This is why we can’t have nice things anymore
For someone like me — young, healthy (knock on wood), and with no need for frequent contact with the health care system — a primary care physician is a nice thing to have. I can go to my family physician for medical school checkups, vaccines, minor acute illnesses… but honestly, if I were to wind up “medically homeless” it wouldn’t be the end of the world.
For someone older or in poorer health, maybe with a chronic medical condition or two, a primary care physician is much more than “a nice thing to have.” Chronic condition management, specialty consult management, generally looking after all the patient’s medical problems… that can wind up being the difference between well-managed illness on the one hand and an expensive trip to the emergency room on the other.
As I’m sure you’ve heard, there’s a growing consensus that the US does not have enough primary care physicians. Why not? There are a lot of potential answers to that question floating around out there, some of which are probably correct at least in part. Opinion tends to coalesce around the following explanations:
- Primary care physicians tend to earn less than other physicians
- Primary care physicians’ lifestyles are not as enviable as those of some other physicians
- Primary care practice is perceived as being relatively more exposed to the hassles and red tape of third-party payers
- Medical students aren’t sufficiently exposed to primary care/good primary care role models and/or medical students encounter too much disrespect for primary care from faculty in other specialties.
- There aren’t enough primary care residency positions relative to specialty residency/fellowship positions.
I can believe all of these to varying degrees, though I’d hazard that the first two (to me, the third is a subset of the second) on the list are the main causes right now. The last one doesn’t strike me as all that persuasive. Residency slots have to be filled by international medical graduates, or simply stay unfilled, because not enough US medical students want to go into those fields. Increasing the number of training positions in primary care won’t solve anything without an increase in medical student willingness to fill these slots. The problem is clearly medical student demand, not training position supply.
Many of the proposals to “fix” primary care have rightly focused on the most plausible causes for the shortage. Some professional organizations would hope to narrow the pay disparity by either cutting specialist pay, tweaking the Medicare pay formula to better compensate “Evaluation and Management” service codes, or simply by going back to Congress and begging for more money (sense a theme here?). Others believe the solution lies in expanding retainer practice, which would have the added bonus of improving pay and lifestyle/regulatory hassle issues. There are some who think that the “Patient-Centred Medical Home” and “Accountable Care Organization” will save primary care (or not).
Others would take more roundabout routes to creating more PCPs. Instead of (or perhaps, in fairness, in addition to) changing the nature of the job to make it more desirable, they would take steps to essentially hoodwink medical students into choosing primary care as a field. Some people think that Nurse Practitioners and Physician Assistants can and will step in to fill the void left by medical students (while “can” may be questionably questionable, the “will” is an even more uncertain proposition).
Yet others have jumped the shark entirely. Via John Goodman some time ago, and KevinMD more recently is a summary of an AMA expert report on the real reason more students aren’t going into primary care: it seems that we’re too nerdy, insufficiently altruistic, and (*gasp!*) bad at advocacy and community organizing. Too much problem-solving acumen, not enough passion for social justice!
The links above point out the many, many flaws in this line of reasoning. There are two big ones that come to my mind, however.
The first is the issue of “social justice.” It’s a nice phrase, and an amorphous concept. I’m in favour of social justice, and for certain methods of achieving it. Ask a typical left-liberal what they think of my conception of social justice and my preferred means of advancing it, and you’ll likely provoke a good deal of rage, sputtering, and denunciation. It’s one of those terms that’s thrown around a lot without being defined. That said, it’s really only one segment of the political spectrum that has a high affinity for that phrase… when you see the AMA using it, you can be pretty sure what it is they’re referring to. According to them, medical school admissions should be based on a political orthodoxy because, well… apparently it will produce more primary care physicians.
This isn’t even the biggest problem with the proposal. Remember how I mentioned earlier that one of the reasons students aren’t going into primary care fields is because of pervasive disrespect for them in the medical academy? The lack of role models and exposure? The constant denigration by medical and surgical specialists? The idea that someone is “only” a primary care physician?
How does the implication that primary care work doesn’t require problem-solving skills do anything other than contribute to these sorts of perceptions? The very idea amounts to a proclamation that primary care is “lesser” medicine! “Primary care physicians aren’t real doctors… I mean… the important skillset for them is community organizing for social justice!”
While this report may have its heart in the right place, I’m sure that medical students will be smart enough to read between the lines and see that it’s merely confirming the prejudice that they’re seeing in all other areas of their training.
This is the medical academy’s solution to save primary care. And that… that is why we can’t have nice things.