David S. Meyers, MD; Carolyn M. Clancy, MD
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Edward J. Volpintesta
February 19, 2009
Save primary care by training new types of primary care doctors
The authors' suggestions for having local community support in providing primary care offices with infrastructure support including social workers, quality improvement officers, social workers, and health educators have merit (1).
The core of the problem however, is not the coordinating functions themselves that primary care doctors have to do but the sheer number of them. The toll they take on their composure and job satisfaction robs them of fulfilling the humane doctor-patient relationship that both they and their patients desire.
Perhaps the logical first step would be to look for ways to produce more primary care doctors in less time. This would increase their numbers. Having more of them in the workforce would mean less administrative and coordination work for each. This could be achieved by placing students into general practice programs early on in their education. For instance why not reduce college to two years and med school to three? Those who want general practice could enter their residencies immediately. Those wanting specialty or research careers could stay on in college or in medical school for more intensive basic science courses. By knocking off three years from training general practitioners could be turned out in eight years instead of eleven.
When I think back on the hours spent on biochemistry, calculus, organic chemistry, physical chemistry, and biology of invertebrates and vertebrates and how little a part they have played, and continue to play in my professional life as a general practitioner, I question the value of the so called "pre-med" programs that many students undergo.
I recall several good students who would have made excellent general practitioners but who gave up on medical school because of low grades in the sciences. Some went on to become chiropractors, optometrists, and dentists; others became teachers and PhD's. Such was the reality of pre-med education when I went through the process forty years ago. After perusing a current MCAT preparation book it seems the process is more biased towards basic science than ever.
Opponents of a shortened approach to producing general practitioners will say that shortening the exposure to basic science would not provide a sound scientific basis needed for residency. I disagree. Is all that basic science really necessary for general practice? And haven't our medical schools really been preparing students for careers in specialties, not general practice? Doesn't the lack of primary care doctors belie educators' concerns and promises to produce more of them?
Medical education is geared to training medical students for careers in research and specialty medicine. The blessings from this approach are great. But doing it at the expense of not providing alternative pathways to produce general practitioners is counterproductive. The result is an unbalanced health care system.
It is overly optimistic to think that increasing the infrastructure personnel alone will solve the primary care problem. Fairer reimbursement is long overdue of course, but attention must also be given as to how best improve the enjoyment and satisfaction that a career in primary care offers doctors.
If medical educators believe that primary care is too important to fail, then shortening the training period for primary care doctors by making it more suitable for what their jobs demand of them is one important way of saving it.
1. David S. Meyers and Carolyn M. Clancy Primary Care: Too Important to Fail Ann Intern Med 2009; 150: 272-273
Marcus M. Reidenberg
Weill Cornell Medical College
February 24, 2009
Student Debt and Primary Care
The editorial by Meyers and Clancy suggested several ways to support primary care but did not discuss a need to support student debt repayment. The AAMC states the average student debt of graduates of public medical schools is $142,140 and that of private school graduate is $173,304. An overall average debt of about $159,000 requires repayment starting after residency of $2600 per month or $31,000 of after tax income per year on a 10 year repayment plan. Bodenheim, in an earlier Annals paper, gave average primary care income as $156,000 annually and Physicianssearch.com stated average primary care pre-tax income at $123,000 in the first year of practice. Repaying $31,000 after tax from $123,000 pretax probably enters into decisions of career choice for some medical school graduates. Consideration of an enhanced student loan repayment program should be part of any comprehensive program to support primary care.
Money plus paradigm shift needed to make primay care attractive
As Dr. Marcus M. Reidenberg mentioned in his Feb. 24 rapid response "Student debt and primary care", helping students to repay their educational loans is an important step in making primary care more attractive, especially in view of their disproportionately lower income compared to specialty practices being on average about one-half.
Many primary care doctors make considerably less than the $123,000 to $156,000 he mentioned. For most doctors making those amounts is inconsistent with primary care because it requires seeing too many patients. To generate those amounts would leave them with little time and energy to give their patients what they expect. Worse, there would be almost none left for their personal lives or participating in medical affairs.
Even if one's school debt were completely forgiven, the work environment would still contain the same amount of administrative drudgery imposed by health insurers as well as the ever-increasing volume of coordination activities.
Money alone will not attract more doctors to pirmary care because any added income will quickly go to pay for more ancillary help. This is sure to happen when the so-called medical home is put into place.
The point is that a new paradigm is needed for primary care. One that takes into account the limits of doctors qnd patients' desires for humane treatment.
If primary care doctors were paid on a fee -for -service basis on usual and customary charges as they were under indemnity insurance , freed from the necessity of getting authorization for tests and consultations, they would derive much more satisfaction from their work. The money saved by not having to pay for personnel to deal with paperwork imposed by insurers alone would save a primary care doctor about $20,000 a year.
1. Reidenberg, M. Letter. Ibid Pg.272-3.
Meyers DS, Clancy CM. Primary Care: Too Important to Fail. Ann Intern Med. ;150:272–273. doi: 10.7326/0003-4819-150-4-200902170-00009
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Published: Ann Intern Med. 2009;150(4):272-273.
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