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Join William E. Fox, chair-elect of the ACP Board of Regents, as we delve into the pressing issue of physician workforce shortages in primary care. William sheds light on recent alarming statistics, including the declining interest among medical students in pursuing careers in primary care. We explore the factors contributing to this trend, such as low reimbursement and administrative burdens, and discuss potential solutions proposed by leading health care organizations. Don’t miss this insightful discussion on the future of primary care and the actions needed to ensure access to quality health care for generations to come.

William E. Fox is chair-elect, ACP Board of Regents.

The American College of Physicians is the largest medical specialty organization in the United States, boasting members in over 145 countries worldwide. ACP’s membership encompasses 161,000 internal medicine physicians, related subspecialists, and medical students. Internal medicine physicians are specialists who utilize scientific knowledge and clinical expertise for diagnosing, treating, and providing compassionate care to adults, spanning from those in good health to individuals with complex illnesses. Stay connected with ACP on X @ACPIMPhysicians, Facebook, LinkedIn, and Instagram @acpimphysicians.

He discusses the KevinMD article, “Why we all need to care about the primary care physician shortage.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome William Fox. He’s an internal medicine physician, and he is chair-elect of the American College of Physicians Board of Regents. Today’s KevinMD article is “Why we all need to care about the primary care physician shortage.” William, welcome to the show.

William E. Fox: Kevin, thank you so much for having me.

Kevin Pho: So we’ll talk about your article in a little bit. First off, just briefly share your own story and journey.

William E. Fox: Well, as you said, I’m an internal medicine physician. I practice primary care in Charlottesville, Virginia. I’ve been interested in primary care, or ambulatory care, since medical school, and actually one of my biggest goals in going into a primary care field was to spend a portion of my career caring for the underserved populations. And I had an opportunity to do that through the National Health Service Corps in a rural part of Virginia.

And after a number of years of doing that, I decided to do something that’s not done a lot anymore, but that is to open up an independent primary care practice. We now have three physicians in our small independent practice, and we are entering our 21st year in business.

Kevin Pho: All right. So like you, I’m a primary care internal medicine physician myself, and as you know, primary care gets kind of a bad rap out there. There’s just so many negative news stories about primary care and the obstacles that you and I face every single day. So against that backdrop, what keeps you going? What gets you to your clinic every day and keeps you going in primary care?

William E. Fox: Well, internal medicine is a wonderful field in general, and internal medicine is often thought of as the doctors that deal with the most complex, difficult situations. In fact, sometimes internal medicine doctors are called the detectives of medicine.

Primary care is a big portion of the internal medicine field, and in addition to the challenging cognitive work of primary care, it’s the relationships with the patients that you develop over years and in fact decades that keep me going every day in the office.

Kevin Pho: Now, I’m going to put you on the spot here. Can you think of a hypothetical, or it could be a real patient encounter, that really illustrates some of the joys of internal medicine primary care practice?

William E. Fox: Yeah, I mean, there are many of them. I will have to search my data banks a little bit just to come up with one. But what I love is, after I’ve been taking care of a patient for maybe several decades, they want the rest of their family to come to me. And that shows that there’s significant trust that we’ve built up over so many years, and they trust the care that I’m giving their family.

Kevin Pho: All right, so let’s talk about your KevinMD article, “Why we all need to care about the primary care physician shortage.” We see countless headlines in the news about the lack of access, especially to primary care. It takes, in my area, a few months for patients to get an appointment with me, and I’m sure it’s the same issue facing primary care physicians across the country. Now, tell us what this particular article is about.

William E. Fox: Well, at the time that we’re recording this, Kevin, match day is just around the corner. And match day is a wonderful event, and it really validates all the hard work that our medical students have been doing over the past four years of their training, and helps them move along their path of personal and professional ambition and goals. And so we really should be celebrating all the success stories that are going to come out of match day coming up.

But at the same time, I thought we should really be looking at the overall health care workforce and infrastructure in this country. So I kind of used match day as an opportunity to take a look at the bigger picture, if you will.

There are certainly some challenges in our health care workforce, especially the primary care workforce, and I think it would be interesting to some of your audience members that there’s no coordinated federal strategy when it comes to physician workforce, even though it is so vital for our health care infrastructure, and even though health care, as you know, occupies almost a fifth of our entire economy. So that was kind of the genesis of the article.

Kevin Pho: So give us the context. What is the current state of the physician workforce today?

William E. Fox: Yeah, we are facing significant shortages in all manner of physicians, and there are legitimate organizations like the Association of American Medical Colleges that have been talking about these shortages for years. In the realm of primary care, there’s an expected shortage of almost 50,000 physicians by the year 2034.

