“It will readily be seen that amid all these claimants for pathological territory there is scarcely standing-room left for the general practitioner.” – Andrew H. Smith, “The Family Physician” (1888)
“The time when every family, rich or poor, had its own family physician, who knew the illnesses and health of its members and enjoyed the confidence of the upgrowing boys and girls during two or three generations, is gone.” – Abraham Jacobi, “Commercialized Medicine” (1910)
“More recent investigation shows that almost one-third of the towns of 1,000 or less throughout the United States which had physicians in 1914 had none in 1925. . . . it will be seen at a glance that the present generation of country doctors will have practically disappeared in another ten years.” – A. F. van Bibber, “The Swan Song of the Country Doctor” (1929)
“But complete medical care means more than the sum of the services provided by specialists, no matter how highly qualified. It must include acceptance by one doctor of complete responsibility for the care of the patient and for the coordination of specialist, laboratory, and other services. Within a generation, if the present situation continues, few Americans will have a personal physician do this for them.” – David D. Rutstein, “Do You Really Want a Family Doctor?” (1960)
“Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.” – Thomas Bodenheimer, “Primary Care – Will It Survive?” (2006)
“Potential access challenges”—that’s the current way of putting the growing shortage of primary care physicians (PCPs). Euphemism melodious of care incommodious. Aggravated by the 33 million Americans shortly to receive health insurance through the Patient Protection and Affordable Care Act of 2010 – health insurance leads to increased use of physicians – the chronic shortage of primary care physicians is seen as a looming crisis capable of dragging us back into the medical dark ages. Medical school graduates continue to veer away from the less remunerative primary care specialties, opting for the well-fertilized and debt-annihilating verdure of the subspecialties. Where then will we find the 51,880 additional primary care physicians that, according to the most recent published projections, we will need by 2025 to keep up with an expanding, aging, and more universally insured American population?
Dire forecasts about the imminent disappearance of general practitioners or family practitioners or, more recently, primary care physicians have been part of the medical-cum-political landscape for more than a century. Now the bleak scenarios are back in vogue, and they are more frightening than ever, foretelling a consumer purgatory of lengthy visits to emergency rooms for private primary care – or worse. Dr. Lee Green, chair of Family Medicine at the University of Alberta, offers this bleak vision of a near future where patients are barely able to see primary care physicians at all:
Primary care will be past saturated with wait times longer and will not accept any new patients. There will be an increase in hospitalizations and increase in death rates for basic preventable things like hypertension that was not managed adequately.
I have no intention of minimizing the urgency of a problem that, by all measurable indices, has grown worse in recent decades. But I do think that Dr. Green’s vision is, shall we say, over the top. It is premised on a traditional model of primary care in which a single physician assumes responsibility for a single patient. As soon as we look past the traditional model and take into account structural changes in the provision of primary care over the past four decades, we are able to forecast a different, if still troubling, future.
Beginning in the 1970s, and picking up steam in the 1980s and 90s, primary care medicine was enlarged by mid-level providers (physician assistants, nurse practitioners, psychiatric nurses, and clinical social workers) who, in many locales, have absorbed the traditional functions of primary care physicians. The role of these providers in American health care will only increase with implementation of the Patient Protection and Affordable Care Act and the innovative health delivery systems it promotes as solutions to the crisis in healthcare.
I refer specifically to the Act’s promotion of “Patient-Centered Medical Homes” (PCMHs) and “Accountable Care Organizations” (ACOs), both of which involve a collaborative melding of roles in the provision of primary care. Both delivery systems seek to tilt the demographic and economic balance among medical providers back in the direction of primary care and, in the process, to render medical care more cost-effective through the use of electronic information systems, evidence-based care (especially the population-based management of chronic illnesses), and performance measurement and improvement. To these ends, the new delivery systems equate primary care with “team-based care, in which physicians share responsibility with nurses, care coordinators, patient educators, clinical pharmacists, social workers, behavioral health specialists, and other team members.” The degree to which the overarching goals of these new models – reduced hospital admissions and readmissions and more integrated, cost-effective management of chronic illnesses – can be achieved will be seen in the years ahead. But it is clear that these developments, propelled by the Accountable Care Act and the Obama administration’s investment of $19 billion to stimulate the use of information technology in medical practice, all point to the diminished role of the all-purpose primary care physician (PCP).
