Disappearing Docs

Active mentors and enhanced practice experiences could motivate more physicians tochoose primary care, easepredicted shortage

Steven Judge, M.D. Stephen Judge, M.D. (R’06), knows exactly how he became a member of an endangered species — the primary care physician. “I fell in love with both the intellectual and the psychosocial approach of general medicine,” said Judge, who practices with the University of Rochester Medical Center’s Clinton Medical Associates. “I had some tremendous role models. I enjoyed seeing what they did as generalists. It represented what I wanted to be as a doctor.

Part of it is the romantic old-fashioned notion of being the doctor who gets to know the patient over a whole lifetime, who gets to know family members and gets to establish long-term relationships.

Marc Berliant, M.D.

“In theory and in reality, primary care is extremely rewarding for the doctor and the patient,” he said. “That is at the heart of it.”

For 25 years, Marc Berliant, M.D. (R’81), experienced the world of a primary care physician that Judge envisions for himself. He cared for patients and their families through the years and the changes life brings. His patients included two and three generations of a family. He helped one generation as the older generation faced death.

“It is a sacred bond. It is a wonderful thing and it sustains you as a physician,” Berliant said. “The magic, too, is when patients come through the door. You have no idea what is wrong with them. They don’t come with a label. They don’t come with a diagnosis. They come with a complaint and it is your job to listen, to take a careful history, do a through examination, formulate a differential diagnosis and figure out what is wrong with them. The challenge is trying to solve the problems of patients without any pre-conceived notion as to what is wrong.”

"We don’t want to have a specialty oriented way of accessing health care. It will be very expensive and there will be a lot of inappropriate consultations with physicians who need to focus on the very sick people in their own specialty practice.”
Marc Berliant, M.D.

The prognosis for primary care, however, is gloomy. The number of active practitioners is falling. Internal medicine has been the traditional source of primary care physicians, but most internal medicine residents now choose specialties rather than primary care. Family physicians increasingly have taken on the role of primary care provider, but their numbers are not growing to meet the need. Judge and Berliant worry about a future with a shortage of primary care physicians.

“We don’t want to have a specialty-oriented way of accessing health care,” said Berliant. “It will be very expensive and there will be a lot of inappropriate consultations with physicians who need to focus on the very sick people in their own specialty practice.” Judge and Berliant are not alone in their worries. Two prominent alumni have written about their concerns. The Boston Globe published an essay in 2008 by Joseph B. Martin, M.D., Ph.D. (PhD’71), professor of neurobiology, former dean of Harvard Medical School and chairman of the New England Healthcare Institute, in which he said “the gravest concern is about the lack of primary care doctors to work in settings where the patient load is high and the pay is less.” In the St. Louis Post-Dispatch, William A. Peck, M.D. (M’60), director of Washington University’s Center for Health Policy and former dean of Washington University’s School of Medicine, wrote:

“These hard-working physicians, including general internists and family physicians, are at the very heart of health care. They usually are the first contact and ongoing caregivers who diagnose patients, manage their care and refer patients to specialists or hospitalize them when necessary. Most patients think of their primary care physician as ‘my doctor.’ Insured and uninsured patients alike are having trouble finding them.”

Berliant, recently appointed chief of the Medical Center’s Division of General Medicine, has made inspiring more doctors to choose primary care a goal of his new job. While the major causes of the potential primary care crisis are national in scope, Berliant believes improved teaching and mentoring and earlier exposure to successful, well-run primary care practices can motivate more people to pick primary care as a career.

“When I’m in the room with a patient, I still think that is the best job a person can have,” Berliant said “We have to be able to show medical students, interns and residents what it’s like to take care of patients in that setting, what goes on in that room, and what the dynamic of that interaction is. And we have to emphasize that as rewarding.”

Poor quality care, higher costs

Resident Bryn Duffy, M.D., and patient Delphine Harvey

In the national debate on health care reform, the looming shortage of primary care physicians plays a significant role. The American College of Physicians (ACP) reported last year that the number of U.S. medical school graduates entering residencies in family medicine and internal medicine has declined by half in the last decade. In 1998, according to a national study, about 55 percent of internal medicine residents chose primary care. But by 2007, the percentage selecting primary care had fallen to 23 percent. From 2004 through 2008 at Rochester’s School of Medicine and Dentistry, 15 out of 100 residents in internal medicine chose primary care. So far, only one resident in the 2009 class of internal medicine residents has chosen primary care. Studies indicate a shortage of 35,000 to 44,000 primary care physicians could occur by 2025. And the consequences of such a shortage would be significant.

“The hallmarks of primary care medicine — first contact care, continuity of care, comprehensive care, and coordinated care — are going to be increasingly necessary in taking care of an aging population with growing incidence of chronic disease, and have proven to achieve improved outcomes and cost savings,” the ACP report states. “Without primary care, the health care system will become increasingly fragmented and inefficient, leading to poorer quality care at higher costs.”

