Intro
America’s rising population, shifting demographics and growing epidemics will continue to present urgent challenges for our healthcare system in 2016. The primary challenge continues to be the availability of primary care physicians to meet the continuously growing demand for healthcare services. Expanded insurance coverage resulting from the Affordable Care Act, aging baby boomers and the rise of medical disorders such as diabetes and obesity are cumulatively impacting the need for additional primary care workers.
Of particular concern is the fact that, currently, only 9 percent of US medical students will select the two adult primary care careers - family and internal medicine - as their specialties. Based on both the aforementioned entry rate for new family practice physicians and estimated future demand for such positions, the U.S. will be facing a projected shortage of approximately 52,000 primary care physicians by 2025. (You should cite this!) This would seem to suggest an urgent need to address this impending shortage of medical doctors. After reviewing and analyzing the current structure of medical education, it’s evident that systemic changes need to be undertaken to ensure a sufficient number of primary care physicians will be available to meet America’s diverse and growing future healthcare care demands. Among several proposed solutions is the subsidizing of either a portion or possibly all costs for a primary care medical education, thereby attracting more students to the field and mitigating the current lack of primary-care physicians. Other solutions include providing team-base care and expanding the role of PA’s and NP’s and, second, incentivizing retiring physicians to transition to primary care. The question remains: Can focusing on the previously noted changes in our current health care system increase the number of primary care doctors and alleviate our impending shortfall of primary care physicians?
Background
As the U.S. population continues to increase, so does the demand for medical services - especially for family physicians in low populated areas. HRSA estimates that with this rising population, the number of doctors required to meet patient care demand will rise from about 805,000 in 2010 to 922,000 by 2020 (Hubbard, 2006). In the past, there have been several initiatives designed to aid in producing more primary care physicians. For example, the National Health Service Corps (NHSC) helps doctors to repay their student loans by offering $50,000 toward student loan debt in exchange for a two-year commitment to work in an underserved area. The United States military, meanwhile, allows students to graduate medical school 100% debt free. With their Health Professional Scholarship Program (HPSP), the military offers free medical school in exchange for a military commitment. Another proposal by doctors Peter B. Bach and Robert Kocher, in an article featured in the New York Times, proposed another solution regarding the shortage of primary care doctors. Bach and Kocher suggest providing free medical school for everyone. (Citation?) The free medical tuition will not come from tax payers, they argue, but from salaries of residency doctors. Bach and Kocher propose that residents that pursue primary care would continue to be paid by hospitals during residency. However, residency doctors who go on to train to become specialists will not be paid during residency. Instead, that money would go to finance the free medical school tuition in question.
Point 1
Primary care physicians accumulate considerably less wealth and will earn lower incomes over their lifetime compared to those of their specialist counterparts. Endorsing free medical education for at least some medical students could potentially lead to a more even distribution of physicians among the various medical disciplines. Primary care physicians make $190,000 a year on average, making it difficult for some to pay off their student loans while concurrently trying to run their business. By comparison, a specialty doctor makes an average of $325,000 per year. During residency, doctors are paid approximately $50,000 per year. If medical residents that are focusing on high paying specialty branches are required to pay for their medical education, then the money that hospitals would otherwise pay to these residents would instead be paid to finance free tuition for those medical schools focused on primary care. In effect, this would offer residents an incentive to pursue the primary care field instead of choosing a specialty practice.
Sixty percent of medical students currently come from families with incomes in the top 20 percentile of the nation, while only three percent come from families in the lowest 20 percent (Conroy, 2014). The rich and affluent shouldn’t be the only individuals able to afford medical school. Free medical school could potentially lure college students away from other career paths and into medicine. For years, I personally debated whether to go to medical school. In the end, the cost was always a major factor for me. Providing free medical tuition or some sort of student loan repayment assistance could draw in candidates that were otherwise deterred from medical schools due to the costs. This could also increase the quality of the applicant pool. In a survey conducted by the Association of American Collages (AAMC), students that appeared to be qualified for medical school on the basis of academic achievements were asked why they chose not to apply to medical school. Many reasons were provided. However, a major deterrent for all students was the cost (AAMC, 2004). Offering free medical tuition would encourage students that would not normally consider medical school to apply. The sad truth is that many students worry about being able to make enough money to pay back the financial dent they have incurred. If medical school were free, this would no longer be a concern.
