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In recent years, there has been a decline in the number of medical students who want to pursue family medicine, though many say it is the frontline for wellness and preventive-care programs that can help reduce healthcare costs. According to the American Academy of Family Physicians (AAFP), the number of U.S. medical students going into primary care, which includes family physicians, general internists and general pediatricians, has dropped 51.8% since 1997. Medical specialists have cited the decline to such factors as longer days, lower wages, less prestige and less administrative headaches. Some experts believe the biggest problem is the payment model because the more procedures a doctor performs, the more money he or she makes. This encourages medical students to pursue a procedure-based specialty as opposed to a primary-care track.

Because it takes about ten to eleven years to educate doctors, health-care experts are worried that the decline will cause a shortage of 40,000 family physicians in 2020 when the demand is expected to spike. Eleven of the top conventional medical schools in the U.S., including Johns Hopkins and Harvard, do not even have a separate family-medicine department. Finding a doctor will become increasingly difficult; there will be longer waits in the waiting rooms and more people will turn to the emergency rooms to get help because the waves of patients will be enormous. When patients visit the doctor’s office, they may also see a nurse practitioner or physician’s assistant instead of the doctor due to the increasing demand. This practice of involving nurse practitioners and physician’s assistants in care is already in place to alleviate physicians from time-consuming tasks in order to focus on the continuity of quality care.

While the U.S. healthcare system has about 100,000 family physicians, it will need 139,531 in ten years; the current environment is only attracting half the number needed to meet the demand. At the heart of the rising demand for primary-care physicians is not only the current group of underserved patients, but the baby boomer generation also, born from 1946 to 1964. This generation will be turning sixty-five in 2011 and will need increasing medical care. If Congress passes healthcare legislation that extends coverage to a significant part of the forty-seven million that do not have insurance, the number of people requiring care will continue to escalate.

In March 2009, U.S. medical school graduates only filled forty-two percent (1,083) of the 2,555 resident positions for family medicine. More than two hundred positions were left unfilled nationwide. More than half of the other spots were filled by non-U.S. students educated internationally, U.S. citizens educated internationally and graduates of colleges of osteopathic medical schools, though graduates of international medical schools and osteopathic medical schools seem to be losing interest in primary care also. This presents the problem of some foreign students with poor English skills not being able to communicate well with their patients.

Members of Congress have taken notice of the potential “crisis” associated with the lack of primary care physicians and have begun looking into bills that could help doctors who choose primary care with loan forgiveness or other debt relief and payment increases for their services.


  1. Gravatar for Mike Bryant

    You would hope that supply and demand would go into this, seems like there will definitely continue to be the need. We are really seeing the increased use of nurse practitioners in Minnesota. For some people, that is the only health care person they deal with.

  2. Gravatar for Facebook User

    Using a true measure of primary care delivery the sham and shame of primary care is revealed. A family physician delivers 25 Standard Primary Care years compared to 2 for internal medicine, 3 - 4 for nurse practitioner or physician assistant graduates, and 15 standard primayr care years for pediatric residency grads. The SPC year is an estimate for an entire class year, such as these 2008 estimates using the 4 factors that determine the SPC Year.

    The 4 factors most closely associated with actual delivery of primary care over a career are multiplied: years in a career times % actually remaining in primary care times % remaining active for a career times a % volume adjuster (the % compared to the gold standard of 100% for a family physician). One might question the value of volume until realizing that the US will be short of primary care for the next 30 years even if we do recover sufficient production. All patients like more time spent and rate practitioners higher for more time, but patients need to have basic access to health.

    There are characteristics by type of primary care that do not change and result in limitations in primary care delivery. The years for a career are 35 (age 30 - 65) for US origin primary care physicians of all types and physician assistants. The career length is 27 years for nurse practitioners and international medical graduates of foreign origins. Delays in entry cut 23% of the workforce of NP and FIMG before they begin.

    NP and FIMG also have the lowest activity in the US workforce as the factor for activity is 60%. For NP this is the result of the most inactive or part time grads. The levels would likely be higher if all grads were tracked more diligently. For FIMG the 60% is the result of usual 10% lost for all practitioners, 20% departing for home nations at graduation, and another 8 - 12% chronically inactive or departed for other nations. All told the foreign origin international medical grad loses 50% of workforce compared to US origin grads due to delays in entry and departures after graduation (AMA IMG report). US origin physicians remain active at 82 - 88% levels and physician assistants are about 70% active over a career.

    Volume of primary care is only 60% for NPs, a remnant of nurse one-on-one training and NP design that results in least primary care volume. Volume is 86% for internal medicine although FIMG IM is likely less than 80% due to adjustments and mismatches that impair volume. PA volume is about 70%. The 100% volume figure for FM remains the standard.

    The sham of primary care training is the lack of retention in primary care for a career for the flexible primary care training forms: IM, NP, and PA. Only 10% of IM grads will begin in IM with departures to come (Hauer, JAMA). The NP totals of true primary care are about 35% (FM, IM, PD forms). The PA grads of 2008 began at 28% primary care. Declines for IM, NP, and PA have averaged 2 - 3 percentage points fewer in primary care with each class year and each year after graduation for the past 30 years. Market forces set in place by health policy determine primary care retention or the destruction of primary care as in current policy.

    So if the US does decide to recover basic health access primary care, the need is 12,000 annual graduates (far less than the 28,000). But the catch is that they must remain active in primary care at 90% for their career and deliver 90% of the volume of a family physician.

    We can try to convince IM graduates to turn down $200,000 to $600,000 salaries to stay 90% in primary care. We can attempt to get NP and PA to turn down a minimum $10,000 more a year to remain in primary care.

    What is most devastating is loss of basic health access for 65% of the US population that resides in 29000 zip codes with just 20 - 25% of specialists and IM and PD. The only forms that serve them with 50 - 60% of grads are the family practice forms and only the family physicians stay in FP mode. The NP and PA family practice broad generalist mode continues to decline the most. What the US design does best is concentrate physicians and now non-physicians in 4% of the land area in 3400 zip codes.

    So when various experts claim more primary care from NP and PA, you can understand this as sham since a decline from over 60% to less than 40% (or much less) results in steadily less primary care, especially in NPs that have remained at 7000 annual grads across the last decade. When internal medicine is claimed as primary care training, you know that someone is selling something. The AAPA has realized the changes and has been honest about their contributions and declines in primary care.

    But if most of the US pop and most of the elderly are to get some help, it can only come from family practice or someone just like a family physician in origins, training, primary care retention, productivity, and distribution.

    Robert C. Bowman, M.D.

  3. Gravatar for Greg Webb

    Dr. Bowman,

    Thank you for taking the time to comment to the blog. Clearly, you have a command of a lot of data.


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