The ACP report points out the causes of the shortage bluntly: excessive administrative hassles, high patient loads, declining revenue and increased cost of providing care. These factors are leading many primary care physicians to retire early and also dissuade medical students and residents, who also face high levels of debt after medical school, to choose other fields or specialties.

“What has happened in primary care since I went into practice is that there has been an increasing burden placed on physicians, often by insurance companies, to have prior authorizations for prescriptions and pre-certifications for tests,” Berliant said. “You have to argue about what you can and cannot do and what you can and cannot prescribe and that has made the job more difficult. It also is somewhat insulting to be told, for example, that I can’t order an MRI without a consultation with a neurologist.”

When he finishes his day seeing patients, Judge said, he routinely works another three to four hours.

“That’s everyday and on the weekends,” Judge said. “Most of us have to work seven days a week to keep up with the paperwork. The balance between work and life outside work is challenging.”

The work atmosphere also affects the career decision of physicians.

“When medical students and residents go out to primary care physician offices, they see people who are working very hard and who too often are consumed with paperwork and things that are not really about providing care,” Berliant said. “They don’t see the professionals as being happy in their job.”

The average debt at graduation from medical school is about $150,000. Because most primary care physicians earn substantially less than specialty physicians, those dealing with high debt might see an economic necessity in choosing a different field.

“Primary care doctors who work hard can still make a good living,” Judge said. “The frustration, though not necessarily mine, is not what they make but what they make compared with other doctors. Primary care doctors still make more money than the vast majority of the population. Some of the problem is the perception of being undervalued compared with subspecialists. People in primary care are not in it just for the money. We want to be able to do a good job and have people understand that what we do is critical to the delivery of high quality health care.”

Master clinicians as models

Resident Serban Staicu, M.D., and patient Richard Dermody

As with many national issues, money is at the center of the discussion of restoring the primary care system. Increased compensation most probably would attract more physicians to primary care and help retain them. But what would be the source of the funds for increased compensation? Wouldn’t specialty physicians resist reductions in their compensation? Proposals for universal health care or for a single provider create an even more complex debate.

At the School of Medicine and Dentistry, Berliant is focusing on education and training as a way to help ease the shortage.

“We have excellent teachers but we have to do even better,” he said. “Preceptors need to be in the room with the patient and the resident to coach the residents, to show them how to have a more positive interaction and to treat the patient with dignity and respect. We need to teach how to be a good clinician with a willingness to listen, to respect different points of view and to collaborate with the patient. A master clinician teacher can demonstrate those principles and they can be modeled. We need to do a better job in the room with the patient.”

Residents should be exposed to a broader patient mix than currently available with the continuity care practice at the Medical Center, Berliant said. Residents also should have early experiences with successful community primary care practices. Medical students also should have the opportunity for an early taste of primary care practice.

“When residents came to my office, it was not a fancy workplace or the patient demographics that impressed them, it was the team of people working together to take care of patients — the nurse practitioner, nurse, secretary and physician working side by side to provide excellent care,” Berliant said.

Family medicine mirrors primary care in the services physicians provide. Family physicians increasingly have
become the providers of primary care as the number of internists choosing the field has declined. About nine out of 10 primary care physicians trained at the Medical Center are family physicians. But the number of people choosing family medicine might not be enough to affect the primary care shortage.

On Match Day this year, about 42 percent of the family medicine residency slots went to those graduating from U.S. medical schools. About 49 percent of the residencies went to graduates of foreign medical schools, osteopathic schools and those who graduated from U.S. schools in previous years. Nine percent of the slots went unfilled.

“I was told at Harvard that I was wasting a Harvard education by going into family medicine,” said Thomas L. Campbell, M.D., (R’82) chair of the Medical Center’s Department of Family Medicine. “There is a lack of understanding and appreciation of a generalist. We can take care of 80 percent of patient problems. Most serious diseases are easily managed by primary care physicians, whether an internist or a family physician, in conjunction with specialists. Primary care is the foundation of good health care.”

A new concept — patient-centered medical homes that would involve a lead primary care physician, physician assistants and/or nurse practitioners, social workers, dieticians and a team to handle paperwork — could attract more physicians to primary care. While there also is increasing sentiment that more medicine can be practiced by e-mail or telephone, Berliant asked: “Will that give more satisfaction to patients or physicians? It is another layer of separation from caring for the patient and may not be the best way to keep the field going.”

“The model of the primary care physician who acts as diagnostician and as care coordinator is still a good model. It leads to healthier patients and actually saves health systems money. One way we will get more money in primary care, and therefore more people to go into it, is to prove that it does save money. And there is the law of supply and demand. If there is a national shortage of primary care physicians, they will have to pay more,” Berliant said. “Ultimately, putting more money into primary care will not solve the problem of the primary care physician shortage. As a profession, we need to design innovative models of health care delivery that will enhance provider satisfaction and improve patient outcomes.”