Growing up in Baraboo and Madison, Jake Bidwell knew early on he wanted to be a doctor. A high school athlete, he considered going into sports medicine or orthopedics. But after seeing teammates lack access to health care for injuries, he changed his mind. “I realized the best way to help the situation and make the most out of my life would be to work in an area of need,” he recalls. “If I was a primary care doctor, pretty much anyone could access me if I put myself in the right type of practice.”
Today, Bidwell practices family medicine at Aurora St. Luke’s and Aurora Sinai medical centers. He’s also medical director for two South Side clinics, one of which is the state’s largest free clinic, serving uninsured, low-income patients.
Unfortunately, fewer medical students across the country are choosing to go into primary care, much less work with underserved groups. Meanwhile, the need for their services continues to grow. Nationally, the American Medical Association predicts a shortage of up to 40,000 primary care physicians by 2025. Wisconsin will have a shortage of 14 to 57 percent by 2030, according to the Wisconsin Council on Medical Education and Workforce. Already, the state is short 374 primary care doctors; Milwaukee alone lacks 20 primary care physicians to serve inner-city patients.
Rural and inner-city residents are disproportionately affected by the shortage, but everyone stands to feel the effects. From longer waits to see a doctor to rising medical costs, the consequences are far-reaching. Meanwhile, finding a solution is a complex task.
Why Not Primary Care?
“There is no doubt in my mind that there are fewer medical students going into primary care careers,” says Dr. Jonathan Ravdin, dean and executive vice president of the Medical College of Wisconsin. Primary care includes family medicine, general internal medicine and general
pediatrics. Of these, family medicine may be in most danger. At the Medical College, only 11 or 12 students out of a class of 195 went into family medicine in 2008. “It was the lowest number that I’ve seen in my 10 years here,” says Dr. Alan David, professor and chairman of the Department of Family and Community Medicine.
Meanwhile, students who do residencies in internal medicine (and sometimes pediatrics) tend to go on to subspecialize in other fields rather than practicing as generalists. Why doesn’t anyone want to be a family doctor? For one thing, they make less money. “Family medicine has the lowest salary of the major specialties in medicine,” explains Dr. Linda Hotchkiss, vice president of academic affairs for Aurora Health Care. Fields such as radiology, orthopedics, anesthesiology and dermatology pay roughly two to four times what a primary care physician is paid, estimates David.
Given the enormous cost of medical school, compensation is an important consideration for many students. The median debt for graduates of the Medical College is $166,000, says Ravdin. Many students also worry about the costs they’ll incur once they graduate, from practice overhead and staff salaries to taxes and malpractice insurance.
Aside from the financial issues, some students shy away from primary care because they think it offers a less “controllable” lifestyle than specialty fields like radiology or dermatology. “The perception is that [in primary care] you always have to be available,” says David. In fact, primary care can be quite flexible, yet the misconception remains.
Complicating matters further is an increasingly broken system of reimbursement, which saddles primary care physicians with extensive paperwork and demands doctors see more patients in order to keep their practices afloat. Older primary care physicians, trained under a different model, tend to be particularly discouraged by the changes, and may pass that dissatisfaction on to students. “Nowadays, for a primary care physician to make it, they have to see around 25 or 30 patients a day,” says Hotchkiss. “You can’t spend as much time with them, you’re worried about your relationship with them, you’re worried about whether you’re catching everything. That’s put a lot of pressure on physicians.”
A national survey of primary care physicians by The Physicians’ Foundation showed nearly 50 percent are considering leaving the field or cutting back on patients in the next three years, largely due to frustrations with insurance and governmental red tape. “The system’s screwed up,” says David. “We have the wrong incentives. We’re trying to measure quality, but they want to do it by numbers and not by process and not necessarily by patient satisfaction.”
While primary care doctors are struggling to treat more patients in a shorter amount of time, they’re also charged with keeping up with medical findings that are growing at a tremendous pace. “There’s so much new knowledge that it’s very difficult to stay on top of the latest and greatest [advances in care],” says Hotchkiss. For some students, the idea of having to know something about everything is unattractive. “Some of my friends who are going into subspecialties really want to be an expert in their field,” explains Jennifer Hanson, a fourth-year Medical College student who plans on going into family and community medicine. “It’s less desirable to be that jack-of-all-trades, master of none.”
