Reflections on Primary Care Physicians and Healthcare Reform

In a recent article in JAMA by Robert H. Brook and Roy T. Young, April 21, 2010, Volume 303(15):1535-1536, the authors write a commentary entitled, “The Primary Care Physician and Healthcare Reform”. With changes coming from healthcare reform leading to more and more people being covered, the need for primary care physicians is actually increasing. Unfortunately the number of primary care physicians is decreasing. There are two main reasons for this:

  1. the scope of practice is being constricted for primary care physicians with their ability to do less and less procedures (think of less OB and procedures) and less and less in hospital care, (think of hospitalists), as well and more importantly
  2. the differential between what they get paid and what specialists get paid. The gap is substantial.

The median salary in large multi-specialty groups for primary care physicians is around $200,000. The median dermatologist salary is $351,000. Given this type of pay differential and the narrowed scope of practice, why should bright, hard-working, debt-ridden or even altruistic medical students choose primary care versus specialty.

In 2010 only 54.5% of 4,999 residency spots in internal medicine were filled, 44.8% in family medicine and in pediatrics 70.5%. In comparison at least 90% of physicians in neurosurgery, orthopedic surgery, and dermatology were filled by U.S. medical school graduates. Young clinicians are simply not willing to forfeit lifetime earnings of over $3 million.

To many of these students the authors state the primary care physician has become like the water boy on a football team, making sure that the really important members of the medical team do their work. Our dilemma is we don’t have great solutions. There could be no change and we could just let the inevitable decrease continue.

An alternative approach is to convince 50% of the students entering U.S. medical schools in 2010 to choose primary care as their professional career path. But, to do this we’ve go to change those other two variables. They need a different set of clinical responsibilities and skills, we should make them leaders in efforts to avoid preventable hospitalizations for patients with chronic diseases, eliminate inappropriate or equivocal surgery, radiological procedures, and help individuals die with the least pain and without expense for vast amounts of money.

Secondly we’ve got to come up with a way that they get paid more in comparison to specialists. Without these changes there is little hope of producing a healthcare system that provides high quality, affordable care to the U.S. population.

One thing these authors didn’t discuss is the use of advance practice nurses. Perhaps the future is that primary care physicians who want to stay in the field truly have to create systems where they work with advance practice nurses and becomes a conductor of a symphony of advance practice nurses in primary care.

I’d love to hear your thoughts on this.

Phil Kibort, MD, is Children’s vice president of medical affairs and chief medical officer. Read his bio here.

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