Monday, October 17, 2005

A Little More Realism About Declining Interest in Primary Care

We have posted before about the how fewer doctors in training seem interested in primary care careers. Up to now, the responses from medical organizations, including some that ought to be promoting primary care, have not seemed very direct.

Thus it's a bit refreshing to see a bit more realism in two articles in the latest American Journal of Medicine (which unfortunately requires a subscription).

An article(1) by directors of internal medicine clerkships (hands-on clinical experiences generally during the third year of medical school) noted that "many factors external to the internal medicine clerkship but inherent to internal medicine practice profoundly influence students' career decisions." These include lower income levels for primary care physicians, but more on-call responsibilities, and especially "the high administrative burden," and "the proliferation of third party payers and resulting decrease in practice autonomy."

They allowed that their clerkships can be tweaked to improve them, and perhaps to make primary care look more attractice to students. But they again concluded,
Many of the factors most salient to the career choice process are beyond the scope and control of the clerkship.
Practicing clinicians and thier national organization smust address flaws in the current practice environment that create unmanageable administrative burdens, comparatively low compensation , and time demands that preclude balancing professional obligations with career choices.
In addition, an editorial(2) stated that

the United States faces serious challenges in health care: cost, access, quality, and a projected shortage of caregivers. Rather than acknolwedge these issues, some leaders hope tinkering with the structure of medical education will reinvigorate primary care medicine and help fix a failing health care system.
This optimism is misguided and does not address the real problem.
The authors then listed five paradoxes:

  • As the United States spends more on health care, the number of uninsured grows.
  • Increased costs and external oversight fail to improve the quality of health care.
  • As the need for primary care increases, interest in such careers declines.
  • Although society needs well-trained physicians and ground-breaking research, medical schools and teaching hospitals pursue clinical dollars.
  • In the nation's capital, political capital is worth more than operating capital.
To begin to address them, they quoted the "Stockdale Paradox," authored by Admiral James Stockdale, the highest ranking military prisoner in the Vietnam War,
You must never confuse faith that you will prevail in the end - which you can never afford to lose - with the discipline to confront the most brutal facts of your current reality, whatever they might be.
However, the editorial is a bit vague about what brutal facts must be confronted. (They only suggested that solutions included an "honest, open discussion," a "more transparent and less fragmented" health care system, more reimbursement for primary care and care of the chronically ill, better performance by medical schools, and having leaders "work together.")
I submit that the missing link here is concentration and abuse of power, which even the authors of this editorial seemed to shy away from confronting.
But we won't here on Health Care Renewal.
Thanks to Retired Doc's Thoughts for the tip.
1. Hauer KE et al. Educational responses to declining student interest in internal medicine careers. Am J Med 2005; 118: 1164-1170.
2. Henderson MC et al. Confronting the brutal facts in health care. Am J Med 2005; 118: 1061-1063.


Elliott said...

Here are some brutal facts:

1. The US cannot sustain the cost of its current healthcare program very far into the future.

2. We don't get very good value for our healthcare dollar.

3. Large, intitutional management of healthcare (Kaiser, VA, even medicare) delivers better value than other regimes.

4. The people with the most power to change the system have the least incentive to change it both from a power perspective and a dollar perspective.

5. Universal healthcare is the obvious solution, but there appears to be no workable migration path.

6. CDHPs do not change any of the above despite the hype.

7. Only a gut-wrenching crisis which is inevitable will change anything.

In other words, the US healthcare system is a train wreck waiting to happen. Nothing is likely to prevent the train wreck from happening. After the crisis some kind of universal healthcare will emerge with its own set of problems, but at a much lower cost. Doctors, pharmaceutical companies, insurance companies and hospitals will all have significant drops in income in the aftermath of the crisis. Primary care physicians are likely to be the least impacted and may even see some aspects of their practice improve.

Anonymous said...

"Doctors, pharmaceutical companies, insurance companies and hospitals will all have significant drops in income in the aftermath of the crisis."

That much might be true, but perhaps not in the way you think. Insurance as a means for paying for medical
expenses is failing. If it fails to provide a satisfactory guarantee for payment to suppliers of healthcare services--enough to adequately cover costs in a timely and reliable way--fewer suppliers may find it an acceptable alternative to cash. Not having insurance may not bcome the barrier to care as much as not having cash.

The realities of the medical marketplace are not going to be magically transformed by creating a giant all- inclusive version of Medicare. That kind of entity will involve certain restrictions, rationing, much as exists in
countries that have exactly that kind of system. There won't be room for the medicolegal free-for-all we have now, or the expectation that providers be able to keep private business model practices going with the present cost structures. Costly education will not be an acceptable condition in a system that severly curtails income that can be earned only after many years of training in relative penury.

Try to imagine a set of conditions you may not have considered: a non-market, where insufficient reward is simply unable to raise an adequate supply of practitioners willing to work, where only a relatively smaller number of cash-paying buyers will get health care that they want, and the others do without. "Universal" health insurance might mean many more people get less, not more. Think that is impossible? History would suggest otherwise, as that was roughly the situation that prevailed in the East Bloc before 1989, except that education there was relatively cheap. In your model, it won't be.

Lee Green MD MPH said...

The article finally starts to point at the elephant in the room. Why don't students go into family practice or general medicine? Lots of pontificating by our specialty societies, basically ignoring the elephant. Subspecialties offer shorter hours, less work, and much higher pay. We see it even within my own specialty, family medicine. I can make twice as much money doing a vasectomy as I can seeing a complex elderly patient with multiple medical problems. The vasectomy takes no more time hands-on, and much less out-of-hours time even including following up complications, and the paperwork burden isn't even close. Until what we say we want the health care system to do is what we pay to do, it won't change. "You get what you pay for" is hardly a new insight, but it's one that seems to be chronically overlooked.