Undergraduate education will always be followed by medical school and residency training. It takes years to become a doctor in the primary care field. And it takes even longer to become a specialty doctor. Producing enough doctors to meet long-term demand is a pressing issue that needs to be addressed immediately. The current imbalance on the number of primary care to specialty doctors that we are facing will ultimately lead to severe shortages. “The trends from these data are clear – the physician shortage will grow over the next 10 years under every likely scenario,” explains AAMC President and CEO Darrell G. Kirch M.D. “Because training a doctor takes between five and 10 years, we must act now, in 2015, if we are going to avoid serious physician shortages by 2025. The solution requires a multipronged approach: Continuing to innovate and be more efficient in the way care is delivered as well as increased federal support for graduate medical education to train at least 30,000 more doctors a year to meet the health care needs of our nation’s growing and aging population.” (Citation!)
Point 2
When it comes to delivery of care, today’s model is centered around the primary care physician. Changing the model to provide a mix that is more inclusive of Nurse Practitioners and Physician Assistants can substantially reduce or eliminate the future Primary Care Physician shortage. Providing changes in the way primary care is delivered can therefore be achieved by merging two models of care - the patient-centered medical home and the nurse heath care center - would help reduce the demand for physicians. The medical home team-based care model delivers the core functions of primary care by employing a staff that includes doctors, nurses, physician assistants, pharmacists, medical assistants, care coordinators, social workers and educators. This care team has the capacity to provide ample care for a larger number of patients. Nurse-managed health care centers (nursing centers) provide a full range of primary care and other specialty services. Nurse-led clinics, on the other hand, are primarily run and managed by nurse practitioners, which could help greatly reduce the need for primary care doctors if they were to become prevalent. In a study conducted by David I. Auerbach et al (2013), it was determined that providing for strong growth in the number of physician assistants and nurse practitioners, along with increases in diffusion of the medical home and the nurse-managed health center models, would both work to shrink the demand for more physicians.
Point 3
Studies estimate that the retirement age for physicians is typically around 66 years of age. With the looming physician shortage, efforts to retain older physicians in the workplace for longer could also help with the impending physician shortage. In an article entitled “Estimating the Residency Expansion Required to Avoid Projected Primary Care Physician Shortages by 2035”, it was determined that by delaying retirement until 68 year of age, the future demand for physicians is reduced to 26,835 from 38,622 physicians retiring at 64 years of age. Senior physicians in the workplace can often be thought of as a resource. Some practices will be better off establishing a reasonable slowdown plan for competent physicians, lessening the overall future projected physician shortage. Research suggests (Nusbaum, 2009) that the bulk of United States workers take on bridge jobs (part-time employment of shifting to a job in a different field) after leaving their profession and before fully retiring from the workforce. One model might encourage these physicians to work on a part-time basis in those areas where there are distinct healthcare shortages. Providing incentives like transportation, malpractice and health coverage, lodging and a stipend for a certain amount of service hours per year could prove equally helpful. By keeping these valuable senior physicians in the workplace for longer, the problem of physician shortages can be addressed on a more immediate basis.
Conclusion
Ensuring that an adequate number of medical physicians are produced to meet the future medical care needs of our society hinges on revamping the cost structure associated with acquiring a medical degree. Looking into a more team-based approach model and creating a work environment that emphasizes team-based care could help leverage a physician’s time and boost their impact on patient health. Also, it would be a great societal benefit to structure practice opportunities in order to retain physicians in the workforce and to endorse job contentment for senior physicians, with the ultimate goal of addressing health care shortages. Trying several different approaches and models could essentially eliminate the looming shortage of health care providers. After all, primary care physicians are vital to the health care system and are essential to meet the requirements of improving patient health. As health care reform advances, the need for a better, stronger and more efficient primary care work force will become even more prominent.
