More of the Same Design Still Fails Most Americans
Including Current Medical Students

Robert C. Bowman, M.D.   

Organized medicine has been lobbying for more specialists for at least the past 7 years. Initially organized medicine carefully avoided the mention of primary care and health access, after all multiple promises of more graduates resolving health access problems have not solved health access. But as the lobbying efforts have neared success regarding federal funding, more primary care has also been indicated.

This lobbying effort has apparently also suspended scientific rigor. Organized medicine has published and caused to be published studies that indicate phantom doctors - doctors that will not exist in the future under the current design. Those familiar with abuses of secondary databases are familiar with various claims of United States workforce that include graduates not even in the United States and not delivering primary care, but these problems have multiplied and have reached the highest levels. Even the General Accounting Office is confused.

Congress has been led to believe that more of the same design will result in more primary care. For example the 2008 Association of American Colleges studies and the 2008 Health Resources Services Administration Physician Workforce Projections  posted just one year ago have internal medicine primary care numbers as increasing dramatically from 111,000 to over 150,000 in the next twenty years. The truth is that internal medicine has already lost about one-third of its primary care workforce with more losses to come. Those familiar with the medical literature should realize that a claim of steadily increasing primary care, regardless of the methods used, is impossible. Studies in JAMA (Hauer) indicate that only 10% of internal medicine graduates or about 800 per year will be entering primary care. New England Journal of Medicine and Annals of Internal Medicine articles (Bodenheimer, Sox, others) note the collapse of internal medicine primary care and the conversion of over 30,000 to hospitalist care in the past 7 years alone (McMahon). Media such as CNN still have US primary care down to 2% of the career intentions of medical students, a mistake due to an association error.

The end result is less than 1000 internal medicine graduates remaining in primary care for recent class years and future class years to come. The maximum possible IM primary care for the next 35 class years is 1000 times 35 years in a career for 35,000 who are age 30 - 65. This estimate does not correct for fewer years (non-citizen), less activity in US practice (older, female, non-citizen) and other departures to hospital, specialty, administration, teaching, other careers, and other nations.

Also studies have yet to emphasize that foreign origin or non-citizen international medical graduates are 45% of internal medicine graduates. Non-citizens deliver half of the workforce of US origin graduates due to delays in entry and departures after graduation. They deliver the least primary care per graduate not only in physicians, but in physicians and non-physicians. (1.3 SPC years compared to 2 - 4 for US origin IM, NP, or PA, 14 for PD, and 25 for FM graduates)

This will result in over 70,000 phantom doctors – doctors that will not exist and that cannot exist by 2020. The studies include projections by HRSA of an increase in primary care physicians of 21% from 2005 to 2020. Internal medicine primary care should be declining below 70,000 (or far below), family medicine is fixed at 90,000 to 100,000 due to only about 2500 entering primary care each year since 1976, and pediatric primary care is locked at 55,000 for the next decades as primary care is saturated in the locations where pediatricians choose to locate. Few understand that 90% of internal medicine, 53% of pediatric, and 15% of family medicine residency graduates fail to delivery primary care along with 70% of non-physician clinician graduates. Few understand that all that the designs for US workforce, the designs for US support of primary care, and the designs of US support for health care for lower and middle income Americans will only support about the same level of primary care as found in 1980, and likely less due to increased costs of delivering care.

The organized medicine and HRSA studies result in distractions and delays that will hide an important recognition – the recognition of basic workforce design flaws that fail to result in sufficient access to primary care for most Americans.

Current health reform has focused on fixing the financial access to primary care for most Americans left out of the coverage design and fixing reimbursement to support primary care where primary care is needed would appear to be enough, but the actual recovery of primary care will take at least 40 – 50 years mainly because it has been neglected since 1980.

Many propose solutions involving more coordinated care, but care delivery requires primary care nurses and primary care physicians - both in shortage for some time to come.

It is also a time of great crisis in America, particularly in the everyday lives of most Americans. All in American should realize that the interests of organized medicine do now always involve the best interests of the United States. The evidence of 1960 - 1965 and the early 1990s should indicate this steady opposition.

