HealthLawProf Blog

Editor: Katharine Van Tassel
Concordia University School of Law

Wednesday, July 9, 2008

Goodbye to the Primacy Care Physician: A Health Care Crisis ... reports on the "passing" of the primary care/family doctor.  Robert Burton writes about the shortage of primary care physicians in the United States and what this means for our health care system as well as noting how the shortage is being partially solved by the hiring of doctors from countries that cannot afford to lose those professionals

. . . The current healthcare debate about accessibility and affordability reminds me of a committee of well-intended E.R. doctors furiously debating the optimal cost, shape and efficiency of various tourniquets, while a casualty victim slowly bleeds to death. Better and more widespread and affordable health insurance won't be of value if you can't find a primary care provider willing and happy to treat you.

Make no mistake: Primary care is the backbone of a good medical system. No matter how great our latest medical technologies, most of our illnesses are best screened or handled by the family practitioner. You don't need a gastroenterologist to treat an ulcer or irritable bowel. You don't need a pulmonologist to treat most cases of asthma and emphysema. And you don't need an orthopedist for most aches and pain. . . .

But primary care physicians -- those trained in family medicine and general internal medicine -- are an endangered species. It's only a bit of hyperbole to say that, if the trend continues, the family doctor will become a fond memory, a nostalgic reminder that the medical system once had a more human face and sense of community . . . .

Currently, roughly 200,000 family practitioners and general internists practice in the U.S. One-third are over 55 and are likely to retire within five to 10 years. Meanwhile, an alarmingly low percentage of students are choosing to become primary care physicians. . . .

To underscore the general lack of recognition of the declining appeal of a primary care practice, consider that in 1976, a Department of Health and Human Services Advisory Committee predicted a surplus of 145,000 primary care physicians by the year 2000. And yet, in 2004, revised estimates suggested that by 2020 there will be a shortage of 90,000 to 200,000 physicians. . . .

This physician distribution is also geographic: Only 11 percent of the primary care physician workforce has opted to serve the 20 percent of Americans who live in non-metropolitan or rural areas. The smaller the community, the more dismal are the prospects of attracting a physician. Many communities are desperate for any warm medical body.

As a consequence of this overall shortage and distribution, more primary care positions are being taken by foreign medical school graduates. Nearly half of the internal medicine and primary care residency slots are now filled by foreign graduates; one in four new practicing physicians in the U.S. is an international medical graduate. . . .

A further ignored issue is how to supervise the education of those trained elsewhere. U.S. medical schools are subject to strict regulation. We don't have a similar mechanism for observing foreign training. Here's a scary set of statistics. According to a New York Times article by Leana Wen, M.D., Rhodes scholar and Global Health Fellow at the World Health Organization in Geneva, "Lower-income countries supply between 40 to 75 percent of U.S.-based, foreign-trained doctors." During a recent tour of the medical schools of three African countries, Wen was astounded to find that none of the students had been supplied with medical textbooks.

Earlier this year in the New England Journal of Medicine, Dr. Ranjana Srivastava, a medical oncologist and internist in Melbourne, Australia, wrote of his experiences tutoring foreign medical graduates, who are trying to obtain a medical credential in Australia. It's a moving description of foreign doctors' plight. Srivastava acknowledges the overwhelming cultural disadvantages the doctors face in crossing the "bridge" to standard Western practice. "I have observed over the years that most foreign doctors receive little encouragement, advice, or collegiality from a medical hierarchy engrossed in its own needs," he writes. And some days, he confesses, "their needs are much larger than I had ever imagined or feel equipped to handle.". . . .

In 2005, British Medical Association chairman James Johnson described the siphoning off of African-trained physicians to the U.K. as morally indefensible, as reported by the BBC. The examples are startling. In Zambia, only 50 out of 600 doctors trained since independence are still practicing in the country. Three-quarters of Zimbabwe's doctors have left since the early 1990s. More than half of all Ghana's doctors have left the country. Yes, our primary concern is providing adequate medical care in the U.S.. But we also need to be aware of how our solutions create shortages elsewhere and have obvious global implications.

In addition to how to best provide universal health coverage in the U.S., we need real debate about how we want our medicine to be delivered. Even if we were to arrive at a perfect solution, it would be six to eight years before these changes affected present primary care physician demographics. The answers aren't obvious and require real innovative thought. We need to restore family practice to a level of desirability that will attract the smart and the compassionate. Otherwise we can count on a dramatic rise in two-tier medicine, continuing geographic mal-distribution of medical care and an increasing reliance upon the physicians of other countries and lesser trained medical personnel to bail us out. Not a pretty picture and not a great stump speech for a political candidate, yet a brewing disaster we cannot continue to ignore.

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