, many of whom will return to their native countries after residency. U.S. medical graduates, however, are choosing specialties that offer more flexible lifestyles, fewer productivity pressures from employers and payers, and greater financial incentives.² Many are choosing internal medicine in preparation for subspecialties such as cardiology and gastroenterology.

In addition to the dwindling number of graduates going into primary care are signs of attrition among practitioners. Although much has been written about physician discontent and dissatisfaction with medicine, data measuring attrition is scarce. One study showed that between 1987 and 1991, 55 percent of a group of primary care physicians younger than 45 years of age who were not employed by the federal government had left at least one medical practice, and 20 percent of the group had left two medical practices.³ A 2004 survey of 67 groups ranging in size from 50 to 150 physicians done by the American Medical Group Association estimated that the overall rate of attrition among physicians was about 9 percent.⁴ This study also pointed out that an earlier survey indicated that the perceived attrition rate by groups was usually around 5 percent.

Regardless of the actual rate of attrition, the estimated cost of replacing primary care doctors is staggering. In 1999, Buchbinder et al estimated that it costs approximately $250,000 to replace a physician—$236,383 for a family physician, $245,128 for a general internal medicine physician, and $264,645 for a pediatrician.⁵ Based on those estimates, an organization with 100 primary care physicians and a yearly attrition rate of 9 percent would spend about $2.25million a year replacing doctors.

Is Primary Care Worth Saving?
Is primary care still a vital part of comprehensive, cost-effective, and patient-centered medical care, or is it a luxury that America can no longer afford and a style of medicine that physicians no longer want to practice? Not only is primary care worth saving, but its rescue may very well be the salvation of the entire American health care system.

For one thing, people want a primary care provider. Evidence suggests that the majority of Americans value primary care and that most rely on either a family physician, internist, or pediatrician for their primary care.⁶ They appear to most value the continuity of care that primary care providers offer. However, they also place value on their physician’s proximity to them; his or her expertise in areas such as women’s health, pediatrics, obstetrics, or various medical subspecialties; broad perspective; and flexibility.⁶ There also is evidence that people in the United States want a physician who not only knows their medical history but who also knows them as a person.

The American Academy of Family Physicians, through patient interviews for the Future of Family Medicine project, determined that above all else patients value their relationship with their physician and tend to overlook inadequate service in order to see a provider whom they perceive as nonjudgmental, understanding and supportive, and honest and direct; and who listens attentively and attends to their emotional as well as physical health.⁷ The study showed that patients tend to assume that their primary care physician is capable of providing quality care and thus judge their health care experience on the effectiveness of the relationship.

Second, primary care is cost-effective. It is well-documented that use of primary care providers rather than subpecialists for primary care needs results in lower costs. The 1998 National Medical Expenditures Survey showed that spending for all health care services was about 50 percent higher for patients who used specialists for their primary care.⁸ The same survey showed that mortality levels were also lower for those patients seeing primary care physicians, even after adjusting for demographics, health insurance status, reported diagnoses, health perceptions, and smoking. A study by Baicker and Chandra showed that in geographic areas with more primary care doctors, residents spent less money on health care and had better health outcomes.⁹ Similar findings have been shown by Starfield on an international level, with countries that place a greater emphasis on primary care showing lower costs for health care and better outcomes.¹⁰

Specialties in Decline
So if primary care is cost-effective and most Americans say they desire it, why is it in decline?

Growing evidence suggests that primary care doctors are not meeting their patients’ expectations.⁶ One reason for this is the growing number of demands on physicians’ time. The U.S. Preventive Services Task Force estimates that to meet recommended care standards for routine health maintenance education, a family physician with a standard volume of 2,500 patients would need to spend 7.4 hours per day every working day of the year doing nothing but counseling patients about routine health maintenance guidelines, such as screenings for various diseases.¹¹ This would leave the physician little time to care for chronic illnesses, counsel patients regarding behavior changes such as smoking cessation or weight loss, or simply listen with empathy to someone in distress. This also would leave little time for documentation of care and other paperwork. The increasing number of health maintenance issues needing to be addressed, the fact that they’re seeing sicker patients, and the administrative paperwork involved in patient care leave the primary care provider with little time for establishing relationships and talking to patients about their lives, regardless of the fact that the actual length of the primary care office encounter increased slightly between 1989 and 1998.¹²

Too much is riding on the shoulders of primary care physicians. It is not reasonable that one physician be able to provide care for patients of all ages and both genders; stay up to date on all the latest discoveries and treatments; be an expert diagnostician; have the patience to care for chronic illness, the compassion to care for those at the end of life, the sophistication to recognize behavioral and social problems, and the communication skills to encourage patients to change their behavior; keep up with the administrative duties, paperwork, and the ever-changing complexities of medical coding; and be able to competently perform all those duties in a variety of venues such as the office, hospital, and long-term care facility. For those reasons, it is no wonder that the primary care physician is described as “rushed and harried” and that the profession
is accused of falling short of its promises.¹³

A Vision for the Future
Clearly, primary care as we have known it in this country is in danger of extinction. But it does not need to lay down and die. It needs to evolve. It needs to be transformed. The Future of Family Medicine project is an attempt to do just this—to transform and renew the specialty to meet the needs of people and society in a changing environment. The final report gives us a vision of what the new animal might look like. It has framed a new model of primary care that will be patient-centered—organized to serve the needs of patients and of the highest quality documented by measurable outcomes, hang on a “backbone” of information systems technology, and employ systems that keep the focus on the physician-patient relationship and allow for quick resolution of problems. And it will be one in which physicians and other health care providers will be adequately compensated for basic services such as performing a history and physical, counseling patients about health behaviors, and guiding them through the health care system.