So we are entering a brave new world in which mid-level providers, all working under the supervision of generalist physicians in ever larger health systems, will assume an increasing role in primary care. Indeed, PCMHs and ACOs, which attempt to redress the crisis in primary care, will probably have the paradoxical effect of relegating the traditional “caring” aspects of the doctor-patient relationship to nonphysician members of the health care team. The trend away from patient-centered care on the part of physicians is already discernible in the technical quality objectives (like mammography rates) and financial goals of ACOs that increasingly pull primary care physicians away from relational caregiving.
The culprit here is time. ACOs, for example, may direct PCPs to administer depression scales and fall risk assessments to all Medicare patients, the results of which must be recorded in the electronic record along with any “intervention” initiated. In all but the largest health systems (think Kaiser Permanente), such tasks currently fall to the physician him- or herself. The new delivery systems do not provide ancillary help for such tasks, which makes it harder still for overtaxed PCPs to keep on schedule and connect with their patients in more human, and less assessment-driven, ways.
So, yes, we’re going to need many more primary care physicians, but perhaps not as many as Petterson and his colleagues project. Their extrapolations from “utilization data” – the number of PCPs we will will need to accommodate the number of office visits made by a growing, aging, and better insured American population at a future point in time – do not incorporate the growing reality of team-administered primary care. The latter already includes patient visits to physician assistants, nurse practitioners, and clinical social workers and is poised to include electronic office “visits” via the Internet. For health services researchers, this kind of distributed care suggests the reasonableness of equating “continuity of care” with “site continuity” (the place where we receive care) rather than “provider continuity” (the personal physician who provides that care).
Of course, we are still left with the massive and to date intractable problem of the uneven distribution of primary care physicians (or primary care “teams”) across the population. Since the 1990s, attempts to pull PCPs to those areas where they are most needed have concentrated on the well-documented financial disincentives associated with primary care, especially in underserved, mainly rural areas . Unsurprisingly, these disincentives evoke financial solutions for newly trained physicians who agree to practice primary care for at least a few years in what the federal government’s Health Resources and Services Administration designates “Health Professional Shortage Areas” (HPSAs). The benefit package currently in place includes medical school scholarships, loan repayment plans, and, beginning in 1987, a modest bonus payment program administered by Medicare Part B carriers.
The most recent and elaborate proposal to persuade primary care physicians to go where they are most needed adopts a two-pronged approach. It calls for creation of a National Residency Exchange that would determine the optimal number of residencies in different medical specialties for each state, and then “optimally redistribute” residency assignments state by state in the direction of underrepresented specialties, especially primary care specialties in underserved communities. This would be teamed with a federally funded primary care loan repayment program, administered by Medicare, that would gradually repay participants’ loans over the course of their first eight years of post-residency primary care practice in an HPSA.
But this and like-minded schemes will come to naught if medical students are not drawn to primary care medicine in the first place. There was such a “draw” in the late 60s and early 70s; it followed the creation of “family practice” as a residency-based specialty and developed in tandem with social activist movements of the period. But it did not last into the 80s and left many of its proponents disillusioned. Despite the financial incentives already in place (including those provided by the federal government’s National Health Service Corps) and the existence of “rural medicine” training programs, there is no sense of gathering social forces that will pull a new generation of medical students into primary care. Nor is there any reason to suppose that the dwindling number of medical students whose sense of calling leads to careers among the underserved will be drawn to the emerging world of primary care in which the PCP assumes an increasingly administrative (and data-driven) role as coordinator of a health care team.
In truth, I am skeptical that financial packages, even if greatly enlarged, can overcome the specialist mentality that emerged after World War II and is long-entrenched in American medicine. Financial incentives assume that medical students would opt for primary care if not for financial disincentives that make it harder for them to do so. Now recent literature suggests that financial realities do play an important role in the choice of specialty. But there is more to choice of specialty than debt management and long-term earning power. Specialism is not simply a veering away from generalism; it is a pathway to medicine with its own intrinsic satisfactions, among which are prestige, authority, procedural competence, problem-solving acuity, and considerations of lifestyle. These satisfactions are at present vastly greater in specialty medicine than those inhering in primary care. This is why primary care educators, health economists, and policy makers place us (yet again) on the brink of crisis.
