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Crossing the ROAD to real reform -- or how American medical education can (or can't) meet the ACA's call to action.

By Dr. Ali Khan
. 2 Comment(s)

"So, why didn't I take the ROAD again?"

It's a question that I regularly hear from many of my co-residents in internal medicine - and no, we're not questioning our travel routes to the hospital.

We all know why we chose internal medicine: the intellectual challenges inherent in treating across organ systems, the excitement of primary scientific investigation and diagnosis and the like. As we struggle through the rigors of primary care training, however, it's hard not to look wistfully at our colleagues in such lucrative, "lifestyle" specialties as radiology, ophthalmology, anesthesia and dermatology - the "ROAD" to riches in modern medicine - and wonder exactly how green the proverbial grass on the other side might be.

In the wake of the Affordable Care Act's [ACA] passage, conventional wisdom suggests that we're about to find out. After all, with the ACA's passage comes the influx of more than 30 million new customers to American primary care offices and hospitals. In a health care marketplace where just two percent of all graduating American medical students will pursue careers in general medicine (according to a 2008 JAMA study), an exponential jump in supply will mean a requisite increase in demand - with a boost in wages for primary care docs surely close behind.

Indeed, the Association of American Medical Colleges (AAMC) now projects a need for 63,000 more doctors by 2015 - with more than half of those in primary care and emergency medicine, the "front line" specialties in American medicine currently. Proposals for new medical schools in locales as far ranging as North Haven, Ct. (Quinnipiac), Detroit (Oakland), Roanoke, Va. (Virginia Tech) and the Inland Empire (UC-Riverside) emerge almost weekly, each promising to train the next generation of American primary care physicians.

Let's recap: a higher demand for generalist doctors, coupled with expanding numbers of medical students entering the profession. The revitalization of American primary care is at hand, right?


Supply and demand only work perfectly in a market without other economic distortions. The distortions currently leading people away from primary care are enormous - and, despite the ACA's best efforts, are likely to persist well into the future. Here's why:

  • We still follow the money: Choosing primary care may be personally meaningful - but to the average primary care physician, it means over $2 million in lost wages over a career compared to the average cardiologist (and over $4 million compared to the average radiologist), according to research by both RAND's Mark Friedberg and a team of Duke researchers. That monetary difference in lifetime income is hard to ignore for any rational actor in a market (free, regulated or otherwise).
  • We still have the terror of debt: The average medical student graduates with over $100,000 of educational loans - all due just six months after graduation. Although that number's a drop in the bucket compared to Friedberg's lifetime income differentials (as cited above), those numbers are indelible for many of my colleagues, some of whom are carrying over $300,000 in debt.
  • We still have a payment model that perpetuates the status quo: Medicare's Resource-Based Relative Value Scale was designed to equalize payment among the cognitive specialties (primary care) and the procedure-based surgical subspecialties. Ironically, it's done the opposite by inadvertently creating financial incentives for the rapid expansion of imaging-based diagnostic and treatment modalities by failing to adjust for amortization of equipment in the reimbursement rate of CT, MRI and radiologic studies. That's a big reason for the explosion in "interventional" specialties that we see in medicine today.

Unfortunately, the incentives in ACA theoretically designed to address these distortions (increase by 10% in Medicare primary care payments, investments in the National Health Service Corps to fund medical student scholarships, and so on) will do little to address any of these disincentives on a macro level. Consider these small exit signs that get overshadowed by the enormous temptation the ROAD provides.

What that means: the root cause of our primary care shortage -  the fundamental incentives underlying American physician workforce decision-making - will continue to drive my colleages into the same distribution of subspecialty choices they currently produce.

In our present system, then - even with the ACA in hand - it looks like there's more to do to ensure this ROAD ends sometime soon.

In my next post: What's on the table to do exactly just that.

Share Your Comments


  1. dennis saacks


    Great article--puts the whole payment system in perspective--pointing out the inequality of payment distribution Would like to hear some corrctive steps to improve the lot of the primary care physician

  2. Davis Liu, MD


    The demand for primary care has been understood for a long time. The supply hasn't kept up because of the financial issues you correctly point out. One important issue you didn't mention is whether the work-life balance for primary care is attractive enough for both doctors currently practicing and those considering primary care. I can tell you as a practicing primary care doctor I love my job. I also realize how incredibly fortunate I am to work in a medical group equipped with comprehensive electronic medical records, with a relatively stable patient base, a collegial work environment, and am compensated with a competitive salary. If I didn't, I would probably wonder why I didn't take ROAD like many primary care doctors or potential future colleagues are asking.

    Those wanting to do primary care must be extremely thoughtful about which medical group they join because primary care isn't all the same. Avoiding the discussion of the federal government's role of community clinics, the future of primary care will thrive in three areas: large integrated healthcare systems like Kaiser Permanente, individual doctor offices virtually integrated by third party vendors as well as other non-physician providers like retail clinics, and the solo practitioner doing the ideal medical practice. The Patient Centered Medical Home will not solve the primary care crisis.

    But I am so glad that I didn't take that ROAD and that I was lucky to end up where I am, because I love what I do.


    Davis Liu, MD

    Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System

    (available in hardcover, Kindle, and iPad / iBooks)



    Twitter: davisliumd

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