The general practitioner—time for another look?

How can we balance supply and demand in primary care? One potential solution could be to revive the general practitioner.


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.

Edward J. Canfield, DO, (center) argues that restrictions against licensed but not specialty-certified physicians have exacerbated the primary care physician shortage.

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.

Long history

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.


  1. Mark

    I would like to see a pathway for a retiring surgeon to do general practice. A recent article in the Bulletin of the American College of Surgeons touches on this.

  2. robert migliorino,d.o.

    Strongly agreed. GP’s wre welcomed five years ago. However;draconian license,staff admin ,etc has killed off this group. Unfortunately,there is a large group of GP’s who cannot obtain positions ,yet there is a claim of physician shortage in this country even though FMGs have had an open door for over half a century.Now, the AMA & AOA want more cash for more unneeded residency positions even though there is a pool of nonresidency physicians available.Politics, is rampant,given the number of states requiring residency training for licensure. This is a blatant joke,as most of the states are in physician poor regions.Besides, who wants to go to Buffalo Gut,Montana when wives,etc want the amenities of the Big City?I could go on & on but, it is like whistling in the wind!

  3. robert migliorino,d.o.

    Please recall that OB-Gyns,Peds,& Internists demanded that they be classified as Primary Care some years ago when they learned that GPs would be paid more by Medicare,Medicaid,& Insurance for being primary care providers.

  4. robert migliorino,d.o.

    The main difference between an FP & a GP is that an FP is signed by contract to deliver infants at some out of the way 25 bed hospital looking to increase its beds occupied status.

  5. robert migliorino,d.o.

    Dr. Canfield;note that most newbies do not go to the U.P. where there are no industries or jobs ,only Medicaid. North of the bridge there is no cash,only pasties.Plus, one must enjoy lots of snow!!!

  6. Ken Unice, D.O.

    Those of us who entered general practice felt comfortable after a 1 year rotating internship. It takes diligence and dedication but it can be done. Over the years at our D.O. internship/family practice hospital residency program, several of these young D.O.’s could have entered practice after 1 year without the OB component. They would have to take the certification test as we did.

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