A group of us were discussing this very issue this week and out of five of us, only one was considering primary care and he admitted that he would probably go with Emergency medicine or oncology instead.
Dr Kevin Pho has a good article this month in USA Today on the shortage of primary care physicians in America appropriately titled, Shortage of primary care threatens health care system.
By way of introduction, Dr. Pho writes…
Primary care should be the backbone of any health care system. Countries with appropriate primary care resources score highly when it comes to health outcomes and cost. The United States takes the opposite approach by emphasizing the specialist rather than the primary care physician.
Dr Pho (a primary care physician) then proceeds to lay out the problem pretty clearly in the body of his article…
How did we let primary care slip so far? The key is how doctors are paid. Known as "fee for service," most physicians are paid whenever they perform a medical service. The more a physician does, regardless of quality or outcome, the better he's reimbursed. Moreover, the amount a physician receives is heavily skewed toward medical or surgical procedures. A specialist who performs a procedure in a 30-minute visit can be paid three times more than a primary care physician using that same 30 minutes to discuss a patient's hypertension, diabetes or heart disease.
Dr. Pho also addresses this situation from our perspective as students and future doctors…
Medical students are not blind to this scenario. They see how heavily the reimbursement deck is stacked against primary care. Whether they opt to become a specialist or a primary care physician, they graduate with the same $140,000 of medical school debt. The recent numbers show that since 1997, newly graduated U.S. medical students who choose primary care as a career have declined by 50%. This trend results in emergency rooms being overwhelmed with patients without regular doctors.
Not everyone agrees with Dr. Pho. Here is a response to his article that Dr. Pho posted on his blog KevinMD that offers some insight by comparing the medical profession to the rest of the business world. Here is just a snippet of the opinion…
Your description of "fee for service" and how it is affecting the medical community reveals the incredible naiveté of doctors and other medical employees. This fee system is, indeed, how business in general works. Different prices for different products is what is termed "product mix" in the real business world. Every company is subject to this phenomenon Some products are incredibly profitable and some barely cover overhead, or are loss leaders. And many of the "consults" or services that I provided as a manufacturer of foodservice equipment earned absolutely no fees. Unlike you, I could not charge for my "professional time". I hoped that it would bring in profitable business and prepared my presentations and dialogues to bring about this result ,but had many failures or missed opportunities. The last two doctors I saw (for a skin condition and for gall stones) both came up with no diagnosis or proposed solution yet each charged me their "fee" of $110 and $230, respectively
In the end it all comes down to money. Can’t blame anyone really. It’s just a matter of being practical. If you can make more money as a specialist, there is little incentive to opt for primary care.
The solution to the problem is to find a way to make primary care a more lucrative field. Dr. Pho offers three suggestions in the conclusion of his original article, which I’ve paraphrased as follows…
1) Pay primary care for their time, rather than per patient
2) Forgive student loans if primary care is chosen
3) Pay primary care the same as specialists (See #1)
Personally, I think point number two is the most viable solution for the short term. I’m sure there are many med students who would seriously consider primary care if they didn’t have to worry about how they were going to pay off the debt.