Saturday, March 21, 2009

Continued decline in primary care

The results of this year's National Residency Match Program (NRMP), referred to everywhere as the Match, show a continued struggles to bring medical students into primary care.

The American Academy of Family Physicians reports that fewer medical students chose to enter family medicine this year. This continues the downward trend since 1997 in the number of students choosing family medicine. Last year showed a small increase in the number, but it appears to have been an exception. This is combined with fewer and fewer residency postions offered over the same period.

So--fewer family doctors are being trained every year. Family physicians provide health care to many, many underserved areas in the United States and if the numbers of family physicians being trained continues to drop, one expects that more and more communities will be designated as medically underserved.

To add to the problem, fewer students entered primary care internal medicine and internal medicine/pediatrics programs. Primary care pediatrics has also been struggling to fill offered positions.

So--primary care physicians, who are in short supply now and will continue to be in short supply for some time are not being trained at the levels needed to maintain the workforce. The largest culprit for this seems to be worries around medical school debt: students are less likely to consider primary care if they carry high levels of debt and instead move toward better-compensated specialties. In addition, the current structure of funding medical schools and the structure of medical school educational programs appears to discourage students from considering primary care (especially family medicine) careers.

As primary care continues to be undervalued in our health care system and as primary care physicians continue to be underpaid relative to the critical role they play in the health care system, it is easy to predict further declines in the family medicine/primary care workforce until either major health care reform makes the career option more palatable for medical students or a level is reached where this difficult situation becomes a greater crisis.

Health care reform

Another digression from my oh-so-interesting life story to touch on health policy again. As is obvious to anyone who has any contact with health care (patients, doctors, etc), health care in the United States is in bad shape. Costs are increasing dramatically, but we still rank very poorly in terms of meaningful health care outcomes. 50% of all bankruptcies in the U.S. are due to medical bills and, of these, 3/4 had health insurance at the time they became ill yet STILL became bankrupt. Doctors are frustrated with insurance hassles, employers (who provide health insurance to most Americans) are struggling with the costs, and patients are going without needed care. Meanwhile, the system itself is focused on dealing with illness and is not adequately focused on promoting wellness and providing preventive care.

President Obama has made health care a priority for his administration, and has proposed 8 principles for quality health care:
  • Protect families’ financial health.
  • Make health coverage affordable.
  • Aim for universality.
  • Provide portability of coverage.
  • Guarantee choice.
  • Invest in prevention and wellness.
  • Improve patient safety and quality care.
  • Maintain long-term fiscal sustainability.
These principles are a starting framework, and the Senate is hoping to have a bill to be voted on within the next 6 months.

This is going to be a KEY period in health care, and might determine the face of U.S. health care for the next generation. I intend to post again soon to give some thoughts on the issue.