The Disappearing Family Doctor
The US must act now to avert a looming shortage of primary care physicians.
By Gregg Coodley
Americans may be divided on many issues, and healthcare policy is certainly no stranger to heated debate, but one preference unites virtually all of us: the ability to have a regular relationship with a primary care physician. More than 90 percent of Americans, according to one recent survey, value having a family doctor they can see for any health issue. Yet regular access to a primary care physician seems likely to become rarer and rarer, for their numbers have been falling for decades and show little hope of reversing that decline. In 1900, the US had an estimated 173 doctors-almost all general practitioners-per 100,000 residents. By 2005 there were only about 46 primary care physicians per 100,000, and in 2015 the number stood at 41.4. Experts expect the ratio to fall an additional 20 to 25 percent by 2030.
The disappearance of the primary care practitioner is more than an issue of nostalgia, for the evidence is overwhelming that primary care is vital, both at a population level and for the individual. A review of 20 years' worth of public health studies found a positive correlation between the supply of primary care physicians and a wide variety of improved health outcomes, ranging from cancer and heart disease to infant mortality and overall life expectancy. Another study found that adults who had a primary care physician rather than a specialist as their usual source of care had lower subsequent five-year mortality rates.
Continuity of care with a primary care practitioner also has a major impact on health. Studies have shown that patients with longer relationships with their primary care physicians are hospitalized less, incur fewer overall costs, visit emergency rooms more rarely, and report the greatest satisfaction with their care.
Perhaps the greatest testimonial to the importance of primary care lies in a 2016 comparison of the United States to 10 other developed countries in the Journal of the American Medical Association. Where the US spends about 5 percent of healthcare dollars on primary care, these other nations spend between 12 and 17 percent. And even though the US spends more overall on healthcare, it trails those countries on measures ranging from life expectancy to infant mortality. Look closer, and a startling primary care practitioner gap emerges. Roughly half the doctors in Canada are primary care physicians, versus only 30 percent in the US. The United Kingdom boasts approximately 60 primary care doctors per 100,000 people-50 percent more than in the US.
So why, given the clear benefits of primary care, are we facing this massive shortfall of primary care practitioners?
14 THE PENNSYLVANIA GAZETTE Jan|Feb 2023
Illustration by Jonathan Bartiett
Multiple factors have contributed to The resulting demoralization of primary care physicians has led to early but does not cut quality-- this decline, but the overarching dynamic is the abandonment of primary care retirements, shifts to other careers, and costs and debt. Training really is shorter, in favor of medical specialties. In the further discouragement to students considering primary care. A 2007 survey in most other developed nations. were generalists. By the 1960s the pro- revealed that two-thirds of primary care Third, since hospitalists have now portion had dropped to one half, and practitioners would not choose primary usurped the role of primary care physi- specialists have outpaced generalists care again if given the choice. A 2012 sur- cians in hospital settings, primary care ever since. By the early 2000s only about vey showed that most of them did not practitioners don't really need three 20 to 25 percent of medical school grad- recommend it as a field. A 2019 study years of training that traditionally focus- uates were going into primary care. showed that almost half of internists and es over 90 percent of hours on inpatient Why do generalists make up more family physicians reported burnout-- care. Primary care residencies could be than 50 percent of the physician work among the highest levels of all specialties. cut to two years--the second entirely in force in other Western nations and yet outpatient care-giving graduates far are so much rarer in America? more primary care training and expo- Perhaps the biggest factor is financial. The income sure at a reduced cost. Primary care physicians, on average, are Finally, the income differential be- paid less than half what specialists earn. A differential between tween specialists and primary care phy- 2009 study estimated that doctors choos- sicians is an artificial construct, based ing high-income specialties could expect specialists and on a historical undervaluing of talking an additional $3.5 million in income over primary care to patients as opposed to performing their careers. And this financial differential procedures. The federal government has has become increasingly hard to ignore physicians is an driven this dynamic by setting reim- amid the rapid increase in medical school bursement rates that are aped by private costs and student debt. In 2018 the median artificial construct. insurers, and the federal government cost of medical school was $243,902 for could use the same tool to shift that dy- public schools and $322,767 for private namic. One study found that fully one- schools. The average debt in 2017 for med- Rescuing primary care--and the myr- quarter of medical students would shift ical students was $192,000. Such debt iad benefits it delivers to individual to primary care if there were adjust- makes it harder to choose a lower-paying patients and the healthcare system more ments in income and hours to reduce career in primary care broadly-is a complex task. But there are the generalist-specialist gap. This is the Non-financial factors have also contrib steps we can take that might help. most straightforward solution, and one uted to the shift. Medical students have First is acknowledging that primary care that could bring the US supply of pri- flocked to specialties with set hours, such and continuity of care are important. mary care physicians in line with other as being a hospitalist. Primary care physi- Patients should not have to switch doctors Western nations. cians, meanwhile, bear a burden of chart- if they switch insurance providers. This These changes are feasible, would not ing and paperwork that frequently step alone would cut costs and improve add to overall healthcare costs, and extends into the evenings and weekends. patient care, since new doctors would not could be accomplished by fiat by insur- And though doctors of all kinds complain have to continually reinvent the wheel for ers, medical schools, residency pro- about the ever-increasing load of bureau- a churning patient population. And this grams, and the federal government. It cratic tasks, evidence shows that this prob- step would not require a radical systemic would behoove all parties to act fast lem is much worse for primary care prac- overhaul, for insurers could still control across multiple fronts to preserve this titioners than specialists, as insurance the bulk of costs-which occur in the hos- fundamental part of the healthcare sys- companies exert ever more control over pital--by mandating to whom primary tem. Americans value family doctors for routine medical decisions. The autonomy care practitioners could refer. good reason. Sometimes patients really of primary care physicians has also been Second, it is time to reevaluate the do know best. eroded in the last 15 years by the rapid length and cost of medical education. engulfment of small independent prac- The repetition of basic sciences in high Gregg Coodley C'81 is a primary care physi- tices by huge corporations and hospital school, college, and medical school car- cian in Oregon and the author of Patients in chains-which has emerged as a signifi- ries an opportunity cost. Studies have Peril: The Demise of Primary Care in Ameri- cant factor in physician unhappiness. shown that cutting medical school from ca Atmosphere Press, 2022.
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