Primary Docs Centerpiece of Reform, but Where Are They?

Neil Parker remembers the time fondly.

He’s an internist and now the senior associate dean for student affairs at UCLA’s medical school, but two decades ago he was helping state legislators craft the language for a landmark law that would have required at least half of all UC medical school graduates to be primary care physicians — and 40% of those primary care doctors would have had to go into family practice. It would have meant a huge shift toward primary care for California’s health system.

The idea didn’t take.

“This was the opposite of ‘Field of Dreams,'” Parker said. “We built it, and they did not come.”

Today, California, like the rest of the country, is facing a shortage of primary care physicians. The nation as a whole is short about 16,000 primary care doctors, according to the U.S. Department of Health and Human Services. There is growing demand for primary care, in part because more people have chronic diseases and the aging population has more long-term care needs. In California, that is especially true, with 20% of the population ages 60 and older, a statistic that will rise as baby boomers age.

Also, in California, the population is burgeoning, creating even more demand. There soon will be fewer physicians in the state, because they’re getting older, too. A University of California report found that, in 2000, more than one-fourth of practicing California physicians were over age 55. That report predicted that growth in physician demand would outpace growth in physician supply by anywhere from 5% to 16% over the next five years.

At the same time, there has been a decline in the number of medical students entering primary care specialties. Less than four years from now, demand is going to skyrocket when millions of people gain health coverage through national health care reform and about five million more Californians will need to find a primary care doctor.

If there is so much demand for primary care physicians, why don’t more doctors go into primary care?

The answers, experts say, are extremely simple and arcanely complicated.

Cash Matters

“It’s a question of lifestyle and money,” Parker said.

“Primary care is the lowest paid of all our physicians,” he said. “When you look at these very bright doctors in primary care and they see specialists doing similar work, where the hours are better and yet they’re paid about three times as much — well, it’s hard to get anyone to do it. You can’t fault these very bright people for choosing the money.”

According to the Journal of the American Medical Association, the median salary in a large, multispecialtygroup practice for a family medicine physician is $198,000; internists make about $205,000 a year and pediatricians,$203,000. Meanwhile, the median dermatologist salary is $351,000.

That’s one of the reasons why in 2010 few medical students wanted to attend primary care residencies. Only 54.5% of internal medicine residencies were filled by the 2010 class, and family medicine residencies were only 45% full. In comparison, according to JAMA, at least 90% of positions in neurological surgery,orthopedic surgery and dermatology were filled by American medicalschool graduates. One of the goals of national health care reform is to create more financial incentives for primary care physicians.

A program in California forgives student loans if students take up primary care specialties and practice for a period of time in underserved areas. That’s also the idea in the national model, called the National Health Service Corps, which would offer scholarship and loan repayment programs and float incentives for primary care physicians to work in underserved areas.

“Where you go for residency often has a lot to do with where you practice medicine,” Andrew LaMar of the California Medical Association said. “Clearly there need to be more physicians in the pipeline.”

The UC system is planning to expand medical education to UC-Riverside, and hopes to have a medical school at UC-Merced, as well.

“A lot of things should help alter the balance,” LaMar said. “How much we’ll have to see.”

Prestige Matters

It is not just money that motivates. It is lifestyle, according to Parker, who said the number of hours a physician works, along with other factors, contribute to job satisfaction. It boils down to something as simple as enjoying your work, Parker said.

“When I was starting out in medicine, we had an hour [of time blocked out] for a new patient, and half an hour for existing patients,” Parker said. “Well, that number went down to 25 minutes, then 20, [and] now it’s 12 minutes in some places.”

In that amount of time, he said, primary care physicians need to talk about a variety of issues ranging from smoking cessation, diet, vaccinations to what might actually be wrong with the patient.

“It’s very hard to do all of that,” Parker said. “The best part of being a doctor is interacting with your patient. If you don’t have time for that, you lose the humanistic and compassionate side of why you want to be a doctor.”

When you’re a specialist such as an orthopedist, he said, you have fewer patients you need to see every hour. “Everyone’s working hard, but it’s a different pace,” he said. “It matters. It’s what you feel like when you’re at work.”

Along with the differences in money, hours, pace and lifestyle, experts say another factor keeps medical students from becoming primary care doctors: prestige.

Twenty or 30 years ago, primary care physicians were considered diagnosticians, and therefore invaluable, Parker said. Now they’re perceived more as gatekeepers, he said, as doctors who only refer patients to other doctors.

That perception would probably wane if pay scales even out a bit, LaMar said. Several specific steps are being taken in medicine to make the primary care doctor a powerful and vital factor in care.

Give Me a Medical Home

The first step toward revitalizing the specialty, Lamar said, is to make it central to a patient’s care.

“It would be really valuable if their role is viewed as concert director,” he said, “rather than one of first chairs.”

The concept of the medical home places the primary care physician at the center of health care, coordinating care and keeping track of the health of the patient, rather than just keeping track of one of that patient’s diseases or maladies.

“The medical home is designed to deliver better care to the patient, by putting the primary care physician at top of the pyramid. The primary care doctor determines the care that patient needs, which is especially important for people on Medicare who have to see multiple specialists and multiple doctors and get multiple tests,” LaMar said.

“What that does is enhances the status of a primary care physician,” he said. “And that’s something that will be very valuable.”

Parker added that, if the primary care physician is at the center of the medical home, that doctor’s work life could be made infinitely better by having someone else pick up time-consuming tasks, like following up on whether or not someone has had a mammogram.

“I think there needs to be a change in the model,” Parker said. “Jobs that we haven’t even created yet.”

Some kind of medical assistant, he said, could be trained to handle a slew of skilled tasks, freeing the physician to figure out the best way to care for a patient, instead of juggling administrative tasks.

“If you take away some of the mundane stuff, that is part of what will make it more exciting,” Parker said. “You have to put the doctor back into doctoring.”

“Health care reform can really begin to change the perception of primary care physicians,” LaMar said. The medical home model and accountable care organizations, which are designed to pool teams of physicians to share medical and financial responsibilities for patients, can help change primary care physicians role by putting them at the hub of these new systems.

“It’s going to be interesting,” LaMar said. “We just don’t know. We’ll have to see how quickly these ACO and medical home models take hold. If there really is a rush to that end,” he said, “it really could be a big impact on the culture of medicine.”

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