Financial incentives associated with primary care are important and probably need to be enlarged far beyond the status quo. But at the same time, we need to think outside the box in a number of ways. To wit, we need to rethink the meaning of generalism and its role in medical practice (including specialty practice). And we need to find and nurture (and financially support) more medical students who are drawn to primary care. And finally, and perhaps most radically, we need to rethink the three current primary care specialties (pediatrics, general internal medicine, and family medicine) and the relationships among them. Perhaps this long-established tripartite division is no longer the best way to conceptualize primary care and to draw a larger percentage of medical students to it. I will offer my thoughts on these knotty issues in blog essays to follow.
 S. M. Petterson, et al., “Projecting US primary care physician workforce needs: 2010-2025,” Ann. Fam. Med., 10:503-509, 2012.
 Quoted in Nisha Nathan, “Doc Shortage Could Crash Health Care,” online at http://abcnews.go.com/Health/doctor-shortage-healthcare-crash/story?id=17708473.
 D. R. Rittenhouse & S. M. Shortell, “The patient-centered medical home: will it stand the test of health reform?, JAMA, 301:22038-2040, 2009, at 2039. Among recent commentaries, see further D. M. Berwick, “making good on ACOs’ promise – the final rule for the Medicare shared savings program,” New Engl. J. Med., 365:1753-1756, 2011; D. R. Rittenhouse, et al., “Primary care and accountable care – two essential elements of delivery-system reform,” New Engl. J. Med., 361:2301-2303, 2009, and E. Carrier, et al., “Medical homes: challenges in translating theory into practice,” Med. Care, 47:714-722, 2009.
 I am grateful to my brother, David Stepansky, M.D., whose medical group participates in both PCMH and ACO entities, for these insights on the impact of participation on PCPs who are not part of relatively large health systems.
E.g., R. G. Petersdorf, “Financing medical education: a universal ‘Berry plan’ for medical students,” New Engl. J. Med., 328, 651, 1993; K. M. Byrnes, “Is there a primary care doctor in the house? the legislation needed to address a national shortage,” Rutgers Law Journal, 25: 799, 806-808, 1994. On the Medicare Incentive Payment Program for physicians practicing in designated HPSAs – and the inadequacy of the 10% bonus system now in place – see L. R. Shugarman & D. O. Farley, “Shortcomings in Medicare bonus payments for physicians in underserved areas,” Health Affairs, 22:173-78, 2003 at 177 (online at http://content.healthaffairs.org/content/22/4/173.full.pdf+html) and S. Gunselman, “The Conrad ‘state-30’ program: a temporary relief to the U.S. shortage of physicians or a contributor to the brain drain,” J. Health & Biomed. Law, 5:91-115, 2009, at 107-108.
G. Cheng, “The national residency exchange: a proposal to restore primary care in an age of microspecialization,” Amer. J. Law & Med., 38:158-195, 2012.
 The NHSC, founded in 1970, provides full scholarship support for medical students who agree to serve as PCPs in high-need, underserved locales, with one year of service for each year of support provided by the government. For medical school graduates who have already accrued debt, the program provides student loan payment for physicians who commit to at least two years of service at an approved site. Descriptions of the scholarship and loan repayment program are available at http://nhsc.hrsa.gov/
 See the rationale for rural training programs set forth in a document of the Association of American Medical Colleges, “Rural medicine programs aim to reverse physician shortage in outlying regions,” online at http://www.aamc.org/newsroom/reporter/nov04/rural.htm. One of the best such programs, Jefferson Medical College’s Physician Shortage Area Program, is described and its graduates profiled in H. K. Rabinowitz, Caring for the country: family doctors in small rural towns (NY: Springer, 2004).
 See especially the 2003 white paper by the AMA’s taskforce on student debt, online at http://www.ama-assn.org/ama1/pub/upload/mm/15/debt_report.pdf and, more recently, P. A. Pugno, et al., “Results of the 2009 national resident matching program: family medicine,” Fam. Med., 41:567-577, 2009 and H. S. Teitelbaum, et al., “Factors affecting specialty choice among osteopathic medical students, Acad. Med., 84:718-723, 2009.
Copyright © 2012 by Paul E. Stepansky. All rights reserved.