Primary Care Is In Crisis. Here’s One Way To Fix It.

04/18/2017 01:15 pm ET
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Every fall, medical students in their final year of study pick a specialty. I’m a professor at a medical school, and these weeks were often frustrating for me. The same thing always seemed to happen: the “status” specialties – orthopedics, dermatology, neurosurgery, etc. – would snap up the most promising and talented students.

I’m a primary care doctor, a generalist who treats patients for everything from broken bones to diabetes to depression. Our specialty isn’t seen as prestigious in the same way that being a brain surgeon is. When students picked other specialties, it didn’t just bother me because I think primary care is a wonderful job. There’s also a severe shortage of primary care in this country. By 2020, the U.S. will face a deficit of up to 90,000 primary care doctors. Right now, nearly one in five Americans — 60 million people — don’t have access to a primary care doctor. The PCP shortage hasn’t always existed. In 1965, about 70 percent of doctors in the United States were primary care physicians, while 30 percent were specialists. Today that ratio is reversed.

This is an unhealthy state of affairs. Research has found that increasing the number of primary doctors has a positive effect on a community’s health. One study, a review of other research on the subject, concluded that every additional primary care doctor per 10,000 people was linked to a five-percent decrease in the mortality rate. Nationwide, a decrease of this magnitude would mean 139,000 fewer deaths per year. Higher numbers of primary care doctors in a community were associated with a range of improved health outcomes, including longer life expectancy, healthier newborns, and lower death rates for cancer, heart disease, stroke, and infant mortality.

In large part, a primary care physician, or PCP, is a first-line health warning system. Without a PCP, people often don’t stay on top of their blood pressure; they allow their sugar to spike; they miss the lump that turns out to be a cancerous tumor. These conditions can turn into life-threatening health problems — heart attacks, strokes, advanced cancer or other issues that might have been averted with regular check-ups.

The shortage is also expensive. Our health care system spends hundreds of millions of dollars dealing with these serious and often very preventable medical emergencies. Early detection and preventive treatment generally save money: to take one example, a PCP visit and a prescription for blood pressure medicine cost much less than treating a heart attack, which often involves an ambulance ride, emergency room visit, a stay in the ICU and months of rehab (if things turn out well).

PCPs are especially important now, in an era when patients are flooded with digital medical information. (Who among us hasn’t paged Dr. Google after a mishap, or when your child has a fever or some strange blotches?) One of the PCP’s key roles now is to act as a filter, separating credible medical information from false, sometimes dangerous, advice.

My 30-year career as a primary care doctor has had its frustrations: Sometimes I can’t spend as much time as I want with patients, dealing with insurance companies can be difficult, and not every patient follows my advice. But I love what I do. I have longstanding personal relationships with many of my patients, and sometimes I make a real difference in their lives.

Unfortunately, most medical students don’t share my view. Many dream of becoming emergency room physicians, dermatologists and orthopedic surgeons, lucrative specialties with more cachet. Higher income is especially important for the many med students who graduate owing tens or hundreds of thousands in student loans.

I’ve come to realize that this really isn’t their fault: Our medical schools, and our health care system, aren’t doing enough to persuade them to consider this option. 

Five years ago, I, along with a few of my colleagues, decided to act. Our idea was simple: We thought that if we could expose students early to primary care, they would realize how rewarding it can be. As obvious as this sounds, few, if any, medical schools in the country do this. So we created a program to reach our med students at a key inflection point, before they made their specialty choice.

Our program, the Primary Care Track (PCT), connects first-year medical students with a mentor who’s a PCP. Throughout medical school, students and mentors meet regularly, and in the summer, the students work with the doctor seeing patients. Students work where there aren’t enough PCPs, either in underserved rural areas of Maryland or in inner city Baltimore. By shadowing doctors, PCT students learn first-hand what primary care really means, for both patients and doctor, and most find the relationships they form to be deeply gratifying.

They learn that medicine is as much about listening and connection as it is about technology and technical skill; they learn that it is about understanding the whole person, not just a particular injury or illness; and they learn the value of becoming part of a community. This sense of community is very powerful. I’ve known some of my patients for decades. I’ve seen them through physical and emotional crises, and this shared experience creates a strong bond.

So far, the program seems to be a hit. A third of the school’s 600 or so medical students have joined; of the PCT students graduating this June, 75 percent are going into primary care residencies, the next step to becoming a full-fledged PCP. Many of our PCT students tell me that before they joined the program, they didn’t even know what a primary care provider really did.

The next step is to expand. We think our approach can be used at medical schools all over the country. Our program can be a model: Every state and region has areas that don’t have enough primary care providers.

The primary care shortage is a complex problem, and it will require a range of solutions, from exposing students to primary care even before they enter college, to reducing student debt so that there is less pressure to choose high-income specialties. But our program can be an important part of this effort. We believe that when given a chance, many students will embrace the specialty. After all, it represents the core of why many  doctors go to medical school in the first place: to provide essential care to those who need it most.

Richard Colgan, MD, is a professor of family and community medicine at the University of Maryland School of Medicine in Baltimore, Maryland

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