There is a physician workforce crisis in primary care, both in the United States and United Kingdom. In the UK, half or more general practice physician training positions have been difficult to fill in certain parts of the country.
In the US, the American Association of Medical Colleges estimates that by 2025 there will be a shortfall of between 15,000 and 35,000 primary care physicians nationally. If you’ve recently tried to make a quick or easy appointment to see your primary care doctor in the US, you have found more often than not it is difficult to do. You end up seeing a nurse practitioner, physician assistant, or get told to go to the local urgent care centre. New patient waits for primary care doctors are up in many parts of the US, and in the UK delivery system, which has suffered chronically from long waiting times, there are calls to turn more patient visits into phone consultations, given the rising workload of general practitioners.
The situation in both countries is neither temporary nor easily fixable. And at its core the reasons for these shortages is similar in both places. Overall, the field of primary care medicine looms as increasingly unattractive to young medical students, for a variety of reasons.
First, it is a complicated field of medicine where the perception remains that one cannot know enough to be highly knowledgeable in all the areas of clinical care required. This makes many young doctors conclude that it involves becoming “a jack of all trades, master of none.” Second, both the unbalanced lifestyle and intense workload of a full-time primary care doctor or general practitioner who works as a partner or employee of a single organization puts many off from the outset. Increasingly, young doctors prefer a healthier work-life balance than their predecessors, at the same time wanting higher compensation for being primary care doctors as acknowledgement of the fact that the job is a difficult one. Yet, salaries for primary care remain low compared to other specialties, and the work-life balance that millennial medical students desire is seen as less and less possible in a field where the everyday responsibilities are often too diverse and highly task-oriented.
But there is a deeper, more profoundly troubling reason for both the growing exodus from primary care by older doctors, and the turn-off of it as a career for younger ones. That reason is the growing realization among both primary care doctors and their patients that relational care, the bedrock of effective primary care delivery, is less and less possible in US and UK health systems. Relational care is care defined by strong interpersonal attributes such as trust, mutual respect, and empathy. It involves doctors developing ongoing relationships with their patients, which foster emotional bonds that improve diagnostic accuracy and treatment efficacy. It involves primary care doctors finding greater meaning in their own work by experiencing the rewards of interpersonal care delivery—seeing their patients as individuals with unique life stories, and playing the roles of friend, advisor, and confidante for those patients.
What can be done about this situation? It may already be too late to turn back the decline of physician-centric primary care. The shortages of primary care doctors cannot be made up easily, and demand for primary care continues to rise. In addition, system forces in both countries, particularly the emphasis on squeezing greater efficiency out of care delivery; the intense focus on measurement and standardizing care through guidelines; and the growing use of non-physician personnel to provide services hamstrings the development of stable interpersonal relationships between doctor and patient, burns out physicians, and leaves patients with lowered expectations for their care.
But that doesn’t mean we should give up. In its fullest realization, primary care medicine still offers the best chance for someone calling themselves a doctor to have meaningful connections with their patients. If we can better convince medical students of that reality, more will continue to choose the field. Even though their expectations have lowered, patients still would respond to competently done relational care, meaning that there remains strong demand for primary care doctors that are in the best position to give that type of care. We need innovations in primary care delivery that commit the system to a renewed emphasis on doctor-patient relationships, rather than emphasizing how to just give patients greater convenience in getting a minimum level of service quality. Young medical students have to be trained and socialized better to understand how to be a relational doctor in a system that won’t always reward or support that type of care. This way, when they choose the field, they will both know what they are getting into and be better prepared to deal with it.
Most of all, though, we need to have a larger societal conversation about the important role of doctors in our primary care delivery system, then advocate strongly within the delivery system and with insurers that the rewards for organizations that pursue a more physician-centric approach will be greater than for those that do not.
By: Timothy J. Hoof