Primary Care Crisis Research Articles

Oversimplifying Primary Care Supply and Shortages

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

Seeding Trials: Just Say “No”

A seeding trial is marketing in the guise of science. In 2003, Annals published a seeding trial sponsored by Merck & Co. No one told Annals the true purpose of the trial until the Editor received a...

Calif. Pediatricians Seek Solutions to Primary Care Crisis

Calif. Pediatricians Seek Solutions to Primary Care Crisis

Hemoglobin Level Variability

Awareness of hemoglobin level variability in dialysis patients is increasing, as is interest in its potential implications. In this retrospective, national study of associations between the degree of hemoglobin level variability in the first 6 mo of 2004 and subsequent mortality rates in the following 6 mo, 159,720 hemodialysis patients receiving epoetin therapy were studied. Monthly hemoglobin values were categorized as low (L; < 11 g/dl), intermediate (I; 11 to 12.5 g/dl), and high (H; >12.5 g/dl). Variability groups were classified on the basis of the lowest and highest hemoglobin categories seen during the 6-mo observation period: low-low (L-L), 1.4%; intermediate-intermediate (I-I), 6.0%; high-high (H-H), 2.3%; low-intermediate (L-I), 18.3%; intermediate-high (I-H), 31.7%, and low-high (L-H), 40.2%. On multivariate analysis, adjusted hazards ratios for subsequent mortality events were as follows: I-I, 1.0 (reference category); I-H, 1.02 (95% confidence interval [CI] 0.95 to 1.11); H-H, 1.06 (95% CI 0.93 to 1.21); L-H, 1.19 (95% CI 1.10 to 1.28); L-I, 1.44 (95% CI 1.33 to 1.56), and L-L, 2.18 (95% CI 1.93 to 2.45). Persistently and transiently low hemoglobin levels and highly variable hemoglobin levels were associated with increased risk of death; transiently and persistently high hemoglobin levels were not associated with increased risk of death. Bayesian modeling indicated that > or =3 mo with hemoglobin levels <11 g/dl may be associated with of increased risk of death. Number of months with hemoglobin values below the target range, rather than hemoglobin variability itself, may be the primary driver of increased risk of death. Further research is needed to distinguish cause from effect and to understand the underlying mechanisms.

Solving Our Primary Care Crisis by Retraining Specialists to Gain Specific Primary Care Competencies

ABSTRACT That this country now has a full-blown crisis in its primary care physician work force is hardly disputed.1-3 Simply stated, other developed industrial countries for many years have practiced medicine with roughly 50% of physicians in primary care and 50% in specialties and subspecialties.4 In the United States, however, we train and employ about 32% primary care physicians (general practitioners, family physicians, general internists, general pediatricians, and some obstetrician-gynecologists and emergency medicine physicians) and about 68% specialists and subspecialists.4 Health indicators show that comparison countries do as well as or better than the United States at providing care at much lower cost, whether cost is measured as the amount spent per capita per year or as a percentage of the gross national product. If that news isn't bad enough, the situation in the United States is rapidly getting worse. The percentage of physicians graduating from US medical

Solving our primary care crisis by retraining specialists to gain specific primary care competencies

Solving our primary care crisis by retraining specialists to gain specific primary care competencies

Crisis in Primary Care: Will Midwives Meet the Challenge?

BirthVolume 20, Issue 2 p. 59-60 Crisis in Primary Care: Will Midwives Meet the Challenge? Diony Young, Diony YoungSearch for more papers by this author Diony Young, Diony YoungSearch for more papers by this author First published: June 1993 https://doi.org/10.1111/j.1523-536X.1993.tb00417.xCitations: 4AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume20, Issue2June 1993Pages 59-60 RelatedInformation

Promoting Primary Care: Where to Start?

To the Editor. —I enjoyed reading Stimmel's article, The Crisis in Primary Care and the Role of Medical Schools.1 In America, relative income defines the perceived value of a profession. If society determines that primary care is valuable and wishes physicians to pursue our specialty, then there are only two ways to improve perceived value. Primary care physicians can be paid more, or all other physicians can be paid much less. Changing the relative income of primary care physicians does not address access issues, however. There is a longstanding alternative that is politically feasible, economically sensible, and likely to increase the prestige of primary care. A primary care physician working in concert with three to five physician assistants as a primary care team can provide quality care for less cost and support higher primary care incomes. We are modifying our family practice curriculum to teach medical students to work

