Saturday, May 28, 2022

The PCP - soon to follow the dodo and carrier pigeon?

The Institute of Medicine defined Primary Care in 1996 as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Whether the focus is on the individual or the community, good access to primary care is associated with more timely care, better preventive care, avoiding unnecessary care, lower costs, and lower mortality.

Most experts feel that in an ideal medical care system, about half of physicians would be in the primary care fields of family practice, general internal medicine and general pediatrics. Where does the U.S. stand? About a third of American physicians now practice primary care, but fewer than a quarter of recent medical school grads chose a primary care specialty, and the Council on Graduate Medical Education projects this number will soon drop to under 20%.

Why the disconnect between what the nation needs and what we have? There are many possible explanations, but as always, “follow the money.” According to the Association of American Medical Colleges, the average medical school debt for 2021 graduates was $203,062. It will not shock you to learn that specialists earn more than primary care doctors, but the magnitude may be surprising. In 2020, the average salary of primary care physicians was $260,000 and that of all specialists $368,000, 42% more. When broken down by field of specialization, the disparities are even greater. In 2021, the average family medicine specialist earned $255,000; the average orthopedist $$557,000 and the average cardiologist $460,000.

When a newly minted MD looks at their debt load, which is more appealing: pediatrics, with a 2020 starting salary of $196,000 or dermatology, where the average is $394.000? In addition to the obvious fiscal push toward specialty care, there are less-easily quantified but important non-monetary factors. Medical students are exposed predominantly to academic specialists and sub-specialists during their clinical rotations, and the message is often “you are too smart for primary care.” When role models are specialists who know everything there is to know about a limited field, that becomes an easy position for the student to envision for themselves.

Another factor is the “burn-out” that many students encounter during their rotations. All physicians deal with ever-increasing paperwork demands, but the burden is disproportionately heaped on primary care physicians. A recent survey asked doctors in different fields to estimate the hours they spent per week on paperwork. The range was from a low of 10 hours for anesthesiologists and ophthalmologists to 18.9 for Internists. It is the PCP who must spend the most time feeding the maw of the electronic medical record (EMR) with meaningless clicks to document items that have minimal benefit to the patient.

What is the way out? The huge discrepancy in earnings must be narrowed. A model that appeals to PCPs is the “concierge” model, which allows them to see fewer patients, give better quality care and earn more. Unfortunately, this is not available to most Americans. The rate setters must give more reward for thinking and talking to patients and less for procedures. The hundreds of “quality measures” doctors are required to document must be limited to those that have been proven to improve outcomes. Less time spent “treating” the EMR will allow more time spent with the patient. Students need more PCP role models during medical school.

In the meantime, if you have a good PCP, be grateful.

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  1. I agree. The culprit is not money per se, because in a free market, compensation would follow supply and demand. More people entering the specializations would push the compensation down. That assumes that, as your article suggests, the number of people available to take either position (PCP or specialist) is the same. If fewer have the ability to be specialists, then there will be a premium paid for employment as a specialist.

    But if it's the same pool of people choosing one path or the other, a free market would respond to over- or under-supply by lowering or raising the compensation-differential, respectively.

    Isn't it clear that the cause of the problem (especially with the needless paperwork and red tape) is government controls?

  2. Unfortunately, the medical care system is unlike traditional "markets", in that there is a wide disparity of knowledge between patients ("consumers") and doctors ("providers"). While people go to a car dealer expecting to negotiate, they usually go to their doctor asking what to do.

  3. Yes, like most other markets in America, from sugar to baby formula, the problem is too much of the wrong kind of government control. Government control is supposed to protect citizens and small businesses, to support healthy communities. But the corrupt US government mostly controls for the benefit of large corporations. Other developed countries get better health outcomes for half our cost because their governments structure and pay to benefit their citizens. They figure out how many primary care doctors are needed, gather the funds (with public approval) and hire them. There people have free access to health care (no bills, no insurance) and plenty of primary care physicians to take care of them and manage it well. Big corporations, especially insurance and pharma companies, have bought our reps to prevent that from happening here.

    For example, our government has killed over half a million of its own citizens through opiate addiction, by bowing to corporate pressure and relaxing the clinically sound controls that protected our citizens. Good medical practice came first in every other developed country, so this corruption carnage didn’t happen anywhere else.

    You could have also mentioned passenger pigeons, Ed. Carrier pigeons were always specially bred, and still exist, although in smaller numbers. We remember them especially today, as so many gave their lives in invaluable wartime service. The passenger pigeon used to be prolific, but is now extinct, due to too little government control.

    If we don’t quickly vote for reps who protect the interests of our community as a whole, we will complete the destruction of the climate and biodiversity our species depends on for the basic necessities of life. I’m not political, just a scientist and engineer. Currently, this primarily means getting rid of republican reps, who are more deeply and widely corrupted.