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The Supply/Demand Paradox for Primary Care Physicians

By Dr. Sachin D. Shah
. 1 Comment(s)

This is the first part of a 2-part series of posts on the value of primary care physicians.

I’m a primary care physician.  I’m not an idiot.  At least I don’t think I am.  But consider the facts. 

I am trained and boarded in both Internal Medicine and Pediatrics, and opted against pursuing a career as a subspecialist.  I did this because I am fascinated by the scope of medicine, the challenges of being a generalist, and the responsibility of trying the improve the health of my patients at both an individual and population-based level.  This seems like important, challenging work to me, and I was drawn to the opportunity to potentially influence a group of patients and help become a valuable (and valued) part of the solution to our nation’s health care cost conundrum.

There’s an obvious, well documented need for containing the rising costs of health care in our country.  Yet our health care system is set up to incentivize fragmented, subspecialist driven care for many of our citizens.  There’s clear evidence that effective primary care contains costs while improving quality.  By emphasizing preventive health care and proactively managing chronic diseases, costly hospitalizations and procedures are avoided.  By having one physician coordinating and overseeing a complicated patient’s health care, redundancy and unnecessary tests and treatments can be avoided.

Thoughtful health care reform measures, including the Patient Protection and Affordable Care Act (PPACA), recognize the importance of primary care physicians in curtailing costs and improving quality of health care.  But everyone is also quick to point out the need for more primary care physicians; even among physicians across all specialties, nearly 80% believe there is a shortage of Primary Care Physicians (PCPs).  Indeed, the access to care that much of health reform seeks to improve relies on having enough primary care physicians to take on the responsibility of caring for those previously uninsured or underinsured patients. 

So great, the demand for PCPs is high.  The supply should follow, right?  Well, based on studies examining our current situation (and personal, anecdotal evidence), our primary care work force is undermanned and oversaturated.  We’re nowhere near having enough PCPs to absorb the imminent influx of Americans with access to health care.  A situation that should be celebrated -- improved access to health care for Americans -- becomes a cause for concern.  We don’t have enough primary care doctors.

Why?  Because primary care in the United States is woefully, embarrassingly, and inexplicably undervalued.  Looking simply at the bottom line, the median income of a primary care physician in the United States is over $135,000 less than their subspecialist colleagues.  Over the course of a career, that translates to a $3.5 million difference in earnings.  At the extreme end of the spectrum, the difference between the median income of a diagnostic radiologist or an orthopedic surgeon and a primary care physician was $250,000 in 2004, which translates into over $6 million difference in career earnings.  So maybe I am an idiot for going into primary care.

It’s no surprise that this stark income disparity, especially after a long and costly medical education and training process, has an understandably enormous impact on medical student behavior when choosing what type of doctor they will become.  Medical students who go into non-primary care specialties will make considerably more money over their careers than those going into primary care despite the relatively limited additional training time and expense involved in subspecializing. 

Moreover the indirect messages that medical students and trainees receive regarding prestige and intellectual rigor play no small role.  It’s striking to me how in many academic medical centers, primary care is considered an albatross around the neck of the institution.  We’re often myopically labeled as the “revenue loss leader” instead of being explicitly recognized as the entry point and foundation for medical care and even a producer of downstream revenue.

I would argue we need more of our best and brightest medical students pursuing a career in primary care than dermatology.  Primary care should be seen as a prestigious and coveted calling.  We are clinicians responsible for being the initial point of medical care for our patients, with whom they can develop continuity over time.  We understand their complete health status and facilitate coordination with other parts of the health system.  These are not simple tasks.

So why is primary care so undervalued?  Please come back for part two of this post tomorrow (April 5th).



Share Your Comments


  1. Sujatha Prabhakaran

    Couldn't agree more. While I think we need good dermatologists, I'm not sure it is a field that requires people at the top of our med school classes. On the otherhand, I'm in awe of all the things a good primary care physician must understand.

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