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Save Primary Care, But Don't Rob Peter to Pay Paul

Phillip Miller, for HealthLeaders Media, May 14, 2009

A recent front page story in the New York Times finally made official what hospitals and the physician recruiters who work for them have known for years: America is running out of primary care physicians.

Why is the well of primary care doctors running dry? Because a growing number of medical school graduates are taking the R.O.A.D. to success—they are selecting Radiology, Ophthalmology, Anesthesiology, Dermatology and other "ologies" over family practice, internal medicine, and pediatrics. The income and the lifestyle offered by surgical and diagnostic specialties simply trump anything that primary care affords.

In a recent survey Merritt Hawkins & Associates conducted on behalf of The Physicians Foundation, some 9,000 primary care physicians were asked what they would do if they could start their careers over. Forty-one percent said they would choose a surgical or diagnostic specialty, 27% said they would choose not to be a physician, and 5% said they would choose a non-clinical role in medicine. Only 27% said they would choose primary care.

That we need to renew interest in primary care among medical students is only made more apparent by current healthcare reform plans, which emphasize prevention, EMR implementation, and standardized care. It will take a robust and willing supply of primary care doctors to achieve these measures, as the Obama administration has acknowledged.

It would be a mistake, however, to grow the supply of primary care doctors at the expense of surgical and diagnostic specialists. The medical home, and other concepts to enhance the pay and prestige of primary care physicians, will create as many problems as they solve if they are imposed on the backs of medical specialists. Paying primary care doctors more by cutting reimbursement to specialists is not the answer.

The reason is simple. Just as there is a growing shortage of primary care doctors, there is a shortage of specialists in many areas. Fifteen medical specialty organizations have published reports projecting national shortages in their disciplines, including specialties such as gastroenterology, general surgery, cardiology, medical genetics, neurosurgery, dermatology, child psychiatry, and various other pediatric subspecialties.

The number of specialists trained in the last two decades has increased only marginally, even though many medical school graduates are choosing specialty medicine over primary care. The overall number of physicians coming out of residency each year has remained virtually flat since the mid 1980s. During that time the population has grown by millions, with the highest growth rate among the elderly who drive the need for specialty care. Demographic trends and the increasing technical sophistication of medicine will accelerate the need for specialist physicians for years to come.

Cutting the income of specialists and limiting their clinical autonomy through standardized treatment protocols will significantly raise the bar of entry into fields where the bar already is set extremely high. Those with the ability to excel through four years of college, four years of medical school, and four or more years of training—and who then can go on to perform life saving procedures—should be highly rewarded.

In the effort to promote primary care we should acknowledge that there are no bad guys. We need more primary care doctors. We also need more specialists. Whatever the healthcare system looks like after reform, it should create an environment where both types of physicians can thrive.


Phillip Miller is vice president of communications for Merritt Hawkins & Associates, a national physician search and consulting firm and an AMN Healthcare company. He may be reached at pmiller@mhagroup.com.

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