Primary care physicians are critical; adding just one primary care doctor per 10,000 people decreases annual deaths by 5.3% and reduces health care costs. Yet of the 800,000 practicing physicians in the United States, only 32% practice primary care, and this number is expected to drop. It is estimated that a mere 18% of current medical school graduates will go into primary care, and that by 2016 the number of retiring primary care physicians in America will exceed the number entering the field5. This is –to put it mildly—concerning. The situation seems to be the result of an unfortunate mismatch between supply and demand that is playing out in American medical schools.
Demand for primary care is on the rise. The silver tsunami, the vast wave of Baby Boomer retirements that began in 2011, is expected to continue at a rate of 10,000 per day until 2029, tallying up a total of 80 million retirees in less than 20 short years. This includes doctors, and they are leaving behind an increasing number of empty posts throughout the US healthcare system. The Affordable Care Act (ACA) will also ratchet up demand for primary care physicians by extending insurance coverage to an additional 32 million Americans by 2019. However, even without the ACA, the national primary care workload is expected to increase by 29% between 2005 and 20255.
On the other hand, the supply of primary care physicians is diminishing. Starting in 1980, a series of reports predicted a physician surplus in the US4. As a consequence, while the American population continued to increase, the number of students graduating from medical school remained essentially static from 1975 to 2000 (between 15,000 and 16,000 per year)5. It’s now expected that the US will have a 30% physician deficit by 20201. In addition to this bottleneck, a compensation gap emerged, with the average income for specialties far outstripping primary care. The average income for specialties has increased 37.5% since 1998, while the average income of primary care physicians only rose 21.4%, not even enough to keep pace with inflation5.
It is utterly unsurprising that doctors are looking for appropriate compensation and financial security. The demands of their profession are herculean, and the trials start early. Admission to medical school in the US requires a bachelor’s degree, admission testing (the infamous MCAT), medical, leadership, and volunteer experience, as well as an excellent grade point average, personal statement, and letters of recommendation. Once in medical school, students receive an average of 21 hours of direct instruction per week for the first two years. In the third and fourth years, which are dedicated to clinical clerkships, that number jumps to 38-47 hours of direct instruction each week. To add insult to injury, after this fairly arduous education, the average medical student in the US will graduate with more than $100,000 in debt2.
And their education is actually far from over. In the final year of medical school, students apply for positions in one of the 4,100 graduate medical education (GME) programs for further training. They can expect to spend the next 3-7 years as a resident in a GME, after which they can choose to gain additional training in one of the 4,800 specialty fellowship programs in the US. Residents and fellows are wildly overworked. Until 2003, there were no restrictions on resident work hours and they routinely worked 80-100 hours per week. Thankfully, that has changed. As of 2011, first year residents work (a still ludicrously high) maximum of 16 consecutive hours, and no more than 24 consecutive hours in subsequent years. Residents take board certification exams, which must then be retaken every 6-10 years. Typically, physicians are also required to log 50 continuing education hours each year2. In medicine, there is truly no rest for the weary.
Medical schools are trying to fill the gap. Since 2005, 75% of medical schools have undergone curriculum reform3. With the aim of expanding the medical student body by 30% (5,500 students per year) to match the projected physician deficit, many schools are increasing enrollment, and 12 new medical schools are under construction. This will have a profound effect on medical education. Teaching more students will demand greater numbers of faculty, more facilities and equipment. Clerkships may shift from the classic academic model to a preceptorial model, where students are assigned to one clinician and accompany him/her throughout the day. It could negatively impact student-professor relationships, and the heightened demand for teaching may reduce professors’ ability to simultaneously run robust research programs. There is also some concern that the applicant pool will be exhausted and raising enrollment will decrease the quality of applicants.
Several other possibilities are also being pursued. There are initiatives for incentivizing (paying more for) primary care. Primary care may come to rely more heavily on non-physician practitioners (NPP), physician assistants and nurse practitioners, the fastest growing sector of primary care. NPP are also more likely to work in underserved areas and with underserved populations. The growing need may also be met by international medical school graduates (IMG), foreign physicians who practice in America. In 2011, IMGs accounted for 40% of primary care residency positions in the US5.
Increasing the number of primary care physicians is essential to the success of both the American healthcare system as a whole and the Affordable Care Act (ACA). Simply put, people need doctors. Even if it succeeds in its sweeping mission to radically expand insurance coverage, the ACA will fall flat if there are no primary care doctors accepting new patients5. Closing the 30% physician deficit while balancing specialization with primary care will be no easy task, and the stakes are high. The medical education system will bear the brunt of this challenge; let’s hope it’s a quick study.
- Bonaminio, GA, SB Leapman, JJ Norcini, RM Patel, & DM Elnicki. (2008). The educational realities of increasing medical school class size. Academic Medicine, 83(10):S101-S104.
- Dezee, KJ, AR Artino, DM Elnicki, PA Hemmer, & SJ Durning. (2012). Medical education in the United States of America. Medical Teacher, 34:521-525.
- Drake, RL. (2014). A retrospective and prospective look at medical education in the United States: trends shaping anatomical sciences education. Journal of Anatomy, 224:256-260.
- Gevitz, N. (2009). The transformation of osteopathic medical education. Osteopathic Medicine and Medical Education, 84(6):701-706.
- Schwartz, MD. (2011). Health care reform and the primary care workforce bottleneck. Journal of Gernal Internal Medicine, 27(4):469-472.
Image source: http://blogs.einstein.yu.edu/a-sleep-doctors-rx-for-medical-students-and-the-walking-exhausted/