One of the biggest challenges of modern medicine is the delicate balance between efficiency and individualized care. Spending too much time on each patient creates emotional and administrative burnout, but spending not enough time with a patient greatly diminishes the quality of care. Particularly in the US, the negative effects of this are seen as the value of our healthcare is low compared to other developed nations. The root of this issue is that the American healthcare system is specialty-driven, not primary-care driven. Let’s break down why that is.
Primary care is described as the long-term relationship a physician has with a patient in which they receive any health concern, coordinate the combination of services required to resolve these concerns and work to resolve any barriers to wellness while keeping in mind the family and community context of the patient. Specialties that fall under primary care typically include family medicine, general internal medicine, geriatrics, and general pediatrics. Primary care is seen to have many great long-term benefits, including greater use of preventative screening and testing as well as chronic condition management, decreased use of emergency services and costs, lower population mortality, and higher overall satisfaction. These effects all stem from the personal and continuous care patients receive from primary care providers and the trust built in that relationship.
Despite these great benefits for patients and the high demand for these physicians (half of the overall doctor’s visits are for primary care), primary care remains an unpopular specialty for recent medical school graduates (CDC). By 2032, the Association of American Medical Colleges expects a shortage of 21,100-55,200 primary care physicians by 2032, while interest in specialized fields steadily increases (KHN News). While primary care is very important, it is not attractive to many medical school graduates for its high effort/low reward specialty. Primary care physicians (PCPs) work as the manager of the entirety of a patient’s care and wellbeing, a job that has a heavy workload of both medical practice and increased administrative duties, including upkeep of the electronic health record technology (PCPs log an hour of desktop medicine for every hour of patient-facing care).
Primary care physicians are also at a disadvantage for reimbursement. The Resource-Based Relative Value Scale (RBRBS) Update Committee (RUC), run by the American Medical Association, is the committee that designates the Relative Value Unit (RVU) for over 7000 medical services. The RVU serves as a recommended, standardized fee for a given healthcare service. This committee has 31 voting members, but only one of those seats is guaranteed for primary care. The process of setting healthcare service prices is heavily dominated by specialists, resulting in PCPs getting paid significantly less than specialists, making the field even more undesirable to medical school graduates.
Particularly concerning is the geographic inequality in access to primary care remains a big issue as there is also a lack of PCPs in rural areas — compared to 53.3 physicians per 100,000 in urban areas, there are 39.8 physicians per 100,000 people in rural regions (NRHA). Designated Primary Care Health Professional Shortage Areas in the US include 65M people, which would require an additional 16,000 PCPs to adequately provide care (US Department of Health). This lack of access in rural/lower income areas only exacerbates the existing healthcare disparities at work. Due to the shortage of primary care physicians, there has been increasing Nurse Practitioner (NP), Registered Nurse (RN), and Physician Assistant (PA) participation in primary care to pick up the slack as well as the field attracting a disproportionately higher proportion of international medical graduates, both of which are changing the face of modern primary care.