The Doctor Is Not In Why Primary Care Faces Growing Shortages

Dr. Rob Jandl has long known about the shortage of primary-care physicians in Massachusetts. But when he recently conducted a survey of doctors in Berkshire County about their practices, the results surprised even him.

“There was an alarmingly high rate of unhappiness and thoughts of reducing hours and leaving the profession. The response rate was 87{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}, so statistically this was highly valid,” said Jandl, an internist and president of Williamstown Medical Associates.

Among the results: 47{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the respondents were somewhat or very dissatisfied with primary care; 63{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} would probably or definitely not enter the profession were they able to make the choice again; and a whopping 91{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} would have reservations about recommending a career in primary care to someone else — or outright discourage it.

Those numbers don’t bode well for the future.

“There is a level of well-documented unhappiness, said Jandl, “and there are lots of reasons for that.”

Dr. Michael Picchioni, associate director of the Internal Medicine Residency Program at Baystate Medical Center, agreed.

“Two things are happening simultaneously,” he explained. “People are changing, and a new generation has different expectations and priorities. And health care is changing; delivering primary care is really hard. It’s hard work, and the financial structure doesn’t reward it very well. The personal rewards are great, but they’re just not great enough.”

Many specialty fields, he noted, allow doctors a more predictable set of hours and responsibilities. “It doesn’t spill over into the rest of their lives. And all the bureaucratic red tape and paperwork isn’t rewarding in any way. Primary care doctors have a large, disproportionate burden; they’re paid less, but they have to work more, and work harder.”

To illustrate, Picchioni used the example of wart removal. “I can get paid to freeze off a few warts in no time at all, maybe 10 or 15 minutes,” he explained. “Then I can spend 45 minutes to an hour with somebody, dealing with much more important health issues, and get reimbursed about the same amount.

“Things that have more immediate risk associated with them, high-tech procedures, get paid really well,” he added, suggesting one reason why many medical specialties are a more popular choice for students these days than primary care.

“Ten years ago, a lot of our graduates used to go into primary care — more than half,” he noted. “Now, it’s a small minority. It’s the same teaching program, with the same leaders and the same emphasis on primary care; the people at the center of the program are primary care-trained practitioners. Yet, this shift has happened in spite of us, you might say.”

This month, The Healthcare News delves into why those numbers have shifted so dramatically, and what the trend, if it continues, means for access to health care in Massachusetts.

Prestige Gap

Surveys show that the percentage of medical students choosing primary care has fallen by 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} in the past decade alone, and a 2008 University of Missouri study suggested that the U.S. could face a shortage of 44,000 general-practice doctors by 2025.

“That’s the critical problem we need to find the answer to; there has been a slow and steady imbalance in the ratio of specialties to primary care doctors nationally and in Massachusetts,” said Dr. Dennis Dimitri, a Worcester-based doctor and president of the Mass. Academy of Family Physicians.

He noted that some of the factors scaring doctors away from Massachusetts — inadequate reimbursement rates from Medicaid and other payers, and a generally high cost of living, to name two — are endemic to most specialties in the state, not just primary care.

But there’s a prestige gap that afflicts primary care these days, he added, arguing that the medical community needs to figure out how to increase what he calls the ‘three Rs’ for such doctors: respect, recognition, and remuneration. “There has to be respect for the important role that primary care physicians play. Certainly, some of that has gotten lost,” he said.

“People need to realize how critical a primary-care foundation is for a well-functioning delivery system. In communities that have higher ratios of primary care physicians to the population, the quality of care improves. In other parts of the developed world, health care systems have an appropriate ratio of specialists to primary care physicians, around 50-50. But the ratio here has slowly been sliding to 60-40 or even 70-30, and that might be heading toward 80-20 if you look at the percentages of students graduating medical schools in the past few years.”

And the pay gap between primary care and some specialties is one factor in that trend, said Dimitri, because salary, though not an end-all goal, is often tied inextricably to job satisfaction and respect. A specialist who performs a 30-minute procedure is often paid three times more than a primary-care physician spending 30 minutes discussing a patient’s condition, yet those two doctors emerge from medical school with the same heavy debt load.

“I’m not saying that gap should be closed, but it should be narrowed,” he argued. “Until that happens, it will have a detrimental affect on attracting medical students into primary care.”

Picchioni agreed that reimbursement and respect go hand-in-hand, and the connection between pay and prestige in today’s society is perhaps greater than in the past. But another shift in prestige occurred when managed care came to prominence beginning in the 1980s.

“That really lowered our status,” he said. “We thought we would be the center piece, the ones who decide what people need and get them those things; we were the ones who really mattered.

