Fewer medical students are entering general internal medicine these days, recent headlines trumpet. But this primary care problem has been going on for some time. And for family medicine (which is the other main specialty that makes up the field of primary care*), there are concerns as well. At my institution, Saint Louis University School of Medicine, the number of students choosing family medicine went up this year, although last year the numbers had dropped by 50 percent from 2009. Nationally, the number of students matching in family medicine in 2011 increased for the second year in a row. This was an encouraging change to a downward trend we've been experiencing and hopefully it will continue.
The matter of declining -or simply not enough- primary care physicians is a huge problem because the numbers of those in need of general medical services are going in the other direction: up, up, up.
The number of Baby Boomers, who will be needing more health care in coming years, is expected to jump from 40.2 million in 2010 to 54.6 million in 2020. And with health reform opening the flood gates to all those who are currently uninsured, the numbers of people clamoring to see the doctor will go even higher.
The huge problem with this, which I barely saw anyone talking about during the ongoing health reform debates, is who, exactly, is going to be providing all this care? The primary care work force is already overburdened and burning out. Add heavier patient loads onto fewer workers who can share the cases (another point is that many doctors currently in practice are planning to retire or transition to other careers much earlier than in years past), and you can see the writing on the wall.
Houston, we definitely have a problem.
As I mentioned, this is nothing new. Compared to many other developed countries, America has a higher ratio of specialists to primary care physicians. About one-third of all physicians in America are primary care physicians, compared to half of doctors in most other industrialized countries.
It is obvious how this shortage of primary care physicians can affect you: Firstly, who ya gonna call when you aren't feeling well? Secondly, the adverse effects of this shortage are far-reaching when it comes to the cost and quality of medical care. A primary care doctor has the potential to lower your costs in many ways. Having more primary care docs can lower health spending per individual. Also, having more primary care physicians in a given area is associated with less use of health care services. In fact, each 1-percent increase in the proportion of primary care physicians has been associated with 503 fewer hospital admissions, 2,968 fewer emergency room visits, and 512 fewer surgeries for an average-sized metropolitan area.
And this means more to your health than you might realize: Adults with a primary care physician have been found to have lower health care expenses and a lower risk of death. Primary care has also been linked to lower death rates from cancer and heart disease, longer life expectancy, and better health overall. Care from primary care physicians has also been linked to improved patient satisfaction and well being.
This shortage of primary care docs hits at a time when we can ill-afford the deficiency. It arrives at a time when millions of new patients, many of whom will have much greater need of the health care system, come flooding in. My advice? Make sure you have a primary care physician now, and try to use the health care system less by doing your part in avoiding costly chronic disease that are largely preventable. I have loads of specific tips for you along this vein in my book The New Prescription: How to Get the Best Health Care in a Broken System.
*(Pediatrics and OB-GYN are the other two that make up the big four specialties in primary care, but for the purpose of this piece, I am focusing on primary care doctors who carry the greatest load in primary adult medicine.
Follow Dr. Cindy Haines on Twitter: www.twitter.com/drcindyhaines
Dr. Cindy Haines: Primary Care: What's The Future?
Home Page -- American Academy of Family Physicians
Family medicine - Wikipedia, the free encyclopedia
Medical-school graduates see dramatic changes in health-care industry
These days people are going to have to be their own PCP. Or perhaps find a good PA who are more likely to do general practice.
http://changingtheguardblog.com/
Does one really need insurance for routine primary and preventive care? No. But somehow health care has become synonymous with health insurance. Insuring primary care is like insuring lunch. You know you're going to need it. You know you can afford it. Why on earth would you pay a third party to pay the restaurant on your behalf, adding overhead and taking a big chunk out of the money you pay—and because of the process, have to wait a week to get a table and then have only 10 minutes to eat?
The model ref'ed in the DIY Health Reform piece has shown it reduces the most expensive aspects of care (surgery, ER & specialist visits) by 40-80%. Denmark "stole" this idea from the U.S. decades ago. It's been so successful, they closed many hospitals as they simply weren't needed. Ben Franklin was right - an ounce of prevention is worth a pound of cure.
Since physicians work far fewer hours than they did a generation or so ago, waiting time for an appointment can be a week or longer. If the caller feels like it's an emergency from a cut to asthma, they are advised to go to the hospital. This only runs up the bill.