Fleshed out, that model might look something like this: Every person living in the United States would have a medical home. This home can be a clinic selected by the patient or one that is assigned if the patient has no preference. The clinic will be located in the patient’s community, and the providers there will speak the patients’ language or have trained medical interpreters readily available. The patient would see his primary care physician and have the majority of his health care needs met at this clinic, as it will include space for group care when needed and space for ancillary service providers such as behavioral health specialists, social workers, health educators, dieticians, and chronic pain coordinators, as well as X-ray and lab facilities. Physicians will take a whole-person approach to care, rather than one that is based just on the disease process.

The patient, in conjunction with his physician, will determine the best approach to meeting his needs. The patient will have access to his physician and/or other team members 24 hours a day. If care is needed outside the medical home, say in a subspecialist’s office or a hospital, it will be coordinated by the physician or team. If the patient presents to the emergency room for a problem that is not urgent, he will be referred back to his personal medical home.

The patient’s records will be kept in an electronic document that both he and his providers have access to. The patient will be able to review his own records, update changes in his health history, contact his providers, schedule appointments, and request medication refills through this electronic health record. The system also will have educational materials and information regarding routine health maintenance available. All staff will be familiar with and dedicated to the principles of care that have come to be known as STEEEP (safe, timely, efficient, effective, equitable, and patient-centered). If the patient does not have health insurance, his care will be provided on a sliding-fee scale, and possibly in the future through a national health service. His relationship with his primary care provider will be a lifelong one, if he so chooses, which will be supported by excellent working conditions and fair compensation for the work that the provider does.

Making the above possible will require an overhaul of the whole health care delivery system. It’s a massive undertaking that needs to involve almost every sector of society. But this overhaul will make primary care specialties more attractive to future generations of physicians, especially if attention is paid to creating reasonable workloads and a fair and adequate compensation model. The current RVU-based compensation model must be revamped or changed entirely. And systems can be made more efficient and thus lighten the workload of the primary care doctors. For example, nurse practitioners, registered nurses, and dieticians working as a team under the direction of the physician can provide excellent and cost-effective care. Nurse practitioners also can review routine health maintenance guidelines with patients and give recommendations regarding them. Information technologies that doctors are adequately trained to use also can reduce physicians’ load. And patients could get basic health information in group classes so that physicians could be freed up to address more complicated medical issues during patient visits.

Clearly, primary care physicians themselves will need to offload some duties to others—to hospitalists, geriatricians, health educators, pain counselors, dieticians, and other providers. And they will need to function more as the directors of care rather than as the givers of care.

The American Academy of Family Physicians and the Society of General Internal Medicine are taking the lead on these issues. But making these types of changes will require participation of all in the medical community. It will require primary care physicians to retrain, to hone their communication skills, and learn more about information technology, working in teams, disease prevention, managing chronic illnesses, behavior-change counseling, and evidence-based care. It will require the public to state loudly and clearly what they want from their primary care doctors and getting primary care doctors to create the partnerships that their patients desire. It will require engaging health care executives and lawmakers in promoting and supporting primary care both financially and philosophically and engaging medical school deans in promoting primary care specialties as desirable career options. Above all, it will require a universal focus on the values of compassion and caring and a commitment to giving doctors the time to establish healing relationships with their patients so that they can adequately promote preventive measures, motivate behavioral change, and manage chronic illness.

With thoughtful reorganization, the use of team-based care, installation of electronic medical records, availability of online information for patient education, and a revamped compensation system, there is hope that the tradition of the “personal physician” can continue and likely be made better than ever before. MM

Judith Easley is a hospitalist for West Side Community Health Services at Regions Hospital in St. Paul. From August 1988 to April 2005, she was a general internist for HealthPartners’ Bloomington Clinic and the Center for Women in St. Paul.
 
References
1. American Academy of Family Practice. Medical student interest in primary care continues to decline (press release). March 20, 2003. Available at: http://www.aafp .org/x20089.xml. Accessed Dec. 7, 2005.
2. American Academy of Family Practice. 2005 Match Information Sheet. March 17, 2005. Available at: http://www.aafp.org/ match/nrmpinfo.html. Accessed Dec. 7, 2005.
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10. Starfield B. Primary Care: Concept Evaluation and Policy New York, NY: Oxford University Press; 1992.
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13. Moore G, Showstack J. Primary care medicine in crisis: toward reconstruction and renewal. Ann Intern Med. 2003; 138(3):244-7.