Also the incredible amount of two trillion dollars in health care represents a most important funding source. This is enough funding to do much much better, or enough funding to prevent any and all changes. This is particularly set in place by the health care design with 75% of physicians found in 4% of the land area in the largest systems.

Americans blessed with top concentrations in so many dimensions fail to understand that most Americans face a number of personal and financial sacrifices just to receive basic services. Their children who become physicians at 3 to 10 times higher probability also fail in this recognition. Physicians should be aware that the design actually angers many Americans yearly. More also feel that they do not have the full attention of their physicians and there are also reasons that this has become reality – a major one being that American physicians have steadily become least like the patients they are treating and the team members that they work with to deliver care. Empathy, service orientation, communication skills, and other key elements essential to the day to day lives of physicians is suffering. But most of all trust is threatened. At some point in your career you should realize that the trust of patient in the doctor is the foundation of any health care. And we are losing this battle of trust.

It is in this context that organized medicine has decided to ask for a substantial increase in federal funding. It has decided to organize a campaign intended to get the federal government to take even more money away from health care for the elderly to spend it on more graduate medical education.

There are particular reasons not to support this plan that are relevant to you and to many others due to the lack of impact on care of the elderly, the lack of an impact upon the health care of most Americans, and the continued lack of attention to health access. This is also the reason that not all of organized medicine supports the current effort, particularly those who remain focused on the permanent delivery of primary care and basic health access. Since this proposal also fails to improve primary care and the health care needed by most Americans, more should be aware of this plan.

Medical students are caught in between. There are reasons for students to support this short term fix proposed by organized medicine to boost residency positions, but there are reasons to be very, very concerned regarding the consequences of more funding fed through the same design. More of the same concentrations of training in a few locations and funding of residency positions that result in specialists and physicians for 4% of the land area and 85% of funding to zip codes in 4% of the land area is more funding for the same failed designs.

The AAMC has made a special appeal to medical students to call on Congress to pass this legislation. They are hoping to take advantage of the enthusiasm of medical students. They hope to keep the focus on short term needs. Osteopathic medical students do face a challenge as there are too few residency positions. United States origin students denied the opportunity for a United States medical school face difficulties as well. For the short term, medical students would appear to benefit from residency expansion. Also there has been expansion of GME positions without federal dollars and there have been conversions of the residency positions less in demand to specialty positions. These are also not favorable to primary care and health access but are also not being brought out into the public for debate and informed decision-making.

But the most basic consideration is that more of the same design still fails most Americans and it will continue to fail even current medical students as they become physicians and as they age and need more health care themselves.

I am particularly disgusted that the AAMC promotion of the expansion plan posted on their web site mentions needs for family medicine, health access, health quality, primary care, the elderly, and vulnerable populations. This promotion effort is a good plan to gain the attention of Congress and those who know about these terms, but it is not a design that will actually meet family medicine, health access, health quality, primary care, elderly, and vulnerable population needs.

Organized medicine has crafted a plan that has ignored real needs of students, Americans in need of health care, and most of the nation. Just a few areas of neglect include more hands in the health care till that deliver no health care at all including liability lawyers, brokers of physician services, profiteers, stockholders, and drug company influences. These are not new influences.

As a young physician I was elected to represent young physicians as the first delegate to the AMA House of Delegates from the Young Physicians Section. My very first efforts as a young physician involved attempts to to gain a health access focus in Oklahoma via the state medical association. The state medical association responded and the state Legislature sent Congress and President Reagan a message, but it was ignored. My efforts were driven by my realization that I was paid the least in the nation to do the most complex care with the least assistance – in solo rural family practice in Oklahoma. Indeed with troubled economic conditions in the mid-1980s, many young physicians such as myself were soon no longer in health access where needed. It was my additional time doing teaching that kept me solvent until I found another health access job, one that integrated teaching, research, and delivery of health care. I focused on training and less on policy for awhile, but have kept returning to policy as primary care still receives insufficient support under much the same design.

