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The Primary Care Shortage

By Dr. Nilesh Kalyanaraman
. 4 Comment(s)

It’s well known that there is a shortage of primary care physicians which is only going to get worse over time. To address this problem, Dr. Peter Bach, the director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering and Dr. Robert Kocher, a guest scholar at the Brookings Institution, propose making medical school free. They argue that medical students would be more likely to choose primary care over specialties if the debt burden of medical school was eliminated. To pay for this, residents in specialty training would, “forgo much or all of their stipends, $50,000 on average.” Residents in training for primary care would continue to receive their stipends as usual.

Though this sounds like an interesting proposal, in reality it wouldn’t work. First off, this is unfair to specialists in training. I’ve gotten into numerous heated discussions about how unfair it is that specialists are compensated much more generously than primary care physicians. That doesn’t mean that I think we need to stiff residents and fellows who go into specialty training; they deserve to be paid for the work they do. Our problem isn’t that any given person becomes a specialist; it’s that too many people become specialists instead of primary care physicians. A better solution would be to decrease the number of spots for specialty training.

Second, the disparity of pay between specialties and primary care wouldn’t change so the economic incentive to go into a specialty would be intact. If the debt of student loans seems manageable by entering a specialty, wouldn’t any debt incurred while training to be a specialist be just as manageable, if not more so? Between moonlighting, family support, and physician loans supporting oneself during specialty training for the promise of a bigger payday is an ever better bet than accruing medical school debt hoping that you can pay it off. In fact, this seems to tilt the scales towards selecting those from higher socioeconomic backgrounds for specialty training since they would have the greatest potential for family economic assistance during specialty training.

Lastly, the authors acknowledge that specialists have been successful over the years in preventing any decrease in the disparity of pay between primary care and specialists. What makes them think that specialists would all of sudden be okay with allowing their trainees to be underpaid or unpaid for their training?

So what do I think we should do? Well, to address student debt we currently have national and state programs that pay off debt for those who enter primary care in underserved areas. We should extend this program to include all physicians who are actively practicing primary care. Loan repayment of $15,000 a year would make the average physician’s $155,000 of debt disappear in 15 years (assuming a 5% interest rate). Such an investment in primary care would certainly be worth the expense. Furthermore, since this is money is unrelated to compensation, it would be outside the political theater that surrounds any change to Medicare. (Medicare sets the compensation for medical services which in turn determines the compensation of all physicians). Decreasing the wage disparity between primary care and specialists is too large a topic to cover here. Suffice it to say, if we’re serious about boosting the number of primary care doctors, we’ll need to address this issue head on.

I applaud Drs. Bach and Kocher for attempting to address the worsening shortage of primary care physicians. But, to really deal with the problem we need to attack the root cause of the primary care shortage, the burden of student debt combined with the large pay disparity between primary care and specialists.

Share Your Comments


  1. malini

    Complex issue but a very real one which needs to be addressed and resolved. Monetary incentives and reducing the disparity of salary between specialists and primary care physicians sound like a practical and sensible solution to minimize the shortage of primary care doctors.
  2. zaneb beams

    i agree, nilesh. this is an important issue. my blog post "who's afraid of primary care?" last month, describes some payment reform and workforce reform measures in the ACA. but i suspect we all worry that these measures are not quite enough.

    i suspect drs. bach and kocher actually don't think we will make medical school free ( after all, even college, and technically, primary school are not free. and everyone knows we can't raise taxes enough to pay for free medical school!).

    But they sure have succeeded in getting people talking about the worsening national shortage of primary care providers. this shortage is pressing in metropolitan areas like washington d.c., but it gets even worse in smaller cities and rural areas.

    last summer i did a speaking tour called " your doctors, your maryland" to inform seniors in maryland about the benefits of ACA. the problem seniors described most often was, not being able to find a primary care doctor, and not being able to get in for sick visits for over two weeks! the shortage is not looming, it is here.

    the shortage is also embodied in the fact that doctors feel like they don't have enough time to care for patients, complete necessary paperwork, and advocate for better health policy. This is because they have to see 20-30 (often more!) patients every day. partially to pay their bills, but also to provide care for all the patients that need them.

    the fact is that real incentives must be put in place. we must either make primary care more rewarding (in terms of money and ego) and/or make it more enjoyable (less patient volume, more quality intellectual work and human relationships).

    i believe it will get better. it has to. the question is, will the policy and politics make it easy, or will our families and neighbors really have to suffer before meaningful and appropriate change comes.

    thank you for raising this important issue again.
    here's to a better health care system in a brighter future!
  3. Rebecca Jones MD

    Thanks Nilesh for your thoughtful post.
    I too felt that specialists were unfairly targeted in their proposal--and not just because I am a specialist!

    We absolutely must figure out how to get enough primary care doctors out there to serve the aging and expanding (literally, as in waist size) population. Of course, as is true with climate change, even as we accept the mess we are in I hope we can also figure out ways to reverse the trend. It may seem like science fiction now, but wouldn't it be amazing to address the pcp shortage by actually keeping people out of the doctor's office?
  4. James H Cook, MD

    This is an interesting proposal (Bach and Kocher), but it would make things worse, not better. B&K do not distinguish between procedural specialists (orthopedists, cardiothoracic surgeons, interventional radiologists) and cognitive specialists (neurologists, rheumatologists, infectious disease specialists, etc); the latter earn much less than the former, and are the ones managing the difficult patients that the generalists can't and the proceduralists won't. The end result of their proposal would be a large crop of ill-trained generalists, a smaller group of procedural subspecialists, and no-one left to do the thinking. This would result in mismanaged care, and do nothing to lessen over-reliance on procedures. And lest the generalists in the audience protest that they're not ill-trained, consider this example from my life: in my institution, the family practice residents spend a month in "neuroscience", which is actually split among several specialties such as pediatric and adult ophthalmology, child neurology, physiatry etc. They spend 1 day in adult neurology, the specialty that I trained in for 4 years post-internship; this in a country where, at any given time, 16% of the population suffers from a neurologic disorder of some sort. One day is not enough to know even when to call for help. I haven't heard any groundswell of support to extend generalist training to 7 or 8 years post-medical school, which is what it would take to begin to handle the problems that the cognitive specialists handle now. I think it's telling that this proposal comes from two physicians who don't actually practice medicine anymore. I am all in favor of increasing the supply of generalists; access is a huge problem. But it needs to be more finely tuned than this.

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