Medical care in America is fraught with crisis, from rapidly escalating costs and the ever-rising proportion of citizens lacking meaningful health insurance to an exploding epidemic of obesity and diabetes that threatens to reverse 40 years of progress against coronary heart disease. But underlying or compounding all these problems is the looming collapse of primary care. High-cost, high-tech, procedurally oriented medicine is booming, and with it the incomes of proceduralists, BigPharma and Medtronics. But the prosaic, day to day management of sick patients with their myriad minor problems is disintegrating, even as we face a tidal wave of increased demand from an aging population. Moreover, many of the proposals on the table to address the uninsured will only exacerbate the primary care shortage. Follow me if you dare.
In every other industrialized nation, the medical care system is based on a solid foundation of primary care (generally defined as family medicine, primary care internal medicine, and general pediatrics). Specialist consultants are called in as needed. In England, for example, neary one half of practicing physicians are in primary care. In the United States, by contrast, the number is 35%; and it's falling like a stone. Among current medical school graduates, only 14% plan to enter primary care practice. Yet even this depressing number overestimates the future supply; an exploding percentage of graduates entering internal medicine residencies choose to specialize prior to graduation. Worse yet, the largest cohort of family doctors and internists—the idealistic graduates of the 1960's and 1970's—is on the verge of retirement. The number of doctors practicing primary care is about to go off a cliff. The immediate consequence is a spiralling workload for those still in practice. In the last two years, two of my partners left the practice to go into more lucrative areas of medicine. Their patients are now shoe-horned into my overbooked schedule. Three more docs in our group are on the verge of retirement. At best, we may get one young doc to replace them. Now, add a new national health insurance scheme or mandate—without addressing the dwindling supply of primary care docs—and things may quickly collapse. The pent-up demand for medical care among the uninsured and underinsured is huge. We have absolutely no reserve capacity to serve them.
Why is this happening? As with so many issues, follow the money. Average yearly pay for primary care physicians clusters around $178,000. For radiology, gastroenterology, anesthesiology, spine surgery, and cardiothoracic surgery it's anywhere from $300,000 to a half million or more. Moreover, this grossly understates the disparity. Most primary care docs work much longer hours in the office, and take grueling 24/7 night call for all those nagging little problems like constipation and severe migraines, not to mention bigger things like heart attacks and pneumonia. Office overhead costs are far higher for primary care than for, say, thoracic surgery, where most actual work is done in the operating room. That $178,000 income presumes full time work, typically 70+ hours/week; it's just not feasible to earn more by working harder, simply because you run out of hours. And you get mighty tired. Primary care docs graduate with the same educational debt anesthesiologists do; but they'll need to work much longer to pay it off. And those nice 7:00 am to 3:00 pm anesthesiology hours are pretty attractive. There have been a number of initiatives to address this huge disparity in pay, beginning with Medicare's RBRVS (resource-based relative value scale); yet the more things change, the more they stay the same. Every attempt to redress this disparity has been an abject failure, due to a malignant combination of institutional inertia, shifting technology, aggressive marketing of costly devices and medicines, and the remarkable ingenuity of proceduralists in gaming the system.
(As an aside, I am entirely aware that $178,000 seems like an obscene amount of money for most folks. But I barely made that my best year in practice. I now get paid rather less, even while working more hours. Please keep in mind that I spent four years in college, four years in medical school, and three years of indentured servitude in residency, followed by ten years in practice before I paid off my $60,000 in educational debt. I work about 75 hours a week, missed most of my childrens' soccer games, and missed seeing my wife wake up from thyroid surgery because I was resuscitating someone who collapsed in the hospital hallway. As I write this I'm at the hospital at 11:30 pm waiting for a baby to deliver, and tomorrow's another full day at the office.)
This crisis has huge negative implications for American health care quality, availability and affordability. A rational, sane and efficient health care system requires a solid primary care base to coordinate and supervise care. Studies have repeatedly demonstrated that access to primary care lowers cost while increasing quality and patient satisfaction. Without a primary care "medical home", patients' care ends up fragmented among multiple subspecialists, none of whom is responsible for the 'big picture'. Patients recieve multiple conflicting treatments, each logical for a single problem in isolation. In the aggregrate this causes polypharmacy, dangerous drug interactions, rising costs, and neglected problems that fall between the cracks. Moreover, specialists tend to feel obligated to pull out the big guns for the problems they manage; hence the number of MRI scans and aggressive diagnostic procedures escalates when specialists rather than primary care docs are calling the shots. It has been repeatedly demonstrated that the rate of a given surgical procedure per 100,000 patients correlates far more closely with the number of surgeons in the region than with any objective measure of "need". This is a significant but unmeasured fraction of the current rapid escalation in the cost of medical care. Yet this leap in cost is not matched by improved outcomes; quite the contrary. Even as aggregate cost goes up, outcomes get worse. Want a coronary bypass operation? In my community I can choose between two hospitals and a half dozen surgeons clamoring for my business today. But need a geriatric evaluation, and...how about November? Is November good for you? Or try to find a family doc for grandpa. In my rural town, precisely zero primary care physicians are taking new patients.
So, what is the medical profession doing about this looming calamity? Well...actively making it worse. It's difficult to explain this to lay people, but the very culture of University hospitals and medical schools is profoundly hostile to primary care. The high priests of academic medicine are brilliant subspecialists, innovative surgeons and similar technically oriented superstars, hailed for their ability to bring research money and publicity to the medical center. Primary care by contrast is habitually denigrated and disrespected. The lip-curling sarcasm directed at the "LMD" (local medical doctor), the withering contempt for primary care in the trenches, has to be seen to be believed. Medical students "bake" for four years in this hot-house atmosphere. Small wonder so few choose primary care. Add in the vast disparity in income, and it's a miracle anyone does.
So what's to be done? How can we reverse the decline of primary care before it becomes a death spiral? Unfortunately, it's already too late to avoid a painful reckoning. The number of practicing geriatric specialists has dropped by about 50% since the 1980s due to low reimbursement and declining interest. Just try and find one in your town. Even if pay for primary care docs doubled tomorrow, the 7 year pipeline from entering medical school to entering practice guarantees a long delay before anything changes. Add in the "block retirement" of the large generation of primary care docs who entered training in the 1960s to 1970s, and there's going to be a gaping hole in medical care in the immediate future no matter what happens. Realistically, we're going to have to recruit thousands of physician assistants and nurse practitioners to do a lot of the basic primary care work of monitoring blood pressure and diabetes. Which is not necessarily a bad thing; the ones I work with are thoroughly competent professionals. But we'll have to drastically reorganize the way we provide and pay for primary care, with the unavoidably smaller number of docs supervising these "mid level providers". No matter how much the AMA screams, we may end up with something closer to Chinese or Cuban models, where most primary care is provided by non-physicians. Don't like that idea? Too bad. Either pay primary care docs a lot more...or pay proceduralists a lot less to level the playing field, and drastically improve the primary care work environment. I just don't see that happening.
Finally, by default, many specialists in medical fields like neurology, cardiology or gastroenterology are already carrying some of the primary care load. Ironically, they lack the specialized training required to competently perform primary care, and there is no incentive (financial or otherwise) for them to learn. Ongoing education programs to remedy this issue...have mostly died for lack of interest. Go figure.
Forgive me if this comes off as an unfocused rant. It's been a long day. On the other hand, a couple of days ago I delivered a beautiful baby girl...for a patient I also delivered about twenty years ago.
Sometimes this is the greatest gig in the world.