My time in organized medicine was a great learning period, but also a period of awareness building as I realized that my desires for increased health access developed during medical school, residency, and solo rural practice were not the desires of organized medicine. Nor were the young physician issues of liability, public health, and profiteering addressed. Medicine was busy adding more specialty types and hospital staff sections - and losing members. Current medical students perhaps are not aware that medical student and resident organizations have broken away from organized medicine in the past for failure to deal with issues vital to medical education and the future of medicine.

Attempts to work at the state and local levels in organized medicine also depressed me. There was no big picture focus on the needs of those left out of the design. As an expert witness I saw large systems of physicians drive fellow physicians out of practice and even propose to drop care of the indigent entirely. The entire focus was funneling more business to large systems, regardless of the consequences for local health care and most Americans. More frightening was physicians that thought they were leading organizations, which were really being led by others.

Even health access organizations such as the Families of Family Medicine did not impress me over the years, although they appear to be coming around. Family medicine hoped that medical schools would embrace primary care, family medicine departments, and respect for health access. It is clear that these were respected only in the years when such efforts brought funding. Now the design reveals dependency for primary care departments and departments that no longer focus on primary care and health access. More of the same not only fails in family medicine, it results in even more residents bypassing family medicine and primary care to specialty careers. Title VII will not rescue primary care or family medicine. It only gets in the way of needed design changes in workforce, in support, and in health care for most Americans.

The nation suffers from the distorting influences of student debt and stressors during medical school that change the attitudes of students and physicians in ways not conducive to best future health care. The reimbursement system is broken and the distribution of health care delivery itself is too much and too little and far too costly. Where is the medical leadership to address these areas and insure the best solution rather than one driven by accountants and lawyers? I have long believed studies that indicate that physicians "get even." These have often been studies of changes in reimbursement where decreases result in more and unnecessary services. My own personal belief is that physicians forced to go through much financial hardship by the design of medical education funding, "get even" over time. And sadly this involves a longer period and more costs for the nation rather than an up front payment for medical education costs and a bit less paid in reimbursement by design. 

Special programs for health access that are abused by those that have top concentrations of physicians and health resources, including medical schools and teaching hospitals that already get the most. My own alma mater even proposed 30 J-1 Visa positions per medical school. Bypasses of various obligation programs are a problem. CHC, rural health clinic, NHSC, shortage designation, bonuses for shortage areas, and high poverty access points have all been utilized to send physicians or funding to locations with top concentrations of physicians. As a result the regulations resulting from abuses are nearly impossible to navigate, making sure that those with the least get the least in the future.

The only solution is not to have grant funded or special programs that can be abused by those more socially and politically organized. We don't ask our school districts to apply for funding for basic education needs. We know how many physicians we need and where. We need the infrastructure that supports this. This means a real primary care workforce design and real primary care funding design and real patient health access design – for 100% coverage for basic primary care access initially and as a top priority.

Frankly we will never know how many specialists are needed until we know how the nation performs with sufficient primary care, rather than more and more patients shifted to costly specialty care, emergent care, and urgent care – forms that exist 75% or more in just 4% of the land area already in top concentrations of physicians. The lack of emphasis on basic health access and primary care has resulted in spiraling costs and worsening quality.

Medical historians should be writing volumes comparing past to present medical leaders. One hundred years ago the medical profession was in disarray in selection, in training, in funding, and in quality. Today the medical profession is in disarray in selection, in training, in funding, and in quality. The medical students one hundred years ago were not prepared academically to be physicians. Today the medical students are wonderfully academic, but insufficient in people skills and awareness of those in need of health care. Training is similarly narrow in focus with regard to primary care, health access, and the needs of most in need of health care. Numerous studies document quality or the perception of quality with regard to practitioners that share common ground with their patients served. Physicians have never been so different in so many dimensions from the American people and the health care team members that they attempt to supervise in health care delivery. Never have physicians had more assistants, nurses, and non-physician clinicians and this has resulted in much more care, but not better care.

In this time of great turmoil in the United States, in the world, in medicine, in health care costs, in medical education, in energy costs, in foreign policy, and in the basic well being of American children -  medical education leadership decided to expand medical school positions. They made this decision despite conferences indicating decreasing teaching patient volume, passive medical education instead of active hands on care, limited student exposures to faculty, increasing faculty distractions for other duties, and decreasing physician quality. This is the opposite decision from one hundred years ago when the nation cut back on medical schools and medical school positions realizing the need for better quality in physicians. Matters are even worse with non-physicians that compete for training spots, are ever younger in entry, and have less and less life and health experience that exposes insufficient training.

