Cities without landmarks
Niagara Falls, U.S./Canada
A friend of mine died not long ago from colon cancer. She was a fit, health-conscious middle-aged woman who phoned her family doctor, complaining of rectal bleeding. Her doctor was too busy to see her for several weeks; his medical assistant, also booked for several days, reassured her that most rectal bleeding is from hemorrhoids. “Wait a few weeks and see if it doesn’t go away,” he told her. The bleeding did stop, temporarily, then returned a few months later. When she finally saw her doctor, her colon tumor was inoperable. Whether her outcome would have been different with an earlier diagnosis can’t be known with certainty. But what can be said is this is not the way medicine should be practiced.
Although not often this dramatic, everyone has his or her own tale of long waiting times, inability to find a new family doctor, or general frustration getting prompt and adequate care. Just as the U.S. financial gurus failed to acknowledge the seriousness of our present credit crisis, today’s politicians are avoiding what promises to be a similar catastrophe in healthcare — the availability of primary care physicians.
The current healthcare debate about accessibility and affordability reminds me of a committee of well-intended E.R. doctors furiously debating the optimal cost, shape and efficiency of various tourniquets, while a casualty victim slowly bleeds to death. Better and more widespread and affordable health insurance won’t be of value if you can’t find a primary care provider willing and happy to treat you.
Make no mistake: Primary care is the backbone of a good medical system. No matter how great our latest medical technologies, most of our illnesses are best screened or handled by the family practitioner. You don’t need a gastroenterologist to treat an ulcer or irritable bowel. You don’t need a pulmonologist to treat most cases of asthma and emphysema. And you don’t need an orthopedist for most aches and pain.
What we need, and most of us want, is the Norman Rockwell version of a concerned, empathetic family doctor we can trust to sniff out the rare or serious illness, manage the ordinary, while also being a medical cleric who knows his patients. What we need is a family friend to whom we can turn for reassurance, comfort and, yes, even bad news.
But primary care physicians — those trained in family medicine and general internal medicine — are an endangered species. It’s only a bit of hyperbole to say that, if the trend continues, the family doctor will become a fond memory, a nostalgic reminder that the medical system once had a more human face and sense of community.
For a moment, put aside the very real contributions we doctors have made to the destruction of our profession. Arrogance, hubris, condescension, greed, complacency, cronyism; you name it, we’ve done it. But it serves no useful purpose to feel a sense of righteous vindication that the American medical establishment has been brought to its knees. Instead, we should be focusing on attracting the next generation’s best and brightest.
Currently, roughly 200,000 family practitioners and general internists practice in the U.S. One-third are over 55 and are likely to retire within five to 10 years. Meanwhile, an alarmingly low percentage of students are choosing to become primary care physicians.
Take a look at the changing choices among the approximately 16,000 students who graduate from U.S. medical schools each year. In 1998, of the 2,930 graduates entering internal medicine residencies (specializing in the diagnosis and treatment of most common illnesses), 54 percent planned on entering primary care practice. By 2005, 2,668 opted for general internal medicine residencies, with only 20 percent of them planning on entering primary care practice. That means that at present, less than 600 graduating seniors per year plan on entering general internal medicine practice.
Primary care residencies, where residents learn to manage common illnesses and perform minor surgical and obstetrical procedures, show the same ominous trend. Between 1997 and 2005, the number of U.S. graduates entering primary care residencies dropped by 50 percent. We can now expect the combined family practice and general medicine residencies to deliver 1,000 to 2,000 U.S.-trained replacements annually. No matter how you slice the figures, five to 10 years down the road, today’s difficulty finding a primary care physician will seem like a minor inconvenience.
To underscore the general lack of recognition of the declining appeal of a primary care practice, consider that in 1976, a Department of Health and Human Services Advisory Committee predicted a surplus of 145,000 primary care physicians by the year 2000. And yet, in 2004, revised estimates suggested that by 2020 there will be a shortage of 90,000 to 200,000 physicians.