Now, for me in my own practice, and I think a lot of physicians, this probably seemed like some abstract number for many years. I don’t think it really impacted us in any meaningful way. But since the pandemic, and since the stress that the pandemic has placed, I think, on our infrastructure, we are now really beginning to see significant challenges with access. And as you just said, it takes people months to be able to get an appointment, not just with me, but whenever I need to send my patients to other physicians, it’s routinely taking months now. And we’re seeing that not just in primary care, but especially the cognitive specialties, like infectious disease, rheumatology, endocrinology, neurology.

Kevin Pho: So what does that mean specifically to patients? If they have to wait months to see a primary care physician, or it takes months for you to refer them to a specialist, what does that mean to patients themselves?

William E. Fox: Yeah, I think the access issues are really important, because when you’re sick and when you need expert opinion and advice, you don’t want to wait for a disease to progress to the point where it becomes much more challenging, much more difficult to treat. Also, the wait causes a significant amount of worry in our patients. Not knowing about the treatment of their illness is very, very distressing on our patients. And so both for their physical health and mental health, it’s really important to get people to the care that they need in a timely manner.

Kevin Pho: So in your own practice, when you have to wait months to send a patient to a specialist, what are some of the things that you do to comfort patients during that time? Is there anything, any strings that you could pull behind the scenes? How do you deal with that delay in care that patients sometimes receive because of that shortage?

William E. Fox: Sure. Well, any internal medicine physician, as you know, has developed over the span of their career good connections with specialists typically. And so in those very significant cases, picking up the phone, making a phone call, asking for a favor, asking to get someone in sooner, is a good strategy. But you can’t use that in every instance, so you have to use those favors judiciously.

Other than that, internal medicine doctors, one of their superpowers is trying to reassure patients. But it does put a lot on internal medicine physicians, especially primary care physicians, to fill in the gaps and begin treatment even in an area where they may not feel completely comfortable, while we’re waiting for the patient to get into the specialist.

Kevin Pho: Now, in general, what are some of the root causes why there is such a physician shortage today and going forward?

William E. Fox: Well, there’s a number of reasons. Number one, our population is growing, and we have the graying of our population. This year, 2024, is like the peak year of the baby boom retirement age. More baby boomers are reaching age 65 this year than any other time in the baby boom generation. So patients are older, there’s more that medicine can do, so every patient is more complex.

On the flip side, more and more physicians are retiring, especially in primary care and cognitive types of practices, and fewer medical students are there to replace them. So we have relatively fewer numbers of primary care physicians entering the workforce to replace the ones that are leaving the workforce.

And part of the reason for all of this is that fewer and fewer medical students are choosing to go into cognitive fields and primary care fields. And we see this in the data, and this is something I refer to in the article. And the main reasons for that, I think, are the twin problems of relatively low reimbursement compared to other fields, as well as significantly high administrative burden.

Kevin Pho: So when you talk about significantly high administrative burden, what exactly are we talking about that medical students see?

William E. Fox: Yeah, I think it’s everything from, as simple and common as, prior authorizations on all the studies that you order and all the medications that you prescribe, to a significant volume of, say, telephone calls and email messages that need to be responded to on a regular basis.

Kevin Pho: And when you say the lower reimbursement in cognitive specialties, just to give that contrast, what kind of numbers are we talking about, in percentages, that medical students are seeing when choosing a specialty?

William E. Fox: Yeah, I don’t have specific numbers to give you now, except to say that there are significant disparities between specialties. Certain specialties can command annual incomes of, you know, the $900,000 range. The last information I saw from Medscape, which publishes salaries on an annual basis, I think pegged an annual salary for internal medicine kind of at the bottom of the list of doctors, about $230,000.

Now, I’ll say a word about that, because in America $230,000 is not a bad salary by any stretch, and I don’t want people to walk away from this making it seem that doctors are concerned about their salary overall. But the disparity between the specialties is what the learners have their eye on, and they see potentially lost income over many years, and that’s what determines their choice of specialty. And that’s important because that then gets back to, what is our health care infrastructure, and do we have the optimal workforce to meet the demands of our country?

Kevin Pho: And medical students, especially in the United States, face a significantly greater educational debt burden as opposed to the rest of the world. So can you talk more about that debt burden that sometimes may influence medical students’ decisions?

William E. Fox: I think it’s a really great point you bring up, Kevin. That is part of the calculus that determines what medical students are going to go into. The average medical student graduates with a debt of over $200,000 now, and that certainly is going to be something that they look at. How best can they repay that debt? And if they see higher paying specialties compared to lower paying specialties, that’s just one more thing that may turn them off from cognitive specialties or primary care.

Kevin Pho: So let’s talk about some potential paths forward. What are some solutions that the American College of Physicians are proposing to address this problem?

William E. Fox: Yeah, I think the good news is that we do feel this is a solvable problem. The American College of Physicians has certainly developed a whole series of policy papers over a series of years outlining potential solutions. The National Academies of Sciences, Engineering, and Medicine also recently put out a whole policy prescription to help with the primary care crisis. A lot of it does have to do with increasing reimbursement, changing pay models, and decreasing overall administrative burden.