“But it didn’t work out that way; we’re the pass-through, inundated with paperwork. Somewhere, we became clerks, and there’s no status in that.”

Still, some areas of Massachusetts, particularly the urban centers, have enough primary-care doctors, said Dimitri, and the state’s main issue is regional. “If you look strictly at the numbers, there’s actually a large number of primary care physicians in Massachusetts. However, there is a bit of maldistribution, so that certain parts of the state are much more acutely affected than others.”

The greatest shortages, he said are in Western Mass. and on the cape and islands. “In those places, what you hear is that, when people try to call a primary care physician to become established as a new patient, they have a hard time finding practices that are open to new patients. Many physicians try to accommodate larger and larger numbers of patients, but the downside is that doesn’t leave you enough time to take care of the ones you already have. So there are problems with access.”

That’s an issue that some feared could be exacerbated by the state’s health care mandate of 2006, which requires most residents to carry health insurance and, at least in theory, has more of them visiting the doctor.

“People have begun to look at this problem, and they’re seeing that individuals are suddenly finding themselves unable to see a primary-care doctor,” Dimitri said. “It’s not a matter of not having insurance; it’s a matter of access to open practices. We’ve done a darn good job in Massachusetts solving the coverage problem, but now we have to deal with the access issue.”

Culture of Change

Dr. Robert Lounsbury, president of RiverBend Medical Group, said his organization has largely been able to avoid some of the recruiting issues related to the primary care gap.

“Not to say there isn’t a shortage — our doctors have many, many patients — but we actually have been fairly successful in courting primary care doctors,” said Lounsbury, noting that the group has hired 11 in the past couple of years.

He said the size of RiverBend — about 100 doctors in all — provides an infrastructure to support some of the non-clinical responsibilities of primary care, such as keeping an eye on regulations and jumping through other bureaucratic hoops. The group has also used electronic medical records for the past three years, which also reduces the back-end load.

“I’m not sure why there’s a shortage, but there are probably multiple factors,” Lounsbury said. “There’s the hassle, and people may view medicine differently than they did 40 years ago. They may choose specialties not just because of their interest in that field but for lifestyle issues.”

On the other hand, Dimitri said the health care climate in Massachusetts should work in the state’s favor when recruiting doctors.

“On the plus side, we do have a very high quality of care delivered in this state as compared to national norms,” he said. “We have better outcomes, more kids get immunized, we have more routine cancer screening, more people who have heart attacks are appropriately treated when they come to the hospital. On those measures, Massachusetts is a good place to get health care. Doctors here work hard and do a good job, and the people of the Commonwealth benefit from that tremendously.”

While that might be true, Picchioni said, it doesn’t address the issue of reimbursement, which requires action in Boston — and “the political process moves slowly, and it’s not very rational.”

“There are no easy answers,” Jandl said. “Some answers are being trumpeted as incremental steps, including student-loan forgiveness and income support by entities such as hospitals trying to keep primary care physicians in the community.”

These are positive steps, he said, while warning that the drift away from primary care is happening at a quicker pace, and in the absence of a coherent master plan to address the core reasons why, the private sector is filling the void, with efforts such as MinuteClinics at CVS pharmacies.

“These are set up to fill the shortage of primary care, but they’re constructed primarily as profit centers, not as a means for providing care, and they do not address the serious problems of people with serious illnesses,” Jandl said. “People need coordination of care and accurate diagnostic decision-making. If anything, these clinics undercut primary care physicians.”

Any solution, he said, has to be multi-pronged, and involve improvements to both doctors’ pay and their practice environment.

“It has to happen at the same time,” said Jandl. “If we pay doctors more without changing the system, the result will be failure, and if you change the system without putting a priority on income, I think that will fail, too. You really have to do both.”

The Doctor Will See You Now

What makes the situation even more irksome, Picchioni said, is that primary care has so much to offer in terms of personal satisfaction, but the way the system is set up now — with doctors under pressure to see as many patients as possible — undercuts that.

“The single most valuable thing about primary care is that central relationship the doctor has with his or her patient,” he said. “Often, in their eyes, we do have the greatest status. We share in their highs and lows in health care as they happen; we’re much more than peripherally involved. Still, everyone I’ve known in this field has made a comment like, ‘I wish I had more time to spend with my patients.’ That’s absolutely true.”

“I think people choose primary care now for the same reasons they’ve always chosen it — the breadth of the practice, you get to see a lot of different things, and you don’t just focus on one system,” Lounsbury added. “And you have a longer duration of relationship with patients. You may be a patient’s doctor for 30 years, and you really get to know people. That’s rewarding.”

Given all the roadblocks primary care physicians have to deal with today, however, it might not be reward enough.