The general practitioner—time for another look?
As our population ages, the need for primary care physicians is increasing dramatically. In Michigan, where I live, 54% of physicians intend to leave practice within the next 10 years, resulting in a shortage of more than 4,400 physicians by 2020, according to a state survey. The same problem is compounded nationally.
Educating physicians is an expensive process. The average debt of medical students upon graduation is more than $160,000, according to both the American Association of Colleges of Osteopathic Medicine and the Association of American Medical Colleges. Deferring interest payments during residency adds another $36,000 to a $200,000 loan at 6% interest.
Studies indicate that compared with other industrialized nations, the United States has too many specialty-trained physicians and not enough primary care generalists. In fact, in most nations, the ratio of generalists to specialists is at least 50-50, with some at 75-25. In the U.S., that ratio is reversed, with approximately 75% of students selecting the more lucrative specialty tracks, perhaps as a solution to their debt problems.
So how can we balance supply and demand in primary care? One potential solution is to bring back the general practitioner. In a state such as Michigan, where we are discussing the option of giving advanced practice nurses independent practice rights, this solution makes a great deal of sense.
I envision a program for training GPs that would enable them to obtain an unrestricted license to practice medicine after completing a one-year rotating internship focusing on outpatient or hospital-based practice. DO and MD general practitioners would be required to pass all three parts of either the Comprehensive Osteopathic Medical Licensing Examination of the United States or the United States Medial Licensing Examination.
Applying to the GP program during their third or fourth year of medical school, students would adhere to certain requirements. For example, they would agree to serve in a health professional shortage area for at least two years—either in private practice, a hospital system or a federally qualified community health center. They would agree not to pursue a specialty residency until completing this term of service.
General practitioners have a long history in the U.S. Many family physicians older than 50 were once GPs who were “grandfathered” into family medicine. In days past, GPs practiced a much broader scope than is expected of today’s family physicians. Almost all GPs delivered babies and followed their patients in the hospital. Some did general surgery procedures, such as tonsillectomies, adenoidectomies, appendectomies and vasectomies. These doctors were expected to be lifelong learners, just as physicians nowadays are.
Primary care physicians today are more office-based and less procedure-oriented. Many physicians still do procedures and hospital work and deliver babies. But limited reimbursement for these endeavors, the time commitment required and the exploding administrative burden have forced physicians to focus on the office, where they make their primary income.
Although not for everyone, the GP program could make a big difference. In Michigan, for example, more than 880 physicians graduated from the state’s four medical schools this year. If only 5% were to choose a GP program like I’ve proposed, 44 new primary care physicians could be at work in underserved communities in just one year, upon completion of their internships. Five years later, 220 doctors would be in general practice. If 10% of new graduates were to opt for the GP program, close to 500 primary care doctors could be entering practice in that time frame.
The general practitioner program would not be the end-all solution to the primary care physician shortage in this country. There are other valid plans. But I would like to begin the conversation on this option.
A family physician in Sebewaing, Mich., Edward J. Canfield, DO, is the immediate past president of the Michigan Osteopathic Association