Is There a (Primary Care) Doctor in the House?

by Tim Foley

Published April 27, 2009 @ 04:50PM PT

If you picked up The New York Times this morning, right above the fold in the coveted “Holy crap this is important! Pay attention!” spot is an article about a crisis that’s been brewing for a long time: the growing shortage of primary care physicians in the United States. I wrote about this year’s match of graduating medical students and residency programs, when once again residency slots for the high-paying specialties of dermatology, radiology and specialized surgery were incredibly competitive for new American doctors, while there were plenty of vacancies in primary care being filled by international medical graduates. Repeat that trend for a couple of decades, and you have the mess we’re in now – poised to expand coverage for millions, yet without the doctors to treat them all.

Before we get too ahead of ourselves, there are plenty of countries with universal health care who are trying to solve this problem as well. As I wrote a few months back, the physician shortage in Japan is about what it is per capita in the United States, largely due to low compensation rates. When you factor in that all citizens have coverage in Japan and frequently use primary care – one of the main reasons their population is so much healthier than the U.S. – you get an average workload per day for outpatient clinics of 49 patients! Canada falls into the same boat. Our Neighbor to the North has almost exactly the same number of doctors per capita we do. The only reason their situation seems worse with regards to non-emergency wait times is because of the fact that we have an estimated 50 million people without coverage who mostly don’t see the doctor at all – if we made health care a basic right tomorrow, our physician supply would look like a catastrophe. For an example closer to home, Massachusetts has famously reduced the ranks of the uninsured, but that’s only exacerbated those waiting to receive care from a primary care physician. Unsurprisingly, even with coverage, the number of Bay Staters receiving care in Emergency Rooms is on the rise even with the Massachusetts Connector – by 7% last year alone.

Here’s the kicker – Massachusetts actually has more primary care doctors per capita than the rest of the United States. Yeah, we’re in trouble.

It’s not hard to figure out what’s driving this. Today’s doctors grow up expecting to have $140,000 or more in medical debt when they graduate. Almost a quarter of them have $200,000 or more in debt. Not only does that dampen enthusiasm for going into medicine at all, particularly for communities of color or students who rely heavily on financial aid and student debt just to get their undergraduate degree, but it also colors the career path of primary care vs. specialization. If you were to get your MD, would you feel more comfortable making $150,000/year as a pediatrician or $550,000 year as a cardiovascular surgeon? Granted, specialists are paid more than primary care in every country on the planet, but nowhere is the disparity as absurd as it is in the U.S. All the incentives in our fee-for-service system are towards doing a lot of expensive procedures, almost regardless of whether that makes the patient healthier. That works very well for specialists – it works not at all for primary care physicians who make their money off the $150 per office visit (as Dr. Aaron Rowland explains in his all-too-painful “Tales of a Family Doctor.”) Similarly, other countries with much higher ratios of doctors to people subsidize some or all of the cost of medical school, particularly France and Switzerland.  Their specialist physicians make less than their American counterparts, but also don't start their professional lives with mortgage-sized education debt.  But the idea of free higher education is borderline heretical in the United States.  The end result: nowhere near enough primary care physicians precisely when we need them the most to improve our health, bring access to all and control costs.

Physician compensation and its cause-and-effect diminution of our supply of primary care doctors is a problem that’s agnostic to the issues of coverage that we tend to obsess over (myself included). If the Obama plan passes, we’ll have to deal with it. If single-payer passes, we’ll have to deal with it. If some undreamed-of other plan passes, we’ll have to deal with it. But given that we’re trying to deal not just with the physician shortage of today but influence the doctors-to-be still in medical school, we need to start dealing with it now.

(Photo credit:  Old Shoe Woman on Flickr.)