Elephant In The Room — The Projected Primary Care Shortage

Projecting future physician workforce needs is a challenging calculation. You have to consider multiple variables to avoid missing the mark. In the mid-1990s, the American Medical Association confidently predicted that the penetration of managed care would lead to a large “physician surplus” and convinced Congress to cap the number of graduate medical education (GME) positions subsidized by the Medicare program. By the look of things today, that might not have been such a wise move.

Two decades later, there is a widespread consensus that the U.S. is actually experiencing a physician shortage that will worsen with population growth, the aging of the baby boomer generation, and an influx of newly insured from the Affordable Care Act.

Although medical schools have expanded to meet the anticipated demand for doctors, the AMA and others are still pushing for the GME cap to be lifted. That way new medical graduates will have enough places to train. But how has the specialty of family medicine fared, and what else can be done to extend capacity of the existing primary care workforce?

Two recent Georgetown University Health Policy seminars answered these questions.

The Robert Graham Center has predicted a doc shortage of 52,000 primary care physicians by 2025. Modest gains in the numbers of U.S. and foreign medical graduates who’ve initiated family medicine residency programs over the past five years falls well short of this projection.

Health Affairs recently examined potential strategies to extend primary care capacity in the absence of an (increasingly unlikely) surge in generalist trainees. Their first “idea”? Telehealth technologies. This would supposedly improve medication adherence and facilitate real-time specialist consultations.

In turn, they believe this technology would lighten the load on family physicians by promoting patient self-management of chronic conditions. This brings to mind an article we read about apps designed for healthcare being like nagging parents. And if there’s one thing we’re sure of, we hated it when our parents nagged.

Getting patients to wake up and want to take care of themselves will always remain a mysterious art. Think about it: we have entire industries dedicated to just such goals. Edward Bernays was a master of this (and considered to be the father of modern advertising). He didn’t sell pianos by saying, “Hey, everyone. You need this great piano.” No, instead, he convinced designers to start making “music rooms” seem normal. TV started to show houses with these music rooms, where people gathered to socialize (and at times play piano). Once it became normal for houses to have “music rooms” piano sales followed suit.

The important takeaway here is that if you want people to buy a piano, they have to wake up and think it’s THEIR own idea to own one. Medicine is no different.

Patients need to wake up and know in their heart, “I want good health.” We believe this influence stems from strong patient-doctor relationships. And that’s why we’re proud of our work as Direct Care docs: we’re creating a subjective value in our service — time to build trust.

Health Affairs second “idea” to improve the impending doc shortage is more radical and controversial. They suggest providing EMT-style training to a new profession of “primary care technicians” who would provide basic primary care services under the supervision of a physician. This would then free physicians to “focus on patients with more complex conditions.”

But these proposals have serious disadvantages. By reducing face-to-face interactions, telehealth could easily make family medicine less rewarding. Family physicians who wind up seeing only patients with multiple complicated chronic conditions might burn out faster, leaving even fewer in the workforce. And our work is broadly cognitive (we have to know something about a lot of things, and then make proper diagnoses and treatment plans). It’s not a narrow, procedure-focused specialty, and therefore it’s less likely to be suited for technicians than, say, anesthesiology or gastroenterology.

Finally, given the persistent and growing income gap between family physicians and subspecialists, the real solution to the primary care shortage may still be staring us in the face. Until we start paying family physicians more, would we expect anything but a shortage of family physicians?