This shortsightedness and inept public policy planning continues in our present crop of presidential candidates. Barack Obama’s answer to increasing the number of med students choosing primary care has been strictly economic — decreasing educational debt, better reimbursement, and better medical infrastructure. John McCain isn’t any better. Neither has addressed the more basic problem of why fewer bright students are opting for primary care practices.
What is needed is an understanding of the diverse, complex and often conflicting motivations prompting students into medicine in general, as well as determining which specialties to pursue. Limiting discussions to the cost effectiveness of medical care is to nearly miss the entire point of the nature of primary care.
To begin with, the reality is that much of office medicine is an art, not a science. The majority of our doctor visits aren’t for life-threatening illnesses for which statistical outcomes can be determined. Common problems such as uncomplicated low back pain or a chest cold will resolve irrespective of treatment, or could be dispensed by a nurse practitioner or physician’s assistant at a reduced cost. The expense of medical training can never be cost-effective if most medical problems don’t require such expertise and can be handled at a fraction of the cost by lesser-trained personnel.
Yet it is this hard-earned expertise that is necessary to ferret out the minor from the serious. When it does, such expertise can be lifesaving, not to mention cost-effective, though these cost benefits might not be obvious when considering overall medical care for 300 million people. At the same time, it is our knowledge of our doctor’s expertise that gives us peace of mind. If we do want our medical complaints, no matter how minor, to be assessed by the best-trained, we need to figure out how to attract the best students back into family practice.
Opting to become a family doc isn’t the same type of choice as deciding on a middle-management job with good perks, opening a pizza parlor or getting an MBA. Graduating college students must commit to a grueling 6-to-8-year training period to acquire professional skills that aren’t easily transferable should they change their mind. Unlike law degrees, MBAs or engineering credentials — which are often stepping stones to completely unrelated careers — being a family doc doesn’t offer a lot of non-medical options.
Worse, there’s a high likelihood that you will be in debt when you graduate. As of 2006, more than 80 percent of graduating medical students carried educational debt, the median being $120,000 for students in public medical schools and $160,000 for students attending private medical schools. Small wonder, then, that the vast majority of students now specialize in fields like radiology, ophthalmology, anesthesiology, plastic surgery and dermatology. These specialties can, on average, offer twice to three times the average income of a family practitioner. In part, this is a reflection of specialists’ receiving two to three times the reimbursement rate of primary care physicians, according to a new study from Harvard Medical School.
Given today’s uncertainty as to the future of private practice, minimizing med-school debts and an initial promise of higher salaries without any long-term guarantees is at best a modest economic carrot. Students must feel compelled to enter primary care; it must be a “calling” as opposed to just one of many possible career options. They need to feel they are entering a field that can provide rich non-economic rewards — intellectual excitement, community and collegial respect, a certain degree of professional autonomy, and most important, the opportunity to earn and occupy a special place in the hearts of their patients. And they need enthusiastic encouragement by those already in the field.
In a 2005 survey of graduating U.S. med school seniors, half considered income and lifestyle as serious obstacles to entering a primary care practice. But the No. 1 deterrent was the lack of positive role models or mentors. Students aren’t hearing their elders extol the wondrous, dramatic and personally rewarding side of medicine. Instead, as of a 2004 survey, they’re reading that three-fourths of the 50- to 65-year-old physicians feel medicine is increasingly unsatisfying. Perhaps the most damning observation is that only one-third of interviewed doctors are recommending that their own children pursue a career in medicine.
Meanwhile, individual physicians, powerless to effect widespread improvements, are also turning to yet another potentially long-term divisive tack: boutique or concierge medicine. Patients who can afford an additional annual fee ranging from $1,500 to $15,000 (depending upon the breadth of services) can easily find a first-rate concierge doctor who will provide 24/7 availability, adequate office time at the patient’s convenience, and even, for a fee, get the doctor to serve as personal advocate during consultation with specialists.