Medical education is in serious difficulty and more of the same will not help. Pediatric and internal medicine studies document that even more teaching volume is being taken away by hospitalists. Non-physician training positions are growing much faster than physician positions. Training of a wide range of non-physicians impacts the available teaching resources as training involves many of the same locations. Instead of health access training sites away from major centers, more non-clinician training competes with medical education.  Care of patients in hospitals and by specialists is moving to nurse practitioners and physician assistants who are 70 – 75% specialist already and steadily moving to even higher levels, all driven by higher funding for specialty and hospital care.

Basic health access was ignored by organized medicine in 1965, in the 1990s, and this continues today. It took less than a decade for a defeated organized medicine to recover and to convert Medicare and Medicaid to benefit organized medicine. The setbacks to organized medicine during the 1990s lasted only a few years before the current rebound, one that has apparently resulted in the destruction of the former largest source of primary care and care of the elderly. Internal medicine graduates in the future will deliver less primary care than any of the other four forms of primary care.

Most important to consider is that the design consistently supported by medicine is the direct opposite of basic health access. More exclusive in admission, in training, in career choice, and in distribution of health funding is actually the only way to defeat health access and the US has gone along with all of these decisions. In editorials, in front of Congress, and to medical schools and medical students organized medicine has denied the ability to deliver health access to the nation countless times. Of course numerous medical schools have done so for over 100 years. The lower and middle income origin medical students that are a smaller and smaller fraction have always distributed. Older graduates of medical schools have 30% greater distribution to most needed health access. And family medicine choice consistently doubles underserved location and triples rural location and the effect remains across all class years and long after obligations end. In fact the problem with understanding loan repayment is that those who choose loan repayment are the same ones who would make much the same career and practice location decisions anyway. Finally medical schools and states that have coordinated health access across birth to admission, admission, training, and policy have consistently succeeded. Logistic regression equations demonstrate the success of efforts involving more normal and less exclusive at every level, especially when combined. (Bowman, They Really Do Go, Rural and Remote Health)

Instead of working to assure that more choose rural, underserved, primary care, and family medicine careers, US medical schools are admitting students that are ever more exclusive in parent income and occupation and most urban origins. Entering medical students are least like most Americans in many dimensions. Foreign origin international medical graduates are also most exclusive in origin. Allopathic private and international graduates not surprisingly choose the most exclusive careers and locations where physicians already are found in top concentrations. Medical schools and graduate medical education programs train more exclusively. Even primary care programs have become dysfunctional and are a factor driving medical students and residents away from primary care (Keirns, Academic Medicine) Organized medicine supports policies that send health funding exclusively (85%) to 3400 zip codes and the peak funding levels involve medical schools, teaching hospitals, research, graduate medical education, and corporate interests.

Medical education leaders have a fixation on the economic benefits of medicine but have failed to count the cost to school district, state, and national budgets as well as businesses and the national economy. Economic calculations to demonstrate shortages or the need for more physicians are one thing. The reality of the current triad of energy costs, foreign policy costs, and health care costs is quite another. This triad has placed a stranglehold on the economy and domestic spending in critical areas involving children, birth to higher education preparation for most Americans, and important national infrastructures. More funding to health care essentially deprives future Americans of the ability to actually become physicians and these are the children that will distribute and relieve health disparities as well as becoming the teachers, nurses, public servants, and other human infrastructure that is most needed to keep the nation running, solvent, and secure. Family physicians, rural physicians, and underserved physicians all are higher probability with more normal and less exclusive origins and are less likely with most exclusive origins – again using studies based on near complete populations of physicians in the Masterfile tracing these physicians to their birth origins.

