Primary-Care Doctor Shortage May Undermine Health Reform Efforts

By Ashley Halsey III
Washington Post Staff Writer
Saturday, June 20, 2009

As the debate on overhauling the nation's health-care system exploded into partisan squabbling this week, virtually everyone still agreed on one point: There are not enough primary-care doctors to meet current needs, and providing health insurance to 46 million more people would threaten to overwhelm the system.

Fixing the problem will require fundamental changes in medical education and compensation to lure more doctors into primary-care offices, which already receive 215 million visits each year.

The American Academy of Family Physicians predicts that, if current trends continue, the shortage of family doctors will reach 40,000 in a little more than 10 years, as medical schools send about half the needed number of graduates into primary medicine.

The overall shortage of doctors may grow to 124,400 by 2025, according to a study by the Association of American Medical Colleges. And, the report warns, "if the nation moves rapidly towards universal health coverage" -- which would be likely to increase demand for primary care and reduce immediate access to specialists -- the shortages "may be even more severe."

Many of the measures needed to compensate for shortages -- such as easing the debt incurred by medical students and expanding the role of community health centers -- are included in the provisions being put forth by lawmakers, but there is no quick or easy fix within the grasp of Congress or the Obama administration.

"You're talking about an eight-to-12-year period to fix the problem," said Robert L. Phillips Jr., director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, part of the American Academy of Family Physicians.

Evidence that demand already exceeds the supply of primary-care doctors ripples through the system as patients increasingly have trouble finding a new doctor, then wait weeks or months for an appointment, spend more time in the waiting room than in the examining room, encounter physicians who refuse to take any form of insurance, and discover emergency rooms packed with sick people who cannot find a doctor anywhere else.

With 248 primary-care physicians per 100,000 residents, Washington fares far better than the national average of 88 doctors per 100,000 people (Maryland has 113; Virginia, 88). Nonetheless, with an average wait of 30 days to see a family doctor, Washington ranks third among cities with the longest wait times.

Fifty years ago, half of the nation's doctors practiced what has come to be known as primary care. Today, almost 70 percent of doctors work in higher-paid specialties, driven in part by medical school debts that can reach $200,000.

"We need to rethink the cost of medical education and do more to reward medical students who choose a career as a primary-care physician," President Obama said in a speech to the American Medical Association on Monday.

The average annual income for family physicians is $173,000, while oncologists earn $335,000, radiologists $391,000 and cardiologists $419,000, according to recent data compiled by Merritt Hawkins, a medical recruiting firm.

The disparity results from Medicare-driven compensation that pays more to doctors who do procedures than to those who diagnose illness and dispense prescriptions. In 2005, for example, Medicare paid $89.64 for a half-hour visit to a primary-care doctor in Chicago, according to a Government Accountability Office report. It paid $422.90 to a gastroenterologist who spent about the same amount of time performing a colonoscopy in a private office. The colonoscopy, specialists point out, requires more equipment, specialized skills and higher malpractice premiums.

In his AMA speech, Obama described that fee-for-service system as one that rewards the "quantity of care rather than the quality of care," adding: "That pushes you, the doctor . . . to order that extra MRI or EKG, even if it's not necessary."

The lure of cutting-edge technology also attracts doctors of the cyberspace generation to the specialties that use most of it.

"There's definitely a huge bias against family medicine and primary care," said Winston Liaw, who is serving his residency at Fairfax Family Practice.

Djinge Lindsay said most of her classmates at George Washington University's medical school went into specialties for the "money and prestige."

"The attitude is that primary care is a fallback if you're not smart enough or good enough," said Lindsay, now a resident in primary care at Georgetown University Hospital.

By 2000, 14 percent of U.S. medical school graduates were entering family medicine. Five years later, the figure was 8 percent, and a recent survey of students interested in internal medicine showed that 98 percent wanted to become specialists.

The career path of these doctors has also been shaped by a desire for greater control of their lifestyle.

"It's an important job to them, but it's not their whole life," said Terence J. McCormally, a Fairfax family doctor who graduated from medical school in 1978. "The class of 1978 was all into delayed gratification: 'We'll work long hours, and we'll stay at the hospital to all hours.' Medical students now aren't willing to delay gratification."

Many want jobs that do not carry as much responsibility for on-call or weekend work. Far more doctors, women in particular, prefer jobs that require fewer than 40 hours a week.

About a third of America's doctors, and half of its medical students, are women. One survey by the Association of American Medical Colleges and the American Medical Association found that female doctors reported working 38.6 "patient care" hours per week and their male counterparts worked about 46 hours.

Fifty-four percent of women counted flexible scheduling as very important, compared with 26 percent of men. Almost twice as many women said they preferred jobs with limited or no "on call" responsibilities.

Family physician Sandy Ratterman's father practiced family medicine in Ohio.

"He worked much harder than I do, but he had a wife [at home] and I don't," said Ratterman, whose husband is a lawyer. She sees patients in Fairfax three mornings a week and cares for her four children, ages 11 to 2, the rest of the time.

In the various legislative proposals under debate, Congress and the administration have moved toward providing incentives for doctors entering residency programs to pursue careers in primary care. Most residency slots are funded through Medicare, giving the government a stick to wield over residency administrators, and changes in Medicare reimbursement alluded to by Obama on Monday could be the carrot that makes primary care more attractive.

But proposals to change that funding scheme to favor primary care have encountered resistance from lobbyists for specialists.

Obama also wants to expand the National Health Service Corps, which helps medical students pay tuition in return for two to four years of service in communities that do not have enough doctors.

Community health centers would be expanded under all of the major proposals. And the measures envision far greater use of nurse practitioners and physician assistants, who would be teamed with doctors in larger groups.

A study by the Robert Graham Center and the National Association of Community Health Centers concluded that 15,585 more primary-care providers would be needed in order for health centers to serve 30 million new patients.

It takes six years to educate a nurse practitioner and a dozen years to produce a doctor. Even if Medicare funding for residency programs is increased, if medical schools increase their enrollments by the 30 percent recommended by the Association of American Medical Colleges and if financial incentives to enter primary care are put in place, it will take years to build the health-care system into the new model.

Washington has also been training a microscope on the groundbreaking effort in Massachusetts to provide everyone in the state with health insurance: Adding 340,000 people to the rolls of the insured there since 2006 has underscored a shortage of doctors. It takes 63 days on average to get an appointment with a family doctor in Boston, more than twice the wait in Washington, and seven times as long as in Philadelphia and Atlanta, according to a Merritt Hawkins survey.

"If Massachusetts is any guide, with increased access you'd see pent-up demand for health care, and you'd see a lot of frustration with the waiting time to access health care," Phillips said. "It'll swamp the emergency rooms, and those people will be seeking health care in the most expensive settings."

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