Concierge medicine allows generalists to make excellent incomes and hand-pick those patients that are most health-conscious, compliant with their treatments, easiest to manage and often the most grateful. It’s understandable that an increasing number of those generalists who are most in demand will opt out of the nightmare of managed care and into boutique practices. The unfortunate trade-off will be even fewer PCPs willing to take on the less affluent, especially those who have time-intensive, difficult-to-manage chronic conditions, multiple medical problems, or who by dint of personality quirks are less compliant with treatments, have drug, alcohol or cigarette habits. By default, the U.S. is well on its way to two-tier primary medical care.
This physician distribution is also geographic: Only 11 percent of the primary care physician workforce has opted to serve the 20 percent of Americans who live in non-metropolitan or rural areas. The smaller the community, the more dismal are the prospects of attracting a physician. Many communities are desperate for any warm medical body.
As a consequence of this overall shortage and distribution, more primary care positions are being taken by foreign medical school graduates. Nearly half of the internal medicine and primary care residency slots are now filled by foreign graduates; one in four new practicing physicians in the U.S. is an international medical graduate.
These statistics aren’t meant to imply any criticism of foreign graduates, but only to point out the rapidly changing demographics of American primary care medicine, and that currently the de facto national healthcare policy is to replace the disappearing U.S.-schooled primary care physicians with doctors trained elsewhere. The underlying message is loud and clear: The U.S. is increasingly reliant upon foreign doctors because U.S.-trained physicians aren’t interested. This is hardly your ideal billboard for recruiting the next generation of students.
A further ignored issue is how to supervise the education of those trained elsewhere. U.S. medical schools are subject to strict regulation. We don’t have a similar mechanism for observing foreign training. Here’s a scary set of statistics. According to a New York Times article by Leana Wen, M.D., Rhodes scholar and Global Health Fellow at the World Health Organization in Geneva, “Lower-income countries supply between 40 to 75 percent of U.S.-based, foreign-trained doctors.” During a recent tour of the medical schools of three African countries, Wen was astounded to find that none of the students had been supplied with medical textbooks.
Earlier this year in the New England Journal of Medicine, Dr. Ranjana Srivastava, a medical oncologist and internist in Melbourne, Australia, wrote of his experiences tutoring foreign medical graduates, who are trying to obtain a medical credential in Australia. It’s a moving description of foreign doctors’ plight. Srivastava acknowledges the overwhelming cultural disadvantages the doctors face in crossing the “bridge” to standard Western practice. “I have observed over the years that most foreign doctors receive little encouragement, advice, or collegiality from a medical hierarchy engrossed in its own needs,” he writes. And some days, he confesses, “their needs are much larger than I had ever imagined or feel equipped to handle.”
It could also be argued that developed nations don’t have the right to dictate what is taught elsewhere, when we aren’t footing the considerable educational costs, and are recruiting doctors from medically disadvantaged areas to ameliorate our own shortages.
In 2005, British Medical Association chairman James Johnson described the siphoning off of African-trained physicians to the U.K. as morally indefensible, as reported by the BBC. The examples are startling. In Zambia, only 50 out of 600 doctors trained since independence are still practicing in the country. Three-quarters of Zimbabwe’s doctors have left since the early 1990s. More than half of all Ghana’s doctors have left the country. Yes, our primary concern is providing adequate medical care in the U.S.. But we also need to be aware of how our solutions create shortages elsewhere and have obvious global implications.
In addition to how to best provide universal health coverage in the U.S., we need real debate about how we want our medicine to be delivered. Even if we were to arrive at a perfect solution, it would be six to eight years before these changes affected present primary care physician demographics. The answers aren’t obvious and require real innovative thought. We need to restore family practice to a level of desirability that will attract the smart and the compassionate. Otherwise we can count on a dramatic rise in two-tier medicine, continuing geographic mal-distribution of medical care and an increasing reliance upon the physicians of other countries and lesser trained medical personnel to bail us out. Not a pretty picture and not a great stump speech for a political candidate, yet a brewing disaster we cannot continue to ignore.
Robert Burton, M.D., is the former chief of neurology at Mount Zion-UCSF Hospital and the author of "On Being Certain: Believing You Are Right Even When You're Not." His column, "Mind Reader," appears regularly in Salon.More Robert Burton.
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