There is a hidden health care crisis in America. Too few US medical school students are choosing to go into primary care, and the current primary care physician workforce is not growing fast enough.
News articles like to talk about “burnout” in the health care profession, but this term has limited application to what is actually happening to primary care physicians in our country. Burnout implies a failing on the part of an individual – someone is overwhelmed and unable to handle job demands. “Moral injury,” on the other hand, shifts the focus to the suboptimal work environment our health care system creates for physicians. It emphasizes that the paucity of primary care physicians is not a matter of individual failure, but of a larger system breakdown.
Modern health care systems require primary care doctors to spend too much time behind a computer screen dealing with electronic medical records and clerical tasks at the expense of seeing and helping patients. This kind of workplace has limited appeal for medical school students choosing how they would like to spend their careers.
Data bears this out. The supply of key primary care physicians in the US has not kept up with increasing demand. While supply projections for advanced practitioners such as nurse practitioners and physician assistants in primary care are surging well past expected demand, there are persistent gaps between projected amounts of needed families and internal medicine practitioners and those expected to be in the workforce.
At the same time, recent years have seen declining shares of US allopathic, or MD, medical school students filling internal and family medicine positions for their residency. Others, like osteopathic physicians, can fill such slots, yet the American Association of Medical Colleges has projected a shortage of 17,800 to 48,000 primary care doctors in the US by 2034.
The structural problems within our primary care system extend to financial incentives. The appealing aspects of primary care – developing long-term relationships with patients and families, focusing on prevention and wellness rather than disease management, working with a diverse patient population – hold less sway with new medical school grads saddled with hundreds of thousands of dollars of debt. It makes the sense that aspiring doctors may choose to pursue more financially lucrative medical specialties, such as surgery or dermatology.
Survey data indicates the lowest-paying sector for physicians to work in are public health and preventive medicine. Physicians who choose to work with the most vulnerable populations, particularly patients receiving Medicaid and Medicare, receive less reimbursement for their services, as rates for these insurance programs generally fall well below those of commercial insurance.
In addition to inadequate pay, primary care physicians also work long hours and see far too many patients (around 20 a day), with an average visit length of 18 minutes. This does not allow enough time to establish relationships with patients and address their complex needs – which increasingly include chronic disease management along with psychiatric and social concerns – far less complete their administrative tasks. The COVID-19 pandemic magnified this problem.
Because of these demands, primary care physicians often feel they cannot provide their best care to patients. One recent study found that primary care physicians who were not part of team-based care would need a 26.7-hour shift to follow recommended guidelines for care.
Getting more doctors to enter – or stay – in primary care is a complicated challenge, but a good start would be investing more in the public health care system and its primary care physicians. Does this mean providing higher compensation to create more parity with other sought-after medical specialties? Absolutely. One avenue for doing so would be to emphasize the importance of primary care and protect it within the Medicare Physician Fee Schedule, which in turn could bolster the fee schedules used for Medicaid. Another avenue to make the field more attractive would be to expand loan forgiveness for physicians who practice primary care.
But increasing revenue opportunities alone will not be enough to incentivize a sustainable workforce shift. We also need to invest in primary care practices to ensure better staffing and task-sharing, so that everyone can practice to the top extent of their license and capabilities. Hiring nurse practitioners, physician assistants and medical assistants can provide support with patient care and help ease clerical burdens stemming from charting, coding and insurance-related issues.
Taken together, these steps can enable more physicians to see primary care as a venue where they can focus on what drew them to medicine in the first place: helping patients.