I was so turned off by the greedy let do this test and that test attitude of physicians here , I found a physician's assistant who understands that budget constraints apply, picks pharmecuteticals off the Wal-Mart $4 list and when a referral is necessary tries to find a physician to work within the patients financial constraints.
Of course there are times that high-tech is necessary. But if you need a scan make sure you go to a free standing facility and NOT one that is hospital based. The cost difference is astounding, especailly if the hospital is doctor owned.
In reality the answer is nurse practicioners, you don't need 10 years of training to diagnose the diseases that primary care doctors take care of. In many cases the internet has enough information to tell you what is wrong with you (assuming some level of intelligence of course). There are specialists for the more complex things, and as you noted we have more than enough of them.
Best advice I can tell people is to familiarize yourself with how the human body works, and what areas of the medical profession deal with what sorts of problems, then do limited self-diagnosing, and try checking with a specialist in the first place.
It's better going to one doctor who knows what's wrong because he's seen it a million times than it is having to deal with a primary care doctor guessing at what the problem is, and not knowing what the best and most current kind of medicine or proceedure is to treat it.
Let me suggest a solutions to your problem of getting a better "quality of life".
a) Go to electronic record keeping. Other professions have done it years ago.
b) Think about learning to live on $150,000 a year, plus your interest income, the income you make as a "consultant", and the free vacations you get to give a lecture.
That might require you to spend less time stressing over the fluctuations in the stock market.
c) If you have a very high mortgage payment, think about living in a regular gated community, not in a "doctor's house". If your mortgage is paid for, then sell your mansion, buy a smaller home, and invest the rest.
d) Of course you drive a car worth over $75,000. You can get a nice ride for $40,000. Of course that will give you less prestige. Consider reducing the number of cars you own to two. It will reduce your INSURANCE bill, which I am sure you hate.
d) As a specialist you must earn over $200,000 a year, probably closer to $500,000. PLEASE
CORRECT me if I am wrong.
e) Consider having your spouse do more than appear at charity events as the "doctor's wife".
f) Consider spending less than a $1,000 a month on eating out.
g) Cancel your next cruise, unless someone else pays you to take it.
Then you can have a better "quality of life.
Before you attack me in response, kindly mention your gross and net income.
You had two d's, so I will include them each:
d. I am a specialist too. I make 150,000/yr and still have 300K to pay back for my schooling. No consulting.
d. I spent 13 years earning < $3000/month for 100+ hours/week. This is less than minimum wage.
d. I drive an old Honda Accord. My husband drives a '95 Passat (he is also a specialist).
c. We cannot afford a home now, with two kids. We rent.
e. I am the doctor's wife and the doctor.
f. I have eaten out 3 times in the past 3 years
g. Never been on a cruise. One vacation in the past 3 years.
-We have two small children who go to public. school.
a. Electronic record keeping is often NOT in the best interest of pt. care. Unless medical records can "talk" to each other...get lab results etc, they are worthless.
-I am sorry if you have been disappointed in your medical care. I'm sure you spend enough money. But there are wonderful doctors who have given up their twenties and thirties to give you stellar care. Please write to your congress person regarding the terrible health care system we have now.
h. I expect your insurance company CEO is driving a lovely car.
Most are now EMPLOYEES. Corporate managers control much of a doc’s life – such as patient QUOTAS. Since managers must be cost-centric, there may be less support, increasing clerical loads on physicians. (Since support staffs often do NOT report to docs, they are often able to unload many tasks to the physicians, especially in unionized situations.) Some new information systems add HOURS of work each day to the docs’ workload, turning docs into data entry clerks. (Generally true when management selects systems without doc input, genuine Dilbert situations. Systems that work just fine for non-docs in a hospital may be disasters for physicians themselves.) Docs pay is mostly stagnant – given typical long hours, some specialty nurses may earn a higher wage on a per-hour basis than primary docs, with a much shorter work week and no real legal liability. Specialist docs often disrespect primary care – they'll dump their own followup work on the primary docs if they can. In corporate arenas, primary care docs generally are at the bottom of the pecking order, with specialists ruling the roost. Docs can be penalized if their patients do not do well - EVEN given that many patients will not follow docs’ orders (I suspect patient ignorance and stubbornness may be the greatest underreported threat to the entire health system). I doubt many docs will recommend a primary care specialty to their children.
