Primary care physicians – general internists, family practitioners, general pediatricians – are on the verge of extinction. With pressures pushing young physicians toward specialization, a primary care crisis looms. Other workforce shortages, in general surgery and nursing, are also on the horizon.
Health reform has reinvigorated a passion for primary care – at least in the eyes of health care payers like Medicare. As the example of Massachusetts demonstrates to us, improving health coverage will only lead to problems in accessing health care if there are an insufficient number of clinicians prepared to care for these new patients. The clarion calls for a looming primary care shortage are coupled to similar calls in recent years for a shortage of general surgeons and registered nurses. Indeed, the current health care workforce may be insufficient to care for the millions of new patients if Congress health reform plans succeed. However, one could argue that in a nation where patients already wait in queues for routine doctors appointments, it appears that the healthcare workforce is stretched beyond capacity.
The articles discussed in this review point out several important facts:
- general surgeons have been on the decline (from about 8% of the physician population in 1975 to 4% in 2005);
- the nursing workforce is aging, is woefully underrepresented by men and Hispanic individuals, and its growth is plateauing;
- US medical graduates are shunning primary care, (only about 42% of family practice residencies are filled by US medical graduates, down from 72% a decade ago).
The problems facing these distinct health care workers arise from multiple causes and will require unique solutions. For nursing, processes which make each registered nurse more efficient in his or her daily tasks coupled with a greater reliance on nurse assistants and licensed practical nurses will allow the current RN workforce to stretch to meet the demands of an aging society.
For surgeons, where only 30 percent of the 1000 new surgeons annually produced by the nations residency programs will stay generalists, the crisis is even more pressing.
For primary care physicians, whose incomes are lower absolutely and are growing slower annually than other physicians, much of the solution may be financial. However, one of the most serious problems befalling primary care is the lack of time they are able to spend with an increasingly-complex patient population.
Many authors agree that the backbone of our health care systems – general practitioners (to include general surgeons) and nurses – are endangered. Unless we can preserve them, or find adequate substitutes, health care for many Americans will suffer.
Amid the concern for making health care more affordable for those that already have it and available for those without it, ensuring an adequately sized and trained healthcare workforce is paramount. Each of the three health reform bills currently before Congress address the health care workforce. Some provisions attempt to better compensate primary care and general surgeons – thereby making them more appealing to new entrants. Other provisions expand opportunities for nursing and the National Health Service Corps. These efforts are needed, but a new model of care may emerge from the decline of available providers. Midlevel practitioners (physicians assistants and nurse practitioners) will likely assume a larger role in primary care in the coming years. Sadly, the classic Marcus Welby style of doctor is disappearing. In order to prevent the extinction of primary care, physicians must start learning how to be better leaders, managers, and business persons. As for nurses, tasks formerly in the scope of practice for RNs are being reassigned to lesser trained individuals. But as an important resource for patients and a critical component of patient safety, nurses will continue to thrive. Medicine will look dramatically different in 20 years: a medical home might be a retail clinic; doctors might only see you for emergencies, surgeries, or specialty consultation; and hopefully clinicians will be compensated for how well they keep you healthy, not just how often they fix you when you fall ill.
Cedric K. Dark, MD, MPH