These can include, Kevin, things as simple as Congress should stop decreasing or cutting pay for physicians year after year after year. I can’t remember a year in the last 20 years that I didn’t go up to Washington to advocate to my congressional delegation, please don’t cut our pay another year. And again, it’s important to understand that when we ask Congress not to cut our pay, it’s not because we’re looking for a raise for ourselves, but we’re also looking to give our staff cost of living increases, and pay for the cost of increasing rent, for example, or pay for the cost of increasing supplies, and just keep us whole. So that’s one simple example.

But in a more forward-looking way, we’re looking at newer payment models that take us away from our current fee for service system. We’re leaning heavily into team-based care models of care, payment systems where you are either fully capitated or have a blended fee for service and capitated model. And then of course, on the administrative side, we put forward many, many recommendations about decreasing administrative burden, and a lot of that advocacy right now is focused on prior authorization and step therapy, for instance.

Kevin Pho: So when it comes to these initiatives that push back against the lowered reimbursement that is seemingly proposed almost yearly, sometimes that doesn’t garner a lot of public support. So give a specific example of how those lowered reimbursements that pressure cognitive specialties, how will that negatively impact patient care?

William E. Fox: Well, I think one thing to keep in mind is that fewer and fewer medical students, as we said, are choosing this career because they see some challenges with it. And in an absolute sense, internal medicine and primary care is really one of the best and most rewarding fields of medicine. I really want to emphasize that. But if they see lower reimbursements, there are fewer physicians going into those fields, and therefore the patients have lower access to those specialties.

In addition, physicians may feel pressured to see more and more patients, a higher volume of patients, in order to keep their incomes whole or try to increase their income level. And when you’re an internal medicine patient and you’re looking at the whole patient, trying to do something quickly is not in the best interest of the patient. These patients are complicated. Internal medicine doctors are often called complexivists because of their ability to deal with these complex situations. But our most important tool is time with the patient, listening to the patient, understanding their story, and trying to help them achieve optimal health.

Kevin Pho: Sometimes when physicians hear from representatives from our organizations, we feel that these proposals have been going on for decades now and there hasn’t been much movement in terms of moving that needle. What are some examples where the ACP actually moved the needle and had these proposals really improve the lives of physicians and of course our patients?

William E. Fox: You know, Kevin, it’s a great point. And in advocacy, something that I’ve learned over many years of doing this is that advocacy goes way slower than you would like it to go, and takes a lot longer than you would like it to. But if you stick with it, you do make some progress. And just thinking about some of the things that we’ve advocated for over the last decade, if you look at those in totality, there’s actually been some progress.

For instance, it used to be that we couldn’t do an annual physical, or what we call an annual wellness visit, on a Medicare patient, and that started in around 2005 and then was expanded in 2011.

In 2013 we had the institution of the Transitional Care Management code, which really helped physicians expedite the safe transition of care from the hospital to the home situation.

In 2021 we had a significant increase in the E/M code valuations, and also a significant simplification of the burdensome requirements.

In 2020, with the onset of the pandemic, we finally got to do what we’ve been asking to do for many years, which is the ability to see our patients via telemedicine and telephone.

And then most recently we’ve had the institution of something called the G2211 code, which is supposed to recognize the extra work that a primary care physician does on a longitudinal basis when they’re taking care of a patient long term.

And then finally, we are moving towards advanced payment models, albeit slowly. So we have a whole series of pilot programs put out by Medicare, and other advanced alternative payment models that are beginning to be utilized.

So if you look at each one of those separately, it may seem like it’s only marginal improvement. But if you look at those in totality, that does indicate that we’ve made some progress in this area. We have not solved the problem, we have a long way to go, but we are making some progress.

Kevin Pho: We’re talking to William Fox. He’s an internal medicine physician and chair-elect of the American College of Physicians Board of Regents. Today’s KevinMD article is “Why we all need to care about the primary care physician shortage.” William, we’ll end with some of your take-home messages that you’d like to leave with the KevinMD audience.

William E. Fox: Well, match day is coming up. It’s a wonderful, wonderful event, and we applaud all the medical students as they move on from medical school to their residency training.

I would say that internal medicine offers a wonderful opportunity for many medical students because it offers a broad range of opportunities. But there are some challenges in the field. We are seeing fewer physicians choose careers in internal medicine, especially the cognitive specialties and primary care, and this is due to the twin problems of lower reimbursement and higher administrative burden.

The good news is that there are solutions that have been proposed that could really help with these things. We just need our leaders at the federal level and in private industry to really take the bold action needed so that we can have a sustainable workforce for generations to come.

Kevin Pho: William, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

William E. Fox: Thank you so much.