Doctors in Demand: Primary problem
Area health care providers say future shortage of primary care and family medicine doctors needs attention nowWhen Dr. Richard Vetter added up the number of doctors over age 50 at Innovis Health a year ago, the result was none too promising.
By: Emily Hartley, INFORUM
- Dr. Bruce Dahl
- Dr. Richard Vetter
- Dr. Bruce Pitts
More...
Doctors in Demand
A two-day look at the family physician shortage and how it’s changing the way your health care is delivered.
- Today: We explain the problem and the reasons behind the growing trend toward specialty medicine and away from family practice.
- Monday: The changing model of health care delivery through the use of hospitalists and team-based care.
When Dr. Richard Vetter added up the number of doctors over age 50 at Innovis Health a year ago, the result was none too promising.
With more than half of the provider’s 53 family physicians nearing retirement and a growing national shortage of primary care doctors, Vetter, like many in health care, knows the problem won’t go away on its own.
“I think we have about a five- to seven-year window here where we could and should intervene, and if we don’t, then I think seven years from now, we’re going to wish we did,” said Vetter, Innovis’ chief of medical services and chairman of the North Dakota Academy of Family Physicians Board of Directors.
Nationally, the American Academy of Family Physicians predicts a shortage of 40,000 family practice doctors by 2020. The need is partially due to an increase in patients, with baby boomers needing more care as they age and an estimated 34 million people gaining health insurance by 2014 under the federal Affordable Care Act signed earlier this year.
Beyond that, factors including high medical school debts and changing lifestyles have turned medical students away from family practice and other primary care positions.
Fewer doctors could mean more trouble for patients looking to access quality care at affordable prices in a timely manner.
Fargo not immune
North Dakota’s shortage of primary care physicians – including family practice, general internal medicine and pediatric doctors – isn’t new. Vetter says there have been 20 to 30 family physician openings across the state since he started practicing 20 years ago.
What’s new is a shortage of doctors in more urban areas, like Fargo.
“When I started, Fargo kind of had a pick of the litter because there were always more applicants than there were positions, and that’s not the case anymore,” Vetter said. “We’ve actually been recruiting for a family physician in Fargo for the past two years and haven’t been able to really fill the position.”
Part of that, Vetter said, is because the position calls for experience in obstetrics, an area increasingly covered by specialists rather than family physicians in urban areas.
Dr. Joshua Wynne, dean of the University of North Dakota School of Medicine and Health Sciences, said the “best estimate” is the state will be short about 160 physicians by 2025, with many of those needed for primary care in both rural and urban areas.
Dr. Bruce Pitts, president of Sanford Clinic, Fargo, said they’ve had success in recruiting doctors over the past year, but it’s taken an aggressive platform.
Pitts said Sanford, as the nation’s largest not-for-profit provider of rural health care services, is “very dependent upon primary care doctors. Being able to pull that off is very, very important to us moving forward.”
Sanford and Innovis both have clinics in North Dakota and Minnesota, and Sanford also has locations in Iowa and Nebraska and one in Oklahoma.
Comprehensive statistics for Minnesota were unavailable, but with 33 openings in family medicine and 16 in internal medicine across North Dakota as of June – the most recent statistics available – providers said something will have to change.
A decline in students
A first step in the multi-layered process of staving off the shortage is attracting more medical students to primary care specialties.
Pitts said openings in family medicine and general internal medicine, which focuses on adult care, are the hardest to fill.
At UND, nearly 31 percent – or 17 of the medical school’s 55 graduates in 2010 – chose to continue in a primary care specialty, down from the 41 percent (24 students) in 2009 and 46 percent (28 students) in 2008.
While that ratio has gone down in recent years, UND still ranks No. 1 in the nation for the percentage of students choosing family medicine, about 20 percent.
Wynne said that’s due largely to students accepted by the medical school. About one-fourth of its students are from towns of fewer than 2,500 people, and more than 80 percent are from North Dakota, where primary care doctors play a large role.
On a national scale, 2,404 residencies (internship-type training in specialty areas after medical school) were filled this year in family medicine, the largest number since 2000. An equivalent 2,404 were filled in 2008.
Of the spots filled, 45 percent were by American graduates, up from 2009’s 42 percent, but still down from the more than 60 percent before 2000.
