WSJ Reports … In Search of More Primary-Care Doctors
Janine Knudsen, a third-year student at Harvard Medical School’s Center for Primary Care, is passionate about becoming a primary-care physician.
She is convinced that the U.S. is moving toward a health-care system that will put a much higher priority on keeping people healthy and out of the hospital, and that the primary-care doctor will play the leading role in this transformation.
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“I see primary-care medicine as the most exciting field in medicine today,” the 25-year-old Ms. Knudsen says, “and I’m thrilled to be on what I believe is the cutting edge of change.”
If the U.S. has any hope of putting a dent in what is expected to be a huge shortage of primary-care physicians over the next decade, medical schools will have to find and train a lot more people who think like Ms. Knudsen.
The Association of American Medical Colleges, or AAMC, predicts that by 2020 the U.S. will be short more than 45,000 primary-care doctors—those who practice internal medicine, family medicine and pediatrics. With millions more patients expected to be seeking a doctor because of the Affordable Care Act and 10,000 Americans turning 65 every day for the next two decades, demand for these physicians is outstripping supply. Yet only about 20% of medical residents go into primary care, according to the AAMC.
To help address the doctor shortage and channel more U.S. students away from specialty fields, some medical schools are adding community-based primary-care training programs, and at least 17 new medical schools have opened since 2005, some committed to training only primary-care doctors, or PCPs. Several of the newer schools aim to educate PCPs specifically for underserved communities, and they use financial incentives such as loan forgiveness to make that happen.
Janine Knudsen, a student at Harvard Medical School, sees primary care as the future. Juliana DiLuca
According to Russell S. Phillips, director of Harvard’s Center for Primary Care, founded in 2010, the U.S. needs to move away from a system that rewards procedures and in which PCPs have been devalued, and instead encourage students to view primary care as a route to creating a more effective health system.
Dr. Phillips and Leonard Feldman, director of the new Medicine-Pediatrics Urban Health Residency Program at Johns Hopkins, say their programs were created with the hope that the doctors they train will become leaders and role models in this new system, where the primary-care physician will collaborate with nurse practitioners, physician assistants, social workers and other professionals to keep people well, taking into consideration the patient’s cultural background and social experiences, among other things.
Changing the Culture
Of course, changing the way primary care is delivered—and perceived—isn’t going to be easy.
One of the reasons the U.S. is facing a shortage of PCPs is because the brightest students are often told they’re too smart not to specialize, and that attitude is reinforced throughout their medical training. Hospital culture often depicts PCPs as paper-pushers and gatekeepers to the world of specialists.
PCPs also earn substantially less than medical specialists, and even those who want to work in primary-care medicine are often deterred by the prospect of paying back a huge amount of student-loan debt. According to the AAMC, the average student debt upon graduation from medical school is more than $166,000, and although loan payback and forgiveness programs exist, there isn’t enough money to go around.
George Thibault, president of the Josiah Macy Jr. Foundation, an organization working to improve health care in the U.S., says that if the U.S. wants to produce more primary-care doctors, especially those who are willing to practice in disadvantaged and underserved areas, medical schools may need to change the way they select students. He says students who have strong ties to their community, want to form long-term relationships and have a commitment to public service are more likely to choose primary care than other students.
“All medical schools can train dedicated, excellent community-driven PCPs,” Dr. Thibault says, “but some have it as their mission and others don’t.”
The University of California Riverside School of Medicine, which enrolled its first 50 students this year, is one that does. The school’s mission is to train physicians who will remain in the community, where there is a shortage of doctors.
“Over 90% of medical training in the United States takes place in academic medical centers,” says G. Richard Olds, the founding dean at Riverside, “but if we want students to go into primary care, we have to push training out into the community with a public-health agenda.”
Like Dr. Thibault, Dr. Olds believes changes in the way medical students are selected will make for better PCPs. Grades and test scores, he says, can no longer be the exclusive criteria for entry into primary care. “I’d even argue,” says Dr. Olds, “that those with the highest grades and Medical College Admission Test scores may not make the best doctors.” Riverside seeks students with public-service work experience and those from disadvantaged backgrounds who are likely to return to their communities to practice.
Too Little, Too Late?
Central Michigan University College of Medicine, meanwhile, is relying on financial incentives to help it address the physician shortage in the central and northern parts of the state. Some 80% of the students in its inaugural class of 64 this year grew up in remote and rural areas of Michigan, and much of the training takes place in the community. Ernie Yoder, the founding dean, says the community has agreed to pay back student loans if doctors settle where the state has the greatest need.
Dr. Olds believes that society ultimately will put a greater value on PCPs, and that their earnings eventually will reflect that.
The tide will turn, agrees Colleen Christmas, director of the internal residency program at Johns Hopkins Bayview Medical Center, because a strong primary-care network can reduce costs. She says a recent study by Johns Hopkins researchers showed that with each 1% increase in the proportion of primary-care physicians, an average city will have 503 fewer hospital admissions, almost 3,000 fewer emergency-room visits, and 512 fewer surgeries annually.
Although medical-school enrollment rose this year to a record 20,055, and more students chose primary-care residencies this year than last, Dr. Thibault says the U.S. has to do more to solve its primary-care problem, such as making better use of nurse practitioners and physician assistants, offering better reimbursement for primary care and creating more residency slots in primary-care specialties.
Many medical educators and innovators agree that efforts to entice more students into primary care will be fruitless unless there is an increase in the number of federally supported medical residencies—the three to seven years of on-the-job training that medical-school graduates must complete before they can practice independently.
Atul Grover, the AAMC’s chief public policy officer, says if the U.S. doesn’t act, the country will end up not having enough training places for the doctors coming out of medical school.
Ms. Sadick is a writer in New York. She can be reached at firstname.lastname@example.org.