Most people rely on their primary care doctors first when they need health care. But a shortage in primary care doctors is only getting worse. Some medical schools have been successful in keeping their grads in primary care. We talk to an expert from one of them to see how it’s done and if other schools can replicate their success.
- Dr. Elizabeth Baxley, Senior Associate Dean for Academic Affairs and Professor of Family Medicine, Brody School of Medicine, East Carolina University
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Reversing the shortage in primary care doctors
Nancy Benson: When you think of going to the doctor you probably imagine your primary care physician, maybe it’s your family physician, general internist, or perhaps the pediatrician who sees your kids. Family practitioners alone handle almost 200 million office visits a year. Nearly 70 million more than the next largest medical specialty, but primary care doctors are in short supply and our health is suffering for it.
Dr. Elizabeth Baxley: Certainly the wait times for medical care in the country are longer than they need to be. We want patients to have access to the right care that they need at the right time. Not be given more care than the need or less care than they need and we know we’re not there yet.
Benson: That’s Dr. Elizabeth Baxley, Senior Associate Dean for Academic Affairs and Professor of Family Medicine at the Brody School of Medicine at East Carolina University.
Dr. Baxley: And a number of people aren’t getting, they’re just not getting access to care where we see them, unfortunately, is in our emergency departments for non emergent care or when they have had things that could’ve been handled earlier where their disease has progressed to a pretty significant level and they’re sicker than they need to be.
Benson: Family physicians and other primary care practitioners try to stretch themselves with staffing arrangements that have become familiar over the last few years. For a lot of routine visits patients don’t see the doctor at all – they’ll see a nurse practitioner or a physician’s assistant instead. Drug store clinics are another response to the shortage, an alternative when you simply can’t get an appointment at the doctor right away. Baxley says those clinics have their place but they cant replace having a medical home.
Dr. Baxley: There are a number of different options out there where you see in even some of the pharmacies and minute-clinic and some of those things and that works for episodic care and it’s convenient. When you think about total care, comprehensive care, for any of us – having that medical home that you can go to where they know you, they who you are, they know who your family members are, they know the context that you live and work in and they understand what your own personal goals are for your health – that’s a different level and that’s where the episodic care really doesn’t meet that need. Episodic care is really good for a lot of things but it doesn’t replace the need for, what a lot of people refer to, as comprehensiveness. And there are many studies, over decades, both in the US and other developed countries that show that with a strong primary care base, you actually do improve quality and reduce cost.
Benson: Nationally, less than a quarter of new doctors go into primary care. So experts project a shortfall of as many as 35,000 primary care physicians within the next ten years. Medical schools are trying to figure out how to combat the trend.
Dr. Baxley: Some of the work that is happening in that is to increase class size of medical school and to increase residency programs specifically in primary care disciplines that are more likely to meet that need. So there’s a lot of effort around that – the challenge when you think about planning for workforces is that, from the time a student enters medical school til they’re out and practicing, is a minimum of seven years – so there’s a long glide path if you will, to get them into training. The work that’s being done now will be realized in the future, but it doesn’t happen over night.
Benson: And it won’t happen at all unless medicine can make primary care careers more attractive. Baxley says economics have a lot to do with it.
Dr. Baxley: Specialty care has been reimbursed at higher rates so procedures as opposed to what we think of as cognitive work, the working with patients and thinking through diagnostics and treatment plans has historically, in this country been, financially reimbursed at higher rates. And then the cost of medical education has gone up over time, it wasn’t ever inexpensive and its costly to educate a medical student so when you look at students graduating with levels of debt that are high and they think about paying off their debt and they think about living in a nice area with their family and able to get that job load down, then often they are attracted to more lucrative specialties. Or they’re distracted from looking at seems to be a more uphill battle in their own personal finances.
Benson: Baxley says that East Carolinas Brody Medical School was established with a mission of training doctors in primary care fields and its tailored programs could be a model for others to follow.
Dr. Baxley: Our student average indebtedness at Brody is nearly $50,000 per student less than the national average. So if you look at last year, the average debtedness at Brody for Brody Medical student at the end of their training was $108,000 compared to over $156,000 as the national average. If you look even beyond that there’s just under a third, 32 and a half percent, just under a third of all medical students nationally whose medical school debt is over $200,000. At Brody, the over $200,000 debt percentage is only 3.4% and the reason this is important is that we could recruit the right students and we can put them through curriculum but if didn’t hold their tuition at something that will allow them to chose their specialty based on what they wanted to do, what their heart told them they wanted to do and not have to think about their pocket book, we wouldn’t get the outcomes that we get. So we have to recruit the right student, we gotta give them the right training, but then we’ve gotta be able to let them chose from their heart and not their pocket book.
Benson: Brody students also learn about more than just medicine – they’re taught how the medical structure works and how sometimes it doesn’t.
Dr. Baxley: We’ve trained medical students about the cardiac system and the pulmonary system and the renal system and then we graduate them having never trained them about the healthcare system that they’re going to work in. And when you think about an industry that’s changing as quickly as ours is and you think about the reports that have come out from the institute of medicine and other places showing that – we don’t have reliable systems, there are errors in healthcare, we don’t have the safest systems as we need to have. That we can provide higher quality care than we provide and that those issues are not individual issues, they’re not because individual nurses or doctors are poorly trained or lazy or come to work not wanting to help people – it’s because our systems aren’t designed as well as they could be to be reliably providing the highest quality of care. So at Brody, we are transforming and significantly transformed our curriculum throughout the four years, so that students really get to understand what the science is behind patient safety quality improvement.
Benson: And importantly, students are required to learn about community practices in an 8-week clerkship, with four of it in primary care. Students also man free clinics out in the community, the results are impressive; more than half of Brody graduates are still in primary care at least 5 years after they’re out of medical school. That’s more than double the proportion of the average medical school. The American Medical Association hopes other institutions can learn. It’s a side a East Carolina and 10 other medical schools with the very big job of finding ways to increase primary care in the nations future healthcare work force. You can find out more about all our guests through our website, radiohealthjournal.net. Our production director is Sean Waldron. I’m Nancy Benson.