“There are fewer American graduates going into family care residencies than used to,” Pitts said. “That may be picking up a little bit, but we’re not sure if it’s a trend or just a blip.”
Any recent upticks in primary care enrollees may be due to an increased awareness of the shortage.
The AAFP says the number of U.S. medical students going into primary care has dropped 52 percent since 1997. Part, but not all, of that drop has been picked up by foreign doctors.
In internal medicine, students are leaning toward sub-specialties and hospitalist practices. It’s estimated that less than 2 percent of all internal medicine specialists now practice general adult care.
Comes down to cash
The recent federal health care reform legislation contains clauses meant to combat the shortage, but reasons for the decrease in interest persist.
Part of it comes down to cash.
Both Vetter and Pitts said money shouldn’t be the deciding factor for students’ specialty choices, but with tremendous debt and large differences in salaries among specialties, it’s a hard factor to avoid.
The average UND medical student’s debt in 2009 was $159,000, up from $138,000 in 2008.
When it came time to be recruited, Merritt Hawkins – a national firm that helps providers recruit physicians – reports that the average salary offer in 2008-09 for a family physician was $173,000 and for an internal medicine specialist, $186,000. Compare that to $258,000 for a neurologist, $321,000 for a general surgeon or $391,000 for a radiologist, and the money adds up.
“It’s just the difference in income potential and balancing that against their debt and their kids and their house and everything else they have to worry about,” Pitts said. “I think it’s a significant factor.”
On top of salary differences, providers say reimbursement from insurance companies for services in primary care is much less than in sub-specialty areas, partly because specialists have more tests and procedures to be paid for.
The new health care legislation aims to address reimbursement issues, granting a 10 percent bonus in Medicare reimbursement for primary care doctors and working to develop a system that pays for the quality of outcomes rather than the quantity of care given. The federal Frontier State Amendment also will bring about $650 million into North Dakota, as well as other states that face lower Medicare reimbursement rates than the rest of the country, over a span of 10 years.
A regular lifestyle
With more fiscally rewarding options available, providers said the sometimes hectic lifestyle of a family doctor is one young physicians are less willing to lead.
As new grads gravitate toward a more structured lifestyle, Pitts said Sanford has changed to provide part-time employment and time off, especially for an increasing number of female physicians who have children.
“I don’t want to make any generalizations, but it’s often said that it takes one and a half (physicians) now to replace one,” Pitts said. “A lot of physicians coming out of training want to work less than full time, and they fully expect to be on call less often, if at all, and to have more regular hours. (They) have expectations for a real family life and time away from work and a much more balanced lifestyle than we think of doctors many years ago.”
The unbalanced lifestyle of many urban doctors is exacerbated in rural areas, where doctors face more pressures to be on call and work longer hours, Vetter said. A lack of amenities and a spouse’s career needs may also push students away from rural practices.
Staving off the shortage
Area providers agree: The physician shortage is one of the biggest problems facing health care. They also agree North Dakota and Minnesota are in a favorable position for combating it.
The integrated style of the region’s health systems, where clinics are tied to larger hospitals, is a plus for recruiting physicians, who providers said get strong support both medically and financially. Moving forward, providers said the need for primary care physicians will likely bring new models of patient care that lessen the reliance on individual doctors.
Advances in technology like online visits and telemedicine, where caregivers can consult with physicians electronically during an appointment, will also continue to grow.
In the meantime, patients in much of the country are waiting longer to get an appointment or turning to emergency rooms and more expensive sub-specialists for problems treatable by primary care physicians.
Wynne said addressing health care’s biggest issues – namely access, cost and quality – comes down to providing the type of inexpensive, personal care that North Dakota and the Upper Midwest are known for.
“North Dakota is somewhat unique in that we have this position nationwide of being perceived as having high-quality health care and relatively low-cost health care,” he said. “It’s logical to make the connection that that’s at least in substantial measure due to the fact that we deliver a lot of our care with primary care docs.”
Readers can reach Forum reporter Emily Hartley at (701) 235-7311
Tags: primary care, family medicine, innovis health, sanford health, health care, north dakota, doctors, physicians, innovis, sanford, health, fargo, moorhead, minnesota, news
More from around the web
RSS Feeds