As a general internist who has been on the front lines of adult primary care for over twenty-five years, it is clear to me that we are living witnesses to a major and rapid transformation in medical care delivery. When Paul Starr published The Social Transformation of American Medicine in 1982, his work covered gradual changes over a 200 year period. We now live in a fast paced world where significant changes occur on a daily basis. There are multiple moving parts to this process that I will discuss in this brief essay.
First, fewer United States medical school graduates are choosing to enter the workforce to provide primary care for adults. Medical schools like to brag that they are “turning out” physicians that will replete the rapidly dwindling supply of general internists. The numbers they provide are misleading and typically include many who will choose to sub-specialize, become hospitalists or change their field. Why this is happening is a topic for an entirely different discussion. But it is clear that many of “the best and the brightest” in our medical schools are choosing specialties such as ophthalmology, radiology, dermatology, and emergency medicine.
The vacuum created by the decreased number of U.S.-trained physicians entering adult primary care is being filled by physicians in other specialties, mid-level practitioners, urgent care centers, and physicians trained in other countries. Other specialties, particularly internal medicine sub-specialists and family practitioners are filling this void. In my experience in Worcester, Massachusetts I find that cardiologists are very eager to manage patient’s non-cardiac medical issues such as hyperlipidemia, peripheral vascular disease, diabetes mellitus, hypertension and cerebrovascular disease. Family practitioners are finding that they have ample opportunity to expand into geriatrics (i.e., patients 65 and older), a field that until now was generally reserved for general internists and geriatricians.
Nurse practitioners and physician’s assistants are now licensed to prescribe controlled substances, and have attained independent status in twenty states and counting. By independent, I mean they do not require the supervision of a licensed physician. The Massachusetts Medical Society has testified in front of the state legislature their strong belief that it is imperative to maintain physician supervision of mid-levels if quality of care is to be assured. One would hope that our government officials and the public would demand this. But other factors are combining to make this less and less likely. There are just not enough general internists and family practitioners to meet patient demand due to problems with the geographic distribution of physicians, an overall increasing population and the “graying” of the population.
While the number and size of medical schools has slowly increased over the last twenty years, it does not compare in scope to the new programs for mid-level practitioners that have opened. One of the most popular choices for mid-levels is primary care, and they are filling these vacant slots with a vengeance.
Another phenomenon is the revolution in urgent care centers throughout the country. Patients want access to care, and they want it now. Primary care physicians do not have adequate access (days open, hours open) and urgent care facilities are filling this void. Patients appear very willing to sacrifice the advantages of “continuity of care” for the sake of convenience. It should be noted that this revolutionary change is in some instances being facilitated by the very organizations (i.e., independent practice associations) that purportedly are there to support primary care docs. It is particularly onerous that urgent care centers are picking off the “low hanging fruit” — sore throats, cuts, burns, UTIs that are the “bread and butter” of the primary care office.
The shortage of physicians providing adult primary care is also being filled by physicians trained in other countries. There is nothing wrong with this per se. In fact, foreign-born and trained physicians have made a huge and important contribution to the U.S. medical community for many years. My concern is that foreign-born physicians may not be able to connect with the patient in the primary care setting. It is one thing to deliver anesthesia, or perform an endoscopy or autopsy. It is quite another thing to clearly and effectively communicate with the patient and their family when they are faced with difficult decisions.
The pros and cons of the electronic medical record are beyond the scope of this essay. However, imagine the hassle for the primary care physician who desires to move their practice to another local medical group that uses a different EMR. Medical records found on one EMR are not readily transferable to a different EMR. The transition from one EMR to another EMR is onerous and a colossal waste of a physician’s time. This creates “job lock” discouraging physicians from moving their patients to a more hospitable environment.
What is driving these changes? The answer is the runaway costs of health care and an increasing population of seniors who require a significant increase in the intensity of care they receive from the medical profession. Corporate America and the medical-industrial complex have responded to this challenge by harnessing the least expensive resources in place of physicians and urgent care centers in place of primary care physicians regardless of how this impacts the quality of care provided. Corporations can pay mid-levels less money and have more of them. It is unfortunate that the board-certified adult primary care physician is not properly valued by the health care system. We are simply widgets who can be manipulated at the will of the corporation. The academic medical centers will build huge and expensive palaces for their orthopedic surgeons leaving their primary care docs the leftovers, like the fifty-year-old building with the bumpy parking lot.
Do not think our medical students miss the aforementioned priorities. They desire to work in a pleasant environment and be paid a fair wage for their efforts. The result is that the least competitive, lowest performing students are often the ones that enter the field of adult primary care. There is an old adage that you get what you pay for. America look out.
There are some, such as the American College of Physicians, whom believe that the patient-centered medical home will be the savior for adult primary care. But I am not aware of any evidence base that supports this notion, nor am I aware of increased physician satisfaction in this practice model. And what do our medical students and graduate trainees think about the medical home? Have we asked them? I will await additional research before I finalize my opinion on this new trend.
I sincerely hope that our government, academic medical centers, and physician leaders will recognize these changes and do their best to insure that the quality of patient care is not lost in the rush to meet an ever increasing demand. The public and the medical profession deserve more. We need, as a country and a profession, to have a public conversation to decide our priorities for this new era of health care.
By the way, if you currently are fortunate to have a general internist or family practitioner that you like, let them know it. And remember when they retire or change specialties, you may not be able to find someone to take their place.
Frederic H. Schwartz is an internal medicine physician.