Cost To Society
Yet “jacks-of-all-trades” are vital to our nation’s health for their ability to prevent and manage chronic disease and to do so in a cost-effective way. “The bottom line is, if you don’t prevent disease and don’t treat it early, the cost of hypertension or diabetes [or other health problems] down the road becomes astronomical,” says Bidwell.
One of the effects of a primary care shortage is that patients wind up in the emergency room, either with conditions that could have been more effectively treated by a primary care doctor, or with advanced diseases that will take much longer (and require more expensive methods) to care for. Other patients may have to wait weeks or months to see a doctor or be forced to travel considerable distances for treatment. Such a lack of access can lead to spikes in infant mortality as well as increases in deaths from cancer, heart disease and other chronic illnesses that a primary care physician would have been best at managing, notes Hotchkiss.
The U.S. is also bracing itself for greater demand for primary care doctors and physicians in general, especially from baby boomers. This includes physicians themselves, roughly a third of whom are now over age 55 and are likely to retire by 2020, according to the Association of American Medical Colleges. To address the problem, by 2015, the AAMC wants a 30 percent increase in medical student enrollment (over 2002 levels). The extent to which this will remedy the primary care shortage, given the disincentives associated with the field, remains to be seen.
Solving A Shortage
Education can be a powerful starting point for addressing these challenges. The Medical College is working to provide students learning opportunities in inner-city clinics and global health settings. Such experiences increase the chances that they’ll go on to work in underserved areas in a primary care discipline. The University of Wisconsin School of Medicine and Public Health uses Aurora Health Care facilities in Milwaukee as its clinical campus. There, residents have the opportunity to work with urban, underserved populations as well as mentors who are passionate about their work. Aurora has also teamed with UW to address the shortage of primary care physicians in rural and inner-city areas. “The idea is to recruit students who live in those communities now and will probably have an incentive, therefore, to go back and practice in those communities,” Hotchkiss explains.
More immediate solutions to the shortage include implementing a team-care approach to treating patients. Team care makes greater use of nurse practitioners, physician assistants, pharmacists and receptionists. Electronic health records can aid in this approach, ensuring multiple providers are delivering the best care.
And then there’s the issue of pay. “On a national level, if we’re serious about this, we’re going to have to incentivize primary care financially,” Hotchkiss says.
Yet David emphasizes that a salary increase alone is worth little without an overhaul of the reimbursement system. “You can double the salaries of all the general internists, family physicians and pediatricians in the country, and they’d be very happy. But within a year, you’d find out that a significant percentage are still unhappy, because their ability to provide care for their patients is still compromised by a very cumbersome, burdensome system that insists on counting minute pieces of work rather than counting the process of care and the quality outcome of care.”
How hard will it be to change the current method of reimbursement? “Turns out, it’s really, really hard,” says Hotchkiss. Changes such as a team approach will have a far more immediate impact, she adds. Rather than changing the reimbursement model, Ravdin believes reliable loan-forgiveness programs for students going into primary care would provide a quicker and more effective solution to the problem.
For Bidwell, a final piece of the solution is for medical educators and mentors to emphasize to prospective students just how rewarding their careers are. “Primary care is more intellectually challenging over your lifetime than any other field in medicine,” he says. Treating patients and families over the course of their lives is also tremendously rewarding, he adds. “There are not many specialties that offer the long-term, close–knit relationships we can have, not only with our colleagues and staffs, but with our patients.”
Caroline Goyette is Milwaukee Magazine’s monthly health columnist.
A roundup of the latest health wisdom
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Wikipedia flubs drug questions.A comparison of Wikipedia.com, the user-edited online encyclopedia, and the Medscape.com drug reference guide found Wikipedia had serious limitations, though it did improve over time. Medscape is also a free online resource, but it’s edited by health professionals. The two sources were compared in The Annals of Pharmacotherapy. Wikipedia scored far worse on its ability to answer questions about medications, particularly dosing. Also, Wikipedia had more errors of omission, and its answers were 76 percent complete compared to 95.5 percent for Medscape. But Medscape isn’t perfect: It had four wrong answers, while Wikipedia had none.
Fish oil helps brains of baby girls.Girls born at less than 33 weeks of gestation were much less likely to have mental delays when given a higher dose of DHA, the active ingredient in omega-3 fatty acids like fish oil. In a study in the Journal of the American Medical Association, DHA was delivered via the breast milk of nursing moms who were given daily tuna oil supplements. If needed, baby formula was used instead. While preterm boys did not show the same benefits, the researchers are recommending the higher-DHA diet as standard practice for premature babies.
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