The Crisis in Primary Care and the Role of Medical Schools

While a number of issues have diminished the attractiveness of primary care residency programs to USGs, the absolute number of residents in these programs has increased rather than diminished over the past decade, although the proportion of USGs choosing these fields has decreased. In the current arena of medical practice, there are many reasons why these fields are not among the most attractive, and there are several remedies that could be applied to increase their attractiveness. Focusing on medical schools as the sole cause of this dilemma, however, is the least effective way of accomplishing this objective; in addition, this will allow those truly able to increase interest in these fields, such as state and federal governments, to have a reason for not doing so. As long as the medical marketplace is sufficiently large enough to accommodate more than the number of graduates from US medical schools in "desirable" residency training positions, one can never effectively "force" a choice of residency training, nor should one. Primary care can be among the most rewarding of specialties, if adequately supported. It is this support that is lacking and must be addressed.

The crisis in primary care and the role of medical schools. Defining the issues

The crisis in primary care and the role of medical schools. Defining the issues

Looming crisis in primary care.

A crisis is looming in primary health care unless the Government takes urgent steps to maintain education funding for all community nurses, nurses' leaders have warned.

Primary Care: The Future for Pediatric Education

There is a continuing crisis in primary care, characterized by inadequate numbers of appropriately trained primary care physicians and the failure to mount an effective and consistent graduate educational program for primary care. This paper reviews the history of the primary care crisis; revisits the definition of primary care; and, through identification of critical issues, presents a primary care educational agenda for the 1990s. Pediatrics is at a crossroads regarding primary care, as powerful social and economic forces are impacting on today's major pediatric care problems. Before the second World War there were more than 300 primary care physicians available for each 100 000 of our population. Today the ratio is 75 for 100 000. This is despite the fact that a shortage of 50 000 physicians 10 years ago no longer exists. The majority view is that a physician surplus of 70 000 will be present by the early 1990s.1 Whether there is a surplus is subject to interpretation and the surplus may end up as nonexistent. Moreover, the availability of primary care physicians varies with geographic location, and even a single figure for this nation provides a distorted picture. The shortage is especially serious in inner cities and in many rural areas. In addition, the use of overall numbers assumes that all primary care physicians are appropriately trained in the general disciplines. For the past century, physicians have cared for patients usually as family physicians. Today, however, the generalist has been replaced by the specialist. Is this a function of financial rewards and society's needs and values or the educational experience?

Roots of the Present Primary Care Crisis

America's medical establishment is experiencing a "primary care crisis'—an extreme dissatisfaction with existing methods of primary patient care.¹No doubt this crisis is partly the result of an expansion of the definition of disease to include aspects of life, such as job failure and unhappiness, which are not well addressed in scientific medical terms. This trend has extended the social role of the physician and has led to the development of new specialties, eg, family practice.²Another factor leading to the current "crisis" is the latest in a series of antiscience movements.³ American medicine has from its inception chosen the abstract concept of "science" as a means of obtaining social recognition. Benjamin Rush's early attempt to substitute "the simplicity of science" for (English) autocratic tradition is an example of this effort.⁴ The profession's early struggle for legitimacy through science met with strong social resistance, primarily due

Roots of the present primary care crisis

Roots of the present primary care crisis

Primary Care for Women

To the Editor.— That obstetricians and gynecologists are primary care physicians for many women is a well-known fact in everyday medical practice. This reader is therefore confused by Pearson's statement that it seems clear that a decision must be made to include the obstetrician and gynecologist as a primary physician, to assure accessibility of continuing care for the female population. Such already is the case. But Pearson leaves aside the question of whether this established practice should simply be continued or actively encouraged. Apparently, the American Board of Medical Specialties and the Association of American Medical Colleges have their doubts. (The American Medical Association, on the other hand, is willing to consider obstetrics and gynecology as a primary care area for existential reasons—perhaps as a way of answering critics who assert the existence of a primary care crisis.) Let us acknowledge that the fall in birthrates, the relative oversupply of

Some thoughts on primary care problems in inplementation.

This paper presents definitions of primary care and the dimensions of the health care crisis in general and of the primary care crisis in particular. The importance of team practice in primary care is described, as are the necessity of creating the social physician as team leader and some changes which appear to be necessary in medical education in order to begin moving toward a solution of the primary care crisis. Primary care is what most patients need most of the time. Changes in the medical education system—changes as fundamental as those which paved the way for the research establishment-will be required to provide it.