Match Day a Reminder of Primary Care's Struggles

Imagine you're back in college as a young idealist with a goal of working in medicine but only a vague idea about how to make it happen. In front of you, two roads diverge.

One path requires four years of medical school after your undergraduate studies, possibly racking up hundreds of thousands of dollars in debt. After that, you work another three years as a resident for low wages. If your passion is primary care and you don't opt for more training to become a specialist, you can begin chipping away at your medical school debt after seven years of post-graduate training with an average salary of about $170,000.

The second path looks a little easier to traverse in comparison. Instead of going to medical school, you study nursing as an undergraduate. You become a registered nurse and acquire a minimum of one year of acute care nursing experience. In as little as two years after that, you can complete a program to become a certified registered nurse anesthetist. When you're done, the average base salary of your profession will be nearly $190,000.

It's not difficult to see why so few medical students are pursuing primary care these days.

CRNA salaries have been outpacing primary care compensation for a while now, but the trend has become severe enough to even attract CNN's attention recently. I'm not highlighting this to wade into the debate about whether CRNAs should be able to practice without physician supervision (they should), or to suggest that CRNAs are somehow responsible for primary care shortages (they aren't). The wage gap is just a symptom of the larger problem of poor primary care reimbursement.

Most doctors in fact don't choose between becoming a CRNA and a primary care doctor. The paths diverge a little later, when they're deciding between practicing primary care or specialty medicine.

Today is Match Day, when each year medical students find out which residency program they were matched with, which can determine the course of their career.

Like previous years, it's likely that more primary care than specialty slots will go unfilled. Top choices are often anesthesiology, surgery, and other specialties that can pay four times as much as family practice or internal medicine.

Part of the difference is due to market value. A recent survey found that a neurosurgeon on average generates $2.8 million in revenue each year for an affiliated hospital (through referrals, tests, and procedures), whereas a family physician brings in $1.6 million. But the real driver has been the lopsided reimbursement system that rewards procedures over cognitive care.

I've written several times in the last few years about this discrepancy and the problems it creates, as well as a range of possible solutions. CMS is working on redistributing reimbursement slightly from specialists to primary care doctors, and healthcare reform will include additional payment bonuses for PCPs. International medical graduates play a big role in filling the gap and keeping primary care afloat.

But these measures aren't going to reverse the trend overnight. To borrow an analogy, the healthcare system is an ocean liner, not a speedboat. Increasing reimbursement 10% or so is a change in the right direction, but the imbalance took years to build up and will probably take a while to correct.

Improving the system of primary care will require more than additional physicians. We need new models of care and better communication between doctors. New technologies and better use of nonphysicians will help.

A good indicator of progress each year will be the results of Match Day, and how many new physicians find it worthwhile to take the road less traveled.