There is no doubt that Affordable Care Act has changed the landscape of medicine in the US. Now, private practice is becoming a thing of the past. Financial pressures, increasing regulatory requirements, electronic medical records and outrageously complex coding systems are forcing long time private physicians to enter into agreements with academic centers and large hospital systems in order to survive. As a result, medicine today is more about increasing patient volumes, completing reams of paperwork and administrative duties than it is about interacting with patients and providing superior care. The American Academy of Family Practice (AAFP) estimates that there will be a significant shortage of primary care physicians in the next several years unless we increase the number of primary care trainees by more than 25% over the same time period. In fact, the AAFP suggests that the primary care workforce must increase to 260K physicians by the year 2025–which translates to an additional 52K primary care doctors.
Given the need for more physicians and the pending shortage (particularly in primary care), many analysts have suggested that the reason for the shortage is a lack of training slots in primary care. The ACA will add an additional 32 million patients to the pool of insured and primary care doctors will be at a premium. In the New York Times this week, the editorial board collectively penned an article discussing their thoughts concerning the doctor shortage. The NYT editorial board suggests that the shortage is all about an imbalance between Residency training slots and medical school graduates and can be easily corrected by federal funding of a larger number of training positions. However, I think that the issue is much more complex and the solution is far from simple.
Primary care is an incredibly challenging specialty and requires a broad knowledge of much of medicine. Reimbursements for primary care work continue to lag and physicians are now spending more time with administrative duties than they are with patients. I do not believe that the so called post graduate training “bottleneck” will come into play. I would suggest that many primary care training slots will go unfilled over the next 5-10 years even without increasing the numbers of available positions. Increasing training slots for primary care specialties may do nothing to alleviate shortages if there are no students who wish to train. While medical school enrollments have increased over the last decade, much of this increased enrollment may be due to a lack of jobs available to recent college graduates. Moreover, as the ACA continues to evolve, physicians are now realizing lower compensation rates, increased work hours, more administrative duties and LESS time spent caring for patients. Many physicians are forced to double the number of patients seen in a clinic day–resulting in less than 10mins per patient–in order to meet overhead and practice expenses. In a separate article in the New York Times, author and cardiologist Sandeep Jauhar discusses the increased patient loads and subsequent higher rates of diagnostic testing that is required in order to make sure that nothing is missed–ultimately increasing the cost of care.
For most of those who have entered medicine, the attraction to the profession is all about the doctor-patient interaction and the time spent caring for others. I would argue that the primary care shortage (and likely specialist shortage) will worsen in the future. Many bright minds will likely forego medicine in order to pursue other less government-regulated careers. In addition, many qualified primary care physicians will opt out of the ACA system and enter into the rapidly growing concierge care practice model. The answer to the physician shortage may be more political than not–politicians must realize that laws and mandates only work if you have citizens willing to devote their time, energy and talents to the practice of medicine. Going forward, more consideration must be given to physician quality of life and autonomy must be maintained. In order to make healthcare reform sustainable, those in power must work with those of us “in the trenches” and create policies that are in the best interest of the patient, physician and the nation as a whole. Cutting costs must be approached from multiple angles–not simply reducing the size of the physician paycheck.
Medicine remains a noble profession. Those of us that do continue to practice medicine are privileged to serve others and provide outstanding care. In order to continue to advance, we must continue to attract bright young minds who are willing to put patients and their needs above their own–at all costs. I think that there is still HOPE to save medicine in the US. It is my HOPE that our government will soon realize that in order to continue to propagate a workforce of competent, caring physicians we must provide time for physicians to do what they do best–bond with patients and treat disease. (as opposed to typing into a computer screen and filling out endless reams of electronic paperwork). It is my HOPE that those physicians in training that will follow in my generation’s footsteps will realize the satisfaction that comes from impacting the health and lives of patients over time. It is my HOPE that the ART of medicine can be saved before it is too late….
Posted in Disparities in Care, Doctor Patient Relationships, Healthcare Reform, Medical Education, Optimizing Patient Care, Professional Well-Being
Tagged ACA, Doctor shortages, medical school, Obamacare, primary care, Reform, Residency
In the satirical novel The House of God, author Samuel Shem writes about experiences as a medical student at Harvard. In the novel, many famous quotations are used that have been passed on from generation after generation of medical students and residents. Some slang terminology is also referenced and characters are created to illustrate the qualities of certain types of students. One particular student that is found in every medical school class is the “Gunner”. The Gunner is a term used to describe a hyper competitive medical student who is motivated by performance and grades and will stop at nothing to succeed. Almost every medical school class in the US has a couple of students with this character trait. All of us who have trained in the past can still remember who these students were in our own classes. Sadly, a Gunner feels no remorse about climbing over others to achieve success on the medical wards when being evaluated by attending physicians. A Gunner never learns how to work well with others and, although performs remarkably well on exams and evaluations, is often left without essential skills for success in medical practice.
