Primary care doctor shortage spurs fears

Some feel it’s damaging nation’s health

There is a severe nationwide shortage of primary care doctors and some observers believe it’s having a negative impact on our health.

Patients either can’t find one of these doctors or must wait weeks or months for an appointment. Experts point out several reasons for the scarcity, essentially coming down to longer hours and less pay, compared to specialists trained in areas like cardiology and orthopedic surgery.

The challenge of being a primary care doctor isn’t stopping Christian Pineda. The Fitchburg resident and soonto-be graduate of UMass Chan Medical School will enter his residency training in family medicine, considered one of the pillars of primary care.

Pineda’s choice doesn’t come without challenges.

“Primary care has the least amount of money and the most amount of work,” Pineda said. “The work-life balance and the pay are not exactly ideal. (Primary care) is not as appealing to medical school students.”

A report from the nonprofit Milbank Memorial Fund appears to support that assessment. Its 2024 scorecard found the number of primary care doctors per capita fell from 68.4 per 100,000 people in 2012 to 67.2 per 100,000 people in 2021.

In addition, 37% of all doctors in training in 2021 started their residency programs in primary care. However, only 15% of that pool practiced primary care medicine three to five years after residency. More than half went into a specialty or worked in a hospital setting. Meanwhile, primary care as a share of total health care spending in the U.S. dropped from 5.4% in 2012 to 4.7% in 2021, according to the report.

What is primary care?

Generally recognized as the first line of defense in health and well-being, primary care doctors examine patients over the course of years during annual checkups and other appointments. The result can be a close relationship between patient and doctor, as the patient’s long-term health needs come into clearer focus. If a particular issue is identified that requires more indepth analysis, the patient can be referred to a specialist.

Besides family medicine, internal medicine and pediatrics are generally considered the foundations of primary care.

Paying down loans

Dr. Michael F. Collins, chancellor at UMass Chan, believes the list also includes obstetrics and psychiatry. Collins himself is a primary care doctor, trained as a general internist. When asked why there is a shortage in primary care providers, his answer went directly to the intelligence of medical school students.

“I like to posit that medical students don’t get stupid when they come to medical school.”

Collins explained many students are saddled with loans to pay for their education. They choose training in a higher-paying medical specialty in order to pay down the debt faster.

Many specialties are higher paying than primary care, according to the 2023 Physician Compensation Report from Doximity, which bills itself as the largest community of health care professionals in the U.S.

The average annual compensation of a neurosurgeon ($788,313), orthopedic surgeon ($624,043) and cardiologist ($544,201) far outpaces pediatrics ($242,832), family medicine ($273,040) and internal medicine ($293,894), according to the report.

Collins also noted this generation of medical school students desires a work-life balance and specialties generally come with a set work schedule, unlike primary care.

Collins also cited medical students’ desire to treat patients, not spend hours in front of a computer keyboard, punching in electronic medical records and submitting electronic pre-authorization requests that insurance companies require for medications and certain steps of care. The Milbank report found 16% of family doctors spent four or more hours daily on electronic heath records instead of patient care.

‘Hidden agenda'

Status is also at play, with specialists perceived as occupying a higher rung in medicine compared to primary care. It’s known as the “hidden agenda” and it can deter medical students from choosing primary care.

“We need to recognize the importance of this workforce to the profession,” Collins said. Recognition must come from insurance companies and large health systems, he said.

“Until we get to that point, I think you’re going to have students vote with their feet,” Collins said. “They’re going to say that’s just not for me because if I go into this highly remunerative specialty, my life will not have some of the issues that would be if I choose to go into one that’s less remunerative.”

Of the 164 soon-to-be UMass Chan graduates in the class of 2024, 49% matched in primary care residency.

Celebrate these doctors

Primary care doctors need to be celebrated for their work, said Dr. Robert Zavoski, chief clinical officer at Family Health Center in Worcester.

“Our nation has a severe shortage of primary care providers,” Zavoski said. “The work they do is tough every day, it’s incredibly important every day and I wish they had more support than they do.”

When asked where the support should come from, Zavoski described a maze of electronic procedures that doctors must navigate before insurance companies and other layers of bureaucracy approve services such as medications and X-rays.

The systems began in the 1970s to save money, but all they did was drive up health care costs, Zavoski said. Managed care followed in the 1980s and 1990s and Zavoski said it created market forces that drove down prices for primary care.

What is the solution?

The short answer, according to industry watchers, is pumping more money into primary care to narrow the salary gap between providers and specialists. Collins believes that with all the talk about the shortage in primary care, market forces will shift and lead to higher salaries for these doctors. When asked where the money will come from to level the playing field, Collins said, “That’s been the dilemma in the profession for a long time.”

A pending bill in the Massachusetts State House would pump more cash into the primary care pipeline. Reportedly, the amount would double over a three-year period and a chunk of the funds would come from insurance companies, hospitals and pharmaceutical companies.

Instead of paying primary care doctors for each service provided, payment would be upfront based on patient and industry metrics that predict the amount of health care services needed.