Where Are the Primary Care Doctors?

Thousands of new patients have flooded doctors’ waiting rooms in the months since Massachusetts passed a bill requiring that all residents obtain health insurance. Over half of the previously 600,000 uninsured residents have since signed onto health care plans, and the influx of new patients is taxing primary care physicians across the state. The Massachusetts Medical Society (MMS) warns in their 2007 report that primary care physicians believe that “a workforce shortage is imminent.”

That shortage has already arrived in Massachusetts. The MMS report revealed that 27 percent of medical directors had trouble recruiting family physicians, in comparison to only 7 percent who found it difficult to recruit specialists such as anesthesiologists, orthopedic surgeons, pediatricians, and radiologists. The lack of primary care physicians translates into longer waits to see a physician for patients: only 42 percent of patients in Massachusetts could be seen by a primary care physician within a week, a drop of 11 percent over the past two years. In one practice in Western Massachusetts, the next opening for a physical is in May of 2009.

The shortage of primary care physicians is an inevitable effect of the mandate for universal coverage in Massachusetts. As previously uninsured patients can now seek care that they had postponed or neglected, the medical system is witnessing a spike in patients and office visits. While this does place an undeniable strain on the health care system, the burden is nonetheless worth the cost: Studies have demonstrated that access to primary care improves health, allowing doctors to practice preventative medicine, monitor chronic diseases, and control rising health care costs. If we intend to actually realize the benefits of primary care, however, we must take active steps—whether through tuition breaks, tax subsidies, or pay scale changes—to encourage medical students to enter primary care.

If the federal government adopts a similar universal mandate, the situation in Massachusetts will have served as an informative preview of what is to come. In the United States, 47 million people currently lack health insurance, and their entrance into the world of the insured will place a huge burden on already overwhelmed primary care physicians. But even ignoring the entrance of uninsured patients into the health care system, the American Academy of Family Physicians predicts that the country will need 40,000 more family physicians by 2020 due to the aging population, a 40 percent increase over today’s numbers.

In spite of the dire need for family physicians throughout the United States, however, American medical students continue to shy away from primary care as a career. Since 1997, the number of medical students entering family medicine residencies has fallen by 50 percent. This year, a two percent increase in family medicine residents was considered by the American Association of Family Physicians to be a triumph. Foreign medical students now fill most of the spaces in family care residencies; this summer, 56 percent of entering primary care residents will be foreign medical students.

Financial disincentives pose one obstacle to residents considering primary care. Insurance reimbursement is one reason students ignore primary care in favor of pursuing lucrative specialties: A Medicare reimbursement for a 30-minute visit with a primary care physician in Boston is only $103.42, while a colonoscopy requiring the same amount of time reimburses a gastroenterologist $449.44. Costs of running an economically viable primary care practice (especially outside of a hospital, which can recoup losses with expensive procedures or tests) in many parts of the country are also prohibitively expensive. And it is easier to recoup the financial losses of medical school tuition—which can run up to $160,000 for private institutions—in a lucrative specialty. Primary care doctors have some of the lowest salaries for physicians, from around $160,000 to $175,000, in contrast to specialists who can easily earn two to three times that amount.

Prestige also contributes to the high proportion of specialists. In one study, only 37 percent of those intending to go into family care ended up in family practice. Those who defected were more likely than those rejecting other specialties to quote a lack of prestige, anxiety over mastering a wide breadth of knowledge, and paradoxically, a low academic content as the reasons for their change in focus.

Market forces alone will not be enough to solve this lack of primary care physicians. State and federal governments, in conjunction with medical schools, must create a system of tax breaks and subsidies—perhaps along the lines of the Harvard Law School’s recent decision to waive third-year tuition for students who pledge to work in public service for five years—to attract more medical students to the field of primary care. Subsidies for primary care residencies, altering the Medicare pay scale, and creating tax breaks for those who practice primary care could further draw students into primary care. Incentives should consider where doctors plan to practice, as well, rewarding those who chose to work in underserved areas that are most acutely affected by the lack of a sufficient number of primary care doctors.

The increase in doctor visits in Massachusetts since the advent of the universal mandate reveals the fact that too many people have long neglected their need for primary care. But, if the universal mandate is to achieve its goal of actual universal care, we must alleviate the difficulty in finding an appointment with a renewed commitment to attracting talented young doctors to the essential and too-often disrespected field of primary care.