Oversimplifying Primary Care Supply and Shortages

Abstract

RECENT REPORTS HAVE WARNED OF A CRISIS RELATED to a shortage of primary care physicians. However, much of the current concern seems to have stemmed from articles in the medical literature specifically reporting that fewer internal medicine residents are choosing to pursue primary care and that fewer medical students are choosing family medicine residencies. Hauer et al found, among a national sample of fourth-year medical students, that only 22% planned careers in internal medicine and just 2% intended to practice general internal medicine. Ebell hypothesized that fewer medical students are choosing primary care specialties as a result of lower salaries relative to other specialties. It is important to note that the results of his trend-line analysis showed this was true only for family physicians. There has not been an appreciable change in the proportion of pediatric residents who choose primary care pediatrics. Thus, the concerns expressed regarding primary care should really only focus on the care of adults. While this is a large and important patient population, adults are not the only group served by primary care physicians. Historically, primary care has encompassed internal medicine, pediatrics, and family medicine; in some instances, obstetrics/gynecology is included. These groups are similar with respect to their primary care roles, but they are markedly different in many other ways, including workforce projections. For these reasons, it is disappointing that national discussions about the “crisis in primary care” have moved beyond the valid concerns regarding a shortage of physicians providing primary care to adults and have somehow come to imply a shortage of all primary care physicians. Multiple government reports also fail to distinguish among the primary care specialties when reporting on the crisis in primary care. For example, in its February 2008 report to Congress, the Government Accounting Office reported findings predicting a shortage of primary care physicians in 2018, without reference to specific specialties. Assessments by those tasked with determining sufficiency of training the physician workforce are no more specific. A 2005 report by the Council on Graduate Medical Education did not distinguish among the primary care specialties when assessing the future training needs of the country in this important area. The need to understand primary care workforce issues in a specialty-specific manner is critical, because any policy changes or economic incentives that affect the proportion of physicians pursuing primary care will likely have a differential effect across the primary care specialties. For example, it might be viewed as positive if the number of internal medicine residents who pursue primary care were to double. Indeed, a November 2008 American Medical Association news release reported a new policy aimed at “increasing the ranks of primary care physicians” without any reference to specific primary care specialties. However, the most recent published data regarding pediatric residents completing training in 2008 demonstrated that 40% were planning to pursue a career in primary care, with 10% still undecided. Similar findings were seen among senior residents scheduled to complete their training in 2009 (G.L.F. and J.A.S., unpublished data, 2008). Thus in pediatrics, a doubling or substantial increase of the proportion entering primary care could result in a possible oversupply of primary care pediatricians, likely at the expense of needed pediatric subspecialists. Markedly increasing the number of primary care pediatricians in the pipeline could create more such physicians than jobs available, resulting in the opposite effect of any intended legislation or other policy solution aimed at primary care. In contrast, the idea that there is a shortage of primary care pediatricians—or that, relative to the past, there are fewer primary care pediatricians to care for the current population of children—is contrary to published workforce and population data. While the absolute number of children in the United States has remained relatively stable, the number of pediatricians has increased substantially (FIGURE). This has resulted in an increase in the number of primary care pediatricians, from 32 to 78 per 100 000 children in the period 1975 to 2005. Similarly, there has been an increase in