Such suffereing that doctors endure. Maybe they should consider being teachers, soldiers, lawyers, bus drivers, engineers, artists, chefs, accountants, professors, social workers, politicians, architects, or dentists. Oh, I FORGOT, no job pays as well as being a doctor.
How they do suffer, having to conform to the rules of a workplace, having to deal with people they can't fully control, having to deal with an ignorant public, having to deal with arrogant collegues who think they are better than they are.
Oh, I FORGOT, that seems to apply to every job there is.
Somehow, people have missed the above message and have used this board to attack primary care doctors as greedy, lazy, useless, a barrier to actually getting good care. There is no other specialty that does what we do (and yes, general internal medicine and family medicine are specialties and require multiple years of residency training after medical school). People who try to get care for their multiple chronic conditions from multiple subspecialists end up with crappie care. Even subspecialists would agree with that. Cardiologists, pulmonologists, gastroenterologists, etc. don't have the interest or the skills to diagnose broadly across disciplines or to manage multiple, often competing, problems.
Technology changes things. I am a mechanical engineer. We used to have something called draftsmen that did drawings for us. Now we have CAD software that lets us do our own drawings. The same with Medicine. Expert software systems can do a great job at diagnosing symptom because the patient can spend much more time with the software than they can a doctor that is constantly checking his watch so he can make it to the next patient. Now if there is something potentially serious the software would make the recontamination to see a specialist.
I am a white American of European descent. (Such disclosures seem to be de rigour these days).
I have been on Medicare Advantage for two years.
The first year I paid the Medicare Advantage provider $96 that was taken directly from my Social Security check. That included Part D.
This January I switched to a new Medicare Advantage Provider and I pay NO PREMIUM whatsoever. Nothing is taken from my check.
The Reason:
Almost all of the Internists provided by my new Medicare Advantage provider are foreign born. My new provider is of Maylay descent and was educated in a Caribbean medical school. He did his internship and residency in New York. He is Board Certified in both Internal Medicine and Geriatrics.
In addition he is thorough, very comptent, and unlike many American trained doctors, a very pleasant person.
I had to change doctors to my new policy. My old doctor, who by the way was born and educated in Mexico, would not take the lower reimbursement provided by my new Medicare Advantage Provider.
My old doctor was very good, but he moved into a much more expensive office, and needed more money that the new office. He also drives a nice sports car. He was, also an excellent doctor.
Allow in those foreign born doctors who meet All of our requirements. It will be good for them, good for America, and keep medical expenses down.
Oh yes, no attacks please. See my above post about compensation. Just trying to be honest and helpful.
I agree we need to return the medical profession to the model we have used througout the history of our country.
We need to do what we have done throughout our history. Encourage QUALIFIED immigrants who meet all of the requirements for the job. Pass all license requirement, including background check, and language proficiency.
We allow qualified physical therapists into this country, because we have a shortage. Why not physicians?
The answer is the American Medical Associaltion. That is one cartel (read union or anti-competitive conspiracy) that needs to be busted.
I don't think every problem can be solved with importing cheaper labor. That can be part of a solution of course, but it doesn't address the underlying issues that have caused the shortage in the first place.
maybe you only listened to its supporters, opponents have long predicted a shortage of doctors especially with the expansion of Medicaid to include 30 million more people
The reason medical students go into specialties instead of primary care is because reimbursement is so much higher. That is a result of the Medicare reimbursement schedule which pays highly for procedures but not consultations. Private insurance adopted the same schedule. It has been a major driver of healthcare costs as providers adapt to maximize revenue.
Just another success of socialized medicine which liberals now want to extend to the rest of us through ObamaCare
The solution: change reimbursement to pay for an episode of care instead of pieces of it, pay according to outcomes, incentivize patients to seek out the most efficient and best providers, a good generalist would do well in such a system
Unfortunately, that system is not ObamaCare
there is no reason why the sickest would be denied care in such a system
there premiums would be higher but they would receive greater subsidies
re banks, its not their responsibility to "look out for the good of society" but to make profits
any medical student who was being "squeezed" could take his business somewhere else, that is how competition works and we neeed to extend it to healthcare too
Some people run with the 'docs want more money = greed' argument... but really it is basic economics. We don't expect other professions to do their highly skilled labor at a loss.
Medical-loss ratio is the key, in my opinion. Outcome-based care reimbursement has a TON of holes in it, especially for certain specialties.