Last week in the New York Times, Author Pauline Chen writes about the inability of the current medical education system to “fail” students with poor interpersonal skills and the inability to work with a team. Now, more than ever, teamwork in medicine is essential to success. In the article the story of a bright, young medical student is detailed. This young student is able to ace all of the written exams but isolates herself from classmates, treats nurses and colleagues with disrespect and is unable to accept constructive criticism. The attending physician supervising the student laments that he is unable to “fail” her due to the fact that there are no objective evaluations in the medical school grading system to deal with important attributes such as bedside manner, communication skills and interaction with nurses and colleagues.
In my opinion, this story illustrates a major flaw in our medical education system. We have a responsibility to students as well as future patients to help create doctors who are not only brilliant diagnosticians and clinicians but are also compassionate, caring and able to easily work with others. No longer is medicine practiced by the Physician in isolation. Today, medicine is centered around a team approach. Nurses, physician extenders, social workers and physicians all work in concert to produce excellent patient outcomes. Healthcare reform has now mandated certain (sometimes arbitrary) quality measures and it is only through a comprehensive team approach that these can be achieved and (more importantly for the government) documented. Nothing productive has ever emerged from a negative confrontation with nurses or colleagues in a hospital. We must reward students who display the ability to work well with others and effectively communicate with staff. More importantly, we must teach students how to readily accept and respond to constructive criticism and continually self evaluate.
Certainly, proficiency with test taking and knowledge acquisition is essential to creating a successful, effective physician. However, a physician who is able to work well with teams and communicate effectively with non physician support personnel is just as essential. We must develop a system put that actively strives to teach and evaluate these important interpersonal skills in medical school. Once students are advanced to internship and residency, these bad habits are much more difficult (if not impossible) to break. Competitiveness and striving for excellence are still important qualities in medical students. However, compassion and concern for others may be even more rewarding in the long run.
When I was in medical school in the 1990s, students were given a bleak picture of the life of a subspecialist. We were told that there would be few job opportunities and that the only way to ensure a job was to pursue a career in primary care. Many of my classmates did go into primary care but the majority of us accepted residency positions in surgery, neurosurgery and other medical subspecialties. As we completed our training, we found that there were actually plenty of job opportunities for subspecialists. In fact, other than in underserved areas, shortly after my graduation from medical school primary care doctors were abundant. However, times are now much different. As discussed in the New York Times this week, it is becoming more and more difficult for patients to find primary care doctors. In a very short time, there will be more than 40 million newly insured patients that flood the system. All of these patients will need primary care providers.
Today’s medical students are saddled with enormous debt. The average cost for a medical education at a public university is $29K per year for four years; the median cost at a private school is nearly $50K per year for four years. Many students leave medical school and enter residency training programs with between $200 to $300K in debt. The cost of a medical education has risen almost 300% over the last 20 years. Now, particularly in primary care, salaries and reimbursements are significantly lower than in previous decades. Add to that the ever-increasing burden of paperwork and administrative duties that are required of primary care physicians and it becomes obvious why there is a shortage of newly trained primary care practitioners. Many students pursue a medical education to make a difference and to help people–many enter school wanting to be primary care providers and work in underserved areas. However, the financial realities of debt often force students to change their minds and seek residencies in subspecialties that hold the promise of better financial return.
Healthcare reform is important. We must focus on providing quality care to patients who need it in the US today. However, we must also reform the medical education system. No longer can we continue to allow the costs of tuition to rise to astronomical levels and at the same time lower the potential earnings for medical school graduates. If we continue on the current path, we will make a medical education an “upside down” investment. Moreover, allowing the tuition of medical schools to soar will make it more difficult for bright students with limited financial means to attend. We will, in fact, self-select medical school classes of the financially privileged and prevent other very talented less affluent students from attending. Although I was fortunate enough to receive an academic scholarship to medical school, I often ate macaroni and cheese and ramen noodles for weeks at a time in order to make ends meet. I had a job moonlighting as an MCAT preparatory course instructor. But, I did have access to an excellent medical education. In addition to containing the cost of a medical education, we must also address the issue of the investment of time–is it really necessary for physicians to attend four years of undergraduate work and then four years of medical school? In many countries in Europe, a combined track of 6 years produces well trained physicians that do very well in US residency training programs. Many students do not begin their careers until their early 30s due to the combination of undergraduate and graduate degrees coupled with prolonged fellowship training programs.
The US offers some of the very best training for physicians in the world. We are fortunate to have some of the finest institutions with cutting edge technology. Our students are able to be trained in the most sophisticated medical procedures and are able to participate in research that makes a difference in the lives of many patients. However, the medical education system in the US is currently broken and something must be done to fix it quickly if we are going to keep up with demand. No longer can we squeeze the young physician at both ends–astronomical educational costs, prolonged times to acquire both undergraduate and graduate degrees must be addressed as salaries and earning potentials continue to be regulated, lowered and limited. Primary care doctors are essential. They are the entry point for patients and the stewards of our healthcare. Yes, there is a shortage of primary care physicians today and even greater shortages loom ahead. In order to fix this problem, we must closely examine the system and make changes that allow for access for all qualified students with a more reasonable time investment. In the end, our goal should be to produce the best physicians in the world, who are motivated to care for the patients who desperately need them today and in the future.