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    Wednesday, March 01, 2006

    Bush Hates Family Doctors: That's the gist, anyways, of this NPR story about community health centers. Seems that even as the Bush Administration pushes to build more community health centers in poor urban and rural areas, there aren't enough doctors to staff them:

    "The question was, whether or not it would be possible to expand these community health centers if there wasn't anybody there to staff them," said Roger Rosenblatt, a professor of family medicine at the University of Washington. Rosenblatt and colleagues polled all of the nation's health centers to find out.

    He says the news they got back -- published in this week's Journal of the American Medical Association -- was ominous: "There were large numbers of vacancies, particularly for family physicians, at a time when the number of students going into family medicine had decreased 52 percent in seven years."

    Adding to the problem, says Rosenblatt, is the fact that the administration is proposing to cut or freeze the few federal programs that help pay for the training of family doctors. The president's budget for Fiscal 2007 would eliminate the primary care training programs under Title VII of the Public Health Service Act, and it would provide no increase for the National Health Service Corps. The NHSC provides scholarships and loan-repayment programs for medical students who agree to practice in areas with doctor shortages.

    Rosenblatt says that expanding one program while cutting others makes little sense. "I think the administration hasn't got a clear comprehensive picture about how all these parts are tied together," he said. "You have to have a workforce to provide the care. Just having an edifice or the organization isn't enough."

    ....And while President Bush likes to talk about market solutions to solving the nation's health care problem, study author Rosenblatt says the fact that some 46 million Americans have no health insurance, and the very need for the government-funded health centers, shows that the "the market doesn't work in medical care."

    Seems the market is working all too well in this case. It's just not giving the results these guys want. Medical students choose specialty fields because they promise better financial rewards than primary care. The lowest doctors on the income scale are pediatricians, family physicians, and internists - in that order. And once they become primary care doctors, they'd rather practice in a comfortable setting like the suburbs than out in the sticks where the hours are demanding and the risks much greater. Where one's forced to practice John Wayne medicine. The study itself makes that clear:

    Major perceived barriers to recruitment included low salaries and, in rural CHCs, cultural isolation, poor-quality schools and housing, and lack of spousal job opportunities.

    The trick is to get family medicine (and pediatrics and general internal medicine) to be as attractive as specialty medicine and rural and poor urban areas to be as attractive as suburbia. One way would be to pay primary care doctors better. (Like that's going to happen.) Or the field more "glamorous." (Even less likely.) Specialty fields are attractive not just because they pay more, but also because a more narrow field of knowledge to master. That doesn't make them easier to learn, but many people feel much more comfortable knowing a lot about a little than a little about a lot. Once technological advances made specialization necessary, it was inevitable that primary care would suffer. As for making rural areas as attractive as suburbia, well, sorry, I can't think of any way to do that. You have to have a special nature to love rural living. And I confess, I don't have it.

    But back to the medical specialty problem. One of the problems, (the "glamour" side of the equation) is that family medicine and primary care in general gets short shrift in medical students. Many of the best medical schools have no departments of family medicine, and their departments of pediatrics and internal medicine are devoted primarily to the subspecialists - the pediatric endocrinologists, pulmonologists, geneticists, etc - who begin in peds and internal medicine before going on to do their specialist fellowships. There's very little exposure to primary care medicine. My medical school happened to be one that was founded with the mission to increase the number of primary care doctors in my state. And yet, primary care got short shrift there, too. Among the faculty. Among the residents. I remember my senior year, a resident telling me "a peanut" could go into primary care. And that was almost twenty years ago, before the decline began.

    There's no good answer to the shortage of primary care physicians, barring forcing medical students to enter the field, which would be a mistake. The only thing worse than not having enough primary care doctors is having plenty of them who all hate their jobs. And make no mistkae, that's what people mean when they talk about "policy solutions" and the market not working. They mean forcing their choices on others.

    It's all the more to be pitied because primary care really is rewarding in ways that specialty care can never be. There's never a boring day. There are aggravating days, yes. And exhausting days, as in any field. But where else but family medicine can you go from the sad decline of old age to the wonderful delight of a newborn baby within the space of 15 mintues? Variety is the spice of life and family medicine has it in spades. It just won't make you rich.

    posted by Sydney on 3/01/2006 09:30:00 PM 6 comments


    I personally could not be a specialist. I cannot imagine doing the same medical procedure day in and day out no matter what I was paid.

    The market is not working in this way. I believe there is a surplus of specialists in many cities so their fees should be dropping and they are not. There is a shortage of primary care doctors so their fees should be rising and they are not.

    By Blogger Jake, at 10:25 PM  

    Not much variety in Peds.

    Which is why Pedies ought to go back to the hospitals from whence we came, and well children properly belong with the FPs, or with P-NPs, or PAs.



    By Blogger Flea, at 11:32 AM  

    From an ecomnomic point of view, the small town where I worked has overtly stopped recruiting Family Physicians. They figured out that FPs are able to provide good medical care less expensively.
    While that sounds like a good goal, the hospital makes much more money if it can keep it's lab and MRI running at full capacity. They can achieve this by hiring specialists who feel it is necessary to do more tests to rule out every possible diagnosis rather than use a more rational approach.
    This was bad for me as a family doctor, but worse for patients who will bear the brunt of the discomfort.
    If more people understood how our specialty driven system costs more in terms of unneccessary testing and patient discomfort, there would be a huge public demand for more primary care physicians. And we will be there as the Baby-Boomers begin to demand a personal physician who can advise them through our complex medical system with compassion.

    By Anonymous CKH., MD, at 12:00 PM  

    The market wants more primary care for less. The market also wants more protocol and guideline driven primary care which can be measured and analyzed. I think the market realizes that this will not come from training more primary care physicians. I think there is going to be a movement toward pushing primary care to mid-level providers (NP's and PA's) who are cheaper to train, work for less money, and are more accepting of checklists, protocols, and guidelines. A shortage of actual primary care physicians may be a good thing. The lower numbers of well trained primary care physicians may actually improve their job satisfaction by assuming positions where they manage groups of mid-level providers or practice in concierge or cash-only settings where they are seeing patients who will pay more for the privilege of seeing a physician. I think this is where primary care is heading.

    By Anonymous Anonymous, at 1:29 PM  

    Anonymous, I agree with you. People will train to be recognized for their skills or simply not becomes MDs in the first place. The return on investment for a primary care physician is less than dentists, specialists, lawyers,and business people in that order.

    As for there being too many specialists, my hospital has been recruiting for GI (this is a critical shortage that we have had for years), neurosurgery, radiation
    oncology, OB/Gyn etc. And of course, primary care. So it seems that doctors are beig underpaid all the way around and that the specialists have found ways to close the income gap better than the primary care dcotors. It's a mistake however, to think one specialty has anything to do with the other in terms of allocating revenes.

    By Anonymous Dani, at 11:27 AM  

    I think I'd do family medicine just for the pleasure of doing it. I know, I know -- I'm a dreamer and seriously misinformed. But I would, anyway.

    By Blogger bill, at 6:16 PM  

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