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Are Primary Care Physicians an Endangered Species?

In the June issue of the GME e-Letter, we noted the many challenges facing primary care and asked, "Are primary care physicians an endangered species?"

In response, we received the following feedback from readers; identifying information has been removed. (Note: These views may not necessarily reflect those of the AMA.)

Primary care internal medicine, pediatrics, and obstetrics-gynecology should be reimbursed at least double what it is now by 3rd party payers for cognitive work. People should be configured into multi-specialty health centers such that everyone has a pediatrician or internist (depending upon age), and all women should have a primary care ob-gyn doctor. 

Primary care suffers not only from low reimbursement rates, but also from a delusional approach that seems to be pervasive in most family medicine programs--the "we get to manage all the trauma, all the ICU cases, and everybody who is admitted to our hospital and we get to work alongside the specialists!"

Most of the family practitionersI know that are sane and can recognize their children, and sleep more than 4 hours per night, use hospitalists to handle their inpatient work, ER docs to cover the ER, and don't do OB. True, if you are going to live in truly rural America you would need those skills, but let's get real--no one is living there.

I find some irony in the continuing news of the decline of primary care. As a pediatric subspecialist, I have gotten limited response from the American Academy of Pediatrics to our subspecialty concerns. We have discussed many times to little avail that due to a heavy emphasis on primary care in the late 1980s to the late 1990s, subspecialists in medicine and pediatrics were suddenly in short supply since 1995 and those working in those fields were overworked and underpaid and burning out. So despite the efforts to push primary care by the federal government and many medical organizations (tying medical scholarships/loans to primary care, department heads pushing primary care), primary care is now in dire straits, as are many subspecialty groups, especially nonprocedural subspecialties. Both groups are hurting.

Though more residents may be seeking subspecialty training, it will be years until the deficit from the 1990s is made up, especially since many residents have debts that make ICU and ER subspecialties more attractive than others, and more women are graduating from medical schools and choosing part-time work.

If baby boomers can last to age 70-75 before going part-time or retiring, it might work out. If not, primary and subspecialty care and American health care are heading to a trainwreck, neither discipline able to help each other out. This medical system badly needs organization and planning.

I am a primary care Med-Peds doctor with a fabulous, fulfilling job. I direct a really busy, patient-centered practice that is thriving and growing and financially sound. I attribute my professional satisfaction to my openness to the opportunity for professional liberation through collaborative integration of effective office management and physician extenders into my practice. I also have had the opportunity to maintain an academic connection despite being in a small community.

I still really value and enjoy direct patient care after 10 years, because I have prevented intoxicating, often toxic amounts of direct responsibility for every single entire patient care encounter in the practice. I have professional time to develop my team and practice leadership skills because I have engaged physician extenders in the health care team in a constructive way. Time for self-reflection and reflection on one's clinical practice is crucial. Any primary care doctor who runs crazy for the entire day without escape time to reflect and plan is doomed to despair. I have successfully maintained my attitude that caring for my patients is a tremendous privilege, and I love my job. My professional satisfaction could be significantly less now if I had remained in solo practice without any effective office management, extender service, or academic connection. The silo experience is really only a "fun" adventure for less than a year until you learn it is overwhelming, exhausting, consuming, and ineffective. If you never take the reflective time to acquire this acknowledgement, it will sour and devour you.

Primary care doctors often get so caught in the daily grind of endless work. Because they refuse to delegate some of the responsibilities in an effective way, their thinking becomes convoluted. These physicians see physician extenders as competitive threats that may "cannibalize" their business. I suspect that if they reflectively stepped back and delegated some of the responsibilities they have mastered over time to physician extenders who find these responsibilities professionally challenging, there could be a real win-win team interaction.

Promoting the professional development of physician extenders will allow the primary care physician community to recognize the potential for challenging, fulfilling professional development in the arenas of team leadership and population management. The reimbursement adjustment is an obvious mandate to enhance the attractiveness of primary care as a career. More pressing, however, is that the definition of a primary care physician needs to be refined and redefined as the true leader of the primary health care team if there is any hope of reengaging bright, altruistic but balanced young minds into this vocation.