"I need to see a doctor." These six words have been written into our programming as modern humans.
We wait in line at the clinic. We make an appointment. We know instinctively that this is the one person to see who can check out our health, fix us up when it can be done, or design a treatment course when we are facing complicated health issues.
But that programming no longer works: There are not enough doctors, and, even if this goes against what we've been trained to think, seeing a physician is not always the best medical choice.
The shortage of primary care physicians is one of the larger trends that made health care reform necessary. Some 56 million Americans don't have a regular doctor. And when you open up more health care access, that scarcity increases. When Massachusetts enacted universal coverage it exacerbated the primary care shortage — something that is expected to occur nationally when some 30 million who have been uninsured seek regular care.
"By 2025, the wait to see a doctor could get a lot longer if the current number of students training to be primary care physicians doesn't increase soon," according to a new University of Missouri study. Jack Colwill, professor emeritus of family and community medicine in the MU School of Medicine, and his research team found that the U.S. could face a shortage of up to 44,000 family physicians and general internists in less than 20 years.
One of the factors complicating this issue is age. "Typically, older adults seek care from generalists nearly three times each year, double the rate of adults younger than 65," Colwill found. That means the number of doctor visits will increase by 29 percent by 2025 while the number of family physicians will increase less than 5 percent.
Last month the New England Journal of Medicine published one practice's 'êsnapshot'ê of the work required for primary care. "Primary care practices typically measure productivity according to the number of visits, which also drives payment," wrote Richard J. Baron, M.D. "Work that does not involve a visit from a patient is invisible to those who support and purchase primary care."
Dr. Baron used electronic medical records to chart that invisible care. "At a time when the primary care system is collapsing and U.S. medical-school graduates are avoiding the field, it is urgent that we understand the actual work of primary care and find ways to support it," he wrote. "Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure."
I think that radical change has to start within each of us, the patient, as we rethink what we need from a health care system. We should ask, and often, what do we expect? And, how do we pay for that?
I also think the education angle is interesting. Higher education is under incredible financial pressure, at the very moment we need more from those same institutions. Once again there is that same need for radical change in practice (medical and nursing schools) design and payment structure.
Just look at what'ês happened to primary care training. A generation ago about half of all medical students picked general medicine over a specialty practice; today's it's only about 30 percent. In the larger health care system the main reason for that disparity is wealth. Specialists earn far more than general practioners; a gap of more than $100,000 per year.
The Patient Protection and Affordable Care Act addresses this shortage with several provisions. For example bonuses will be paid for Medicare and Medicaid for primary care practices and repayment of student loans for underserved areas with the National Health Service Corps.
The Indian health system represents one of those underserved areas. The Congressional Research Service recently reported: "The IHS has a high vacancy rate in many of its health professions, 20 percent for physicians, dentists, and nurses, for instance, as of December 2008." The new law opens up a number of options for American Indians and Alaska Natives interested in health careers: scholarship and loan repayment programs; incentives designed to encourage health professionals to work in Indian health; funds for continuing education; and new demonstration projects using students. There will be new grants for "teaching health centers" and for expanding or creating primary care residency programs. The law also allows for newly accredited or expanded primary care residency programs.
But even then will that be enough? How long will it take to fill those pipelines? The answers might not come from a doctor. More on this topic next week.