Missing Persons: Eliminations of Primary Care 1980s and 2000s

Robert C. Bowman, M.D.

Graphic representations of primary care reveal much about the priorities of medical education, medical leaders, and United States health policy. When physicians are plotted by type of physician or by primary care production, the missing persons in the United States are found to be primary care physicians, particularly the family physicians most needed for health care for most of the population. A past century of data collection by the American Medical Association, by experts such as Colwill and COGME, and physician databases indicates the rapid rise of specialty physicians with flat or little increase in primary care and family physicians.

Total Physicians, Primary Care Physicians, Family Physicians 1960 2050

Also consider that primary care and FPGP physician levels are flat despite the incredible increase of the US population. Then also consider the elderly doubling in the next 20 years with a quadrupling of primary care needs as Americans age.

Sufficient recovery in primary care requires primary care that remains in primary care, that remains most active and productive, and that remains distributed across all US locations. Only the family practice MD, DO, NP, and PA forms accomplish needed location and only the physician family practice forms remain in family practice and primary care. 

The United States could try a massive increase of 15,000 more primary care graduates using the flexible primary care forms. This graphic demonstrates no improvement in primary care with 5,000 more internal medicine, 5,000 more physician assistant, and 5,000 more nurse practitioner graduates above current or expected increases with no improvement in primary care. This graphic reveals that even with intervention, it is as if nothing was done at all. To generate the 125,000 more Standard Primary Care years in annual primary care reduction to begin to address primary care deficits, the nation would need to graduate over 40,000 more of any or a combination of the flexible forms that have only 2 to 4 Standard Primary Care year per graduate contributions.

As with physician assistant doubling from 1998 to 2008, the expansion in numbers results in no gain as primary care retention levels fall at 1 - 2 percentage points a year not just in new class years, but in all class years. The failure of flexible primary care training forms is that they are flexible and depart primary care during training, at graduation, and each year after graduation. See Primary Care Retention failures  Since the 1970s, the IM and NP and PA declines in primary care have averaged 2 to 3 percentage points of primary care retention decline per year. In 2008 with over 22,000 flexible primary care graduates and only 3000 permanent primary care graduates in family medicine and 3000 somewhat permanent primary care graduates in pediatrics, the national design for primary care and health access is revealed as grossly insufficient with no relief on the way. The Standard Primary Care per year rate for all five sources of primary care have declined from 20 SPC years per graduate to less than 6 SPC years per graduate.

The proper choice of permanent primary care with 5000 more family physicians a year resumes the production curve that would begin to resolve the primary care deficits resulting from the 1980s and 2000s. Note also that representations by class year only indicate movement toward recovery in a specialty or in primary care. With 35 years of sufficient production, recovery can be accomplished. For the first 15 years of sufficient production, levels of active primary care graduates remain insufficient. With primary care production that fails to remain primary care, sufficient primary care levels are difficult if not impossible.  The graphics also indicate that primary care production is possible, as in the 1970s when the United States quadrupled primary care numbers with a doubling of primary care percentage coupled with a doubling in medical school graduates during optimal health access policy.

Deficit periods and the growing deficit from the 2000 class year to whenever the United States actually decides to produce enough primary care that remains in primary care represent insufficient production as well as conversion of primary care sources to specialty care production. One should question the fact that the United States still considers internal medicine, physician assistants not beginning in family practice, and nurse practitioners other than family nurse practitioners as primary care. Even the family practice NP and PA forms are not reliable at the current time.

Reliable health access requires steady, dependable sources of primary care that remain in primary care. This also requires health policy supportive of primary care and the populations in need of health care. Policy is the critical determinant of market forces. Market forces together with policy determine health access. Origin and training factors can influence health access, but only as far as policy allows. This can be seen in graphics that consider policy impacts by class year and also consider birth origins such as with family physicians. Policy has clearly returned flexible forms such as internal medicine and physician assistants from 40% levels above 50% levels remaining in primary care during the 1990s policies, with massive declines since this time. 

A more complex graphic compiles family practice choice in actual US MD graduates considering birth origins by income quartile (or foreign born US grad) and medical school by MCAT categories along with class year health policy impacts. The permanent primary care choice of family medicine preserves the impact of health policy impacting medical student choice. Flexible forms require more sophisticated year to year (or month to month) data captures to illustrate the departures from primary care.