The Future of “Primary Care”—Frail and Vulnerable?
I was recently asked to participate in a panel discussion regarding the “future of primary care.” At first, I thought they asked me to discuss the future of internal medicine, and I had envisioned a lively discussion regarding new technology and procedures that are quickly becoming the standard of care in cardiology, pulmonology, and other subspecialty areas. Manpower issues were not forefront in my mind, since my residents are eagerly applying to fellowships in these areas and dreaming of future careers viewed as exciting and highly compensated. When I was informed that this was to be a discussion on primary care aspects only, I quickly put to paper major concerns I have had for a long time. Primary care medicine as it currently stands is in peril of vanishing, and the time for change has come to prevent it from continuing on its current course of slow death.
We have all heard of the diminishing number of U.S. medical graduates pursuing careers in family medicine, and few international graduates leave their native countries to seek training in this area. Internal medicine is no exception. We must not be complacent in hearing that the number of U.S. medical school graduates seeking careers in internal medicine has leveled off or even increased slightly, because it is the final career path and not the residency training program that counts. The majority of internal medicine residents choose to become subspecialists, especially those international graduates who fill 50% of our internal medicine residency slots at the present time. The development of the hospitalist profession in recent years has become another challenge to primary care medicine, with the number of residents in medicine choosing this highly structured and well-paid career path that has been growing in recent years. I just finished the annual rite of interviewing prospective residents for a residency program in internal medicine that I direct.
While we are a community teaching hospital, I was surprised with the results. Yes, we had close to 2000 applicants—a new high—and we interviewed more than 400 worthy candidates. I was quite disappointed to learn, however, that when asked about future career plans, less than 5% expressed any interest in pursuing a career in primary care medicine! Who will be the primary care providers of tomorrow? Will the nurse practitioner replace the internist and the family medicine physician? Will the nation eventually recognize the crisis and do something to bring physicians back to what was once considered a most noble and rewarding profession? Clearly, economics is a major obstacle, with primary care physician salaries far below that of subspecialists. Internal medicine must already compete with other higher-paying specialties such as anesthesia and ophthalmology, among many others, for graduating medical students, and those who do choose internal medicine residencies still have many options to pursue, most as subspecialists.
The cost of running a primary care office has risen, and administrative demands such as the Health Insurance Portability and Accountability Act (HIPAA) and self-reporting for Medicare have become more difficult to comply with without increases in office staff. Prestige remains an issue, and one must not forget the challenging lifestyle. Our medical residents have grown accustomed to regulated hours and “CAPS” for numbers of patients to be seen and admitted to the hospital; these restrictions will most likely carry over as expectations for their future and will have an impact on their career choice. Medicare fees continue to decline, with the 4.5% drop this year hopefully being reversed by the legislature. Every year the threat to survival becomes a greater challenge. New “billing codes” add expense to a regulated budget and mandate reductions in fees for future professional activities. Any percentage cut from a primary care physician’s income is crucial to survival when one has such limited earning potential and relatively high costs. The margin of profit is just not there! I was disappointed to learn that a fellow panel member, a former resident and Chief Medical Resident of mine who had remained in the community to work as a primary care physician, stated to all in attendance that if given the chance to choose again, she would have become a hospitalist and not a primary care physician.
Economic demands now prevent this excellent physician from following her patients in the hospital; there are too few hours in the day for office practice as it is to make ends meet. She has now stopped doing time-consuming pelvic exams as part of her routine care, referring all women to gynecologists. Most worrisome, this eager and hard-working internist, approximately 6 years from residency, has had to start “moonlighting” doing physicals for an insurance company to earn sufficient income to make ends meet. As we face the new millenium and its challenges of many more older persons living longer with chronic disease conditions, the need has never been greater for primary care physicians. We have for many years given up hope that the geriatrician will be the main provider of primary care for the elderly. Economic and manpower issues have torpedoed this option as well, and the geriatrician for the most part works with the older person’s primary care provider to maximize medical care as appropriate. Will the future be dependent on fewer primary care physicians who will need to work in concert with physician extenders and subspecialists? Fragmented medical care will become a greater reality if this model continues to grow in popularity. Even here we are seeing the salaries of physician extenders rise; there currently is little difference between the salary demands of the nurse practitioner and primary care physician.
Patients who claim that they enjoy the additional time that a physician extender provides to them, as compared to the “average 7-minute visit” with their primary care physician, may now be faced with similar reductions in time, as financial demands on the practice of medicine must be met. Patient dissatisfaction may lead to change, but clearly there is no uniform voice at present to bring this issue to the forefront. While the 45 million U.S. citizens without health insurance remains the biggest threat to our nation’s health care, the issue of primary care will haunt us in years to come, and will likely increase the cost to our health care system in the long run as we become more specialty-oriented. We have seen the rise of “boutique medicine” as primary care providers search for ways to maximize earning potential. Some physicians have withdrawn from Medicare participation, though Medicare now is unfortunately on par with what most other insurance companies pay for visits; with our aging population, this is clearly not a solution. Preventive services are time consuming and not universally reimbursed. The primary care provider is faced with altering practice patterns in order to make ends meet—but at what cost to their patients and their medical reputation and liability? The crisis is mounting, and the time for action is now if we are to return primary care to its proper role and compete in the ever-changing health care marketplace. The future of primary care is concerning to say the least, and much like many of our older patients, frail and vulnerable. I welcome your comments.
Send comments to Dr. Gambert at email@example.com.