Primary Care Crisis

Family doctors, pediatricians, and internists, commonly known as primary care physicians, are the backbone of the American healthcare system. Their critical roles in disease prevention, diagnosis, and treatment significantly improve quality of life for millions of Americans and decrease the soaring costs associated with trips to the hospital and emergency room. However, in 2010, the U.S. faced a shortage of 9,000 of these physicians, and the Association of American Medical Colleges estimates that that number will increase to over 65,000 by 2025. This shortfall is fueled by the aging physician workforce (almost half of workers are more than 50 years old), the lack of doctors-in-training who intend to enter primary care, and, most recently, the implementation of the Affordable Care Act. The healthcare law has admirably increased access to health services for millions of patients, but it will only further increase physician shortages if the situation is not adequately addressed.

Reversing this trend requires a multifaceted approach and is of the utmost importance if the U.S. is to rein in rising healthcare costs and provide sustainable, high-quality healthcare to its citizens. The seemingly obvious first step is to increase the number of primary care physicians, but this proposal faces fundamental challenges. The primary care fields do not present an attractive career option for many aspiring doctors. Those in primary care have much lower salaries than doctors who specialize, despite working for a similar number of hours; they must also contend with the most paperwork. In 2013, physicians in family medicine earned an average of $175,000, while radiologists, for example, averaged $349,000. Regardless of a physician’s level of selflessness, reimbursement holds a major sway, considering that the average medical student in 2013 graduated with $169,901 in debt, not including expenses from undergraduate studies.

Despite these challenges, increasing the number of primary care physicians is possible and will require increased incentives to make primary care a more feasible career option. This does not necessarily mean we need to increase salaries; instead, we need to focus on more feasible loan repayment and forgiveness programs, which currently exist but need to be increased in scope. For example, the Students to Service program offers loan repayments of up to $120,000 for medical students who enter primary care and practice in underserved areas. Lawmakers should appropriate more funds toward these kinds of programs, as this investment will decrease long-term healthcare costs. In fact, a report conducted by Johns Hopkins researchers estimates that, if we raise the proportion of primary care physicians by one percent, “an average city will have 503 fewer hospital admissions, 3,000 fewer emergency-room visits, and 512 fewer surgeries annually.”

While these methods can and should be implemented, a more promising solution to the growing crisis involves fundamentally redefining the roles of healthcare personnel. Instead of delegating most responsibilities to the physician, a clinical team approach may be more effective, allowing nurses and physician’s assistants to perform many of the functions currently performed by doctors. A report in “Health Affairs” argues that nurses and physician assistants could administer 60 percent of the preventive procedures ordinarily performed by primary care doctors, including vaccinations and cancer screenings. This redistribution of duties could free up 10 percent of physicians’ schedules, allowing them to see more patients and make more effective use of their time.

Medical homes currently employ this method, spreading healthcare duties among a variety of personnel, including assistants, nurses, nutritionists, and pharmacists. Services provided by these medical homes constitute 15 percent of primary care in the U.S., and it is estimated that if these homes grew to provide half of the nation’s primary care, the physician shortfall would decrease by 25 percent. To be sure, expanding medical homes to this extent is a daunting task, and lawmakers will need to enact state legislation that expands the number of tasks and procedures that nurses and physician assistants can perform. However, if this model is applied in doctor’s offices and hospitals as well, we could see a sharp decline in physician shortages.

However, it is important to combine the use of the clinical team model with methods to increase the number of primary care doctors. Nurses, physician assistants, and other healthcare personnel cannot perform all the tasks of extensively trained physicians, and physicians by themselves cannot provide high quality care to every patient with the current shortage. Other solutions should also be incorporated. For example, medical schools need to change their culture so that the brightest students do not feel pressured to specialize. Specialty doctors are certainly needed, but primary care physicians face the most deficiencies.

Ultimately, the US spends more on healthcare than most developed countries, and yet has not seen markedly better health. Primary care physicians, with their contributions to preventive care, are the key to reining in this large and inefficient spending. If we wish to reform the American health system, we first need to address the shortage in primary care, and we need to do so now.

Anthony Thai ’17 is a Crimson editorial writer living in Straus Hall.