Meanwhile organized medicine spent millions of dollars to illustrate the important economic impact of medical education with at least 512 billion in annual impact for US MD schools alone (not even a complete study). And then organized medicine failed to understand that what it was doing was illustrating the problem of more of the same design. The economic impact of medical education as currently designed is very limited to a few locations and a small portion of the population. About half of the impact or 256 billion involves just six states (actually a few dozen zip codes in these states). About 25 states receive less than 10%. The design of graduate medical education could impact much of the nation but restrictions to the top concentrations of physicians insure that few benefit. For example training could be found in most of New York City but remains concentrated in Manhattan and a few other zip codes while the rest of the city has insufficient physicians, particularly in primary care. About 65% of the US population cannot find sufficient primary care in a local zip code or an adjacent zip code (30 – 50 primary care physicians per 100,000) at a time when primary care physicians and non-physicians are melting away and at a time when local primary care needs will be increasing from 90 to 110 primary care physicians per 100,000 as the population ages. Physician Distribution by Concentration site

It is easy to find Representatives or Senators in a few of these favored states receiving most of the benefits of current health care spending to sponsor legislation. Since the states with substantial electoral votes are involved, such a proposal will have powerful allies. What will not be represented to Congress or the administration or the public will be the needs of future physicians, future children, or even those left out of the design, like the current and future elderly.

Internal medicine training is now down to 90% specialty in outcomes. Only 10% or 800 internal medicine graduates a year begin in primary care and departures for hospitalist, hospital, specialty, urgent, and other careers continue. Over 2000 more leave primary care than enter each year. By 2040 internal medicine will have less than 40,000 active primary care physicians. This is all that can result from 1000 per year entering primary care for 35 years after the past class years retire or depart. This is down from over 110,000 in 2000. Internal medicine is departing care of the old, older, and oldest at a very bad time since each of these populations is set to double by 2030.

Every second the United States grows by 1 person not over 65 and by 1 person of all ages less than 65. Those over 65 require 2 to 4 times as much primary care. Studies demonstrate that American health care is out of position for the elderly.

·         Failure in funding for the elderly – the current low reimbursement for primary care defeats primary care (and most care) for the elderly. A 21% cut hanging on and hanging on in Congress would also defeat primary care and care for the elderly.

·         Funding priorities for Medicare and Medicaid (hospital, specialty, drugs, long term care) siphons funding away from primary care and makes primary care more complex

·         Failure in primary care internal medicine, the primary source of care for the elderly now a small portion of care and getting smaller

·         Failure in geriatrics with 1% of graduates and 80% of geriatricians where only 30% of the elderly are found – basically a failure due to the most complex primary care paid at the low primary care rates

·         Failure in heart attack and stroke center locations (Perotta, JAOA)

·         Failure in location of primary care as 70% of the elderly are found in 28,000 zip codes with only 23% of physicians away from higher cost of health care and higher cost of living locations where 85% of health spending, 75% of physicians, and 80 – 92% of specialists are found. (Bowman, PDC)

·         Failure in primary care training and geriatrics training in medical school and residency training

Ferrer documented that family physicians equitably serve the elderly (60% saw a family physician for ambulatory care in 2004), adults, women, children, the poor, the near poor, and minorities. Rosenblatt, Hart, and others documented that family physicians serve Community Health Centers at 2 to 4 higher levels compared to other physicians and non-physicians. Mold family medicine priority for Medicare patients who were poor, less educated, minority, and rural.

In my studies 53% of all family physicians and 60% of osteopathic family physicians are found in the same zip codes in practice where 65% of the US population and 70% of the elderly are found. Pediatric and internal medicine primary care physicians that remain in primary care have only 30% of graduates found in such locations. Only MD, DO, NP, and PA forms of family practice deliver most needed health access and care of the elderly where needed, and only the physician forms stay in family practice.

The United States does need more residency positions so that it can increase the physician supply, but what it does not realize is that specialty supply has been addressed. Each source of specialty workforce has increased by 50% or more – US MD, US DO, international, physician assistant, and nurse practitioner. In the past ten years the physician assistants entering the specialty workforce have increased 180% as the annual PA graduates have doubled from 3100 to 6500 and the percentage entering has increased from 46% to 72%. (Data from AAPA site)

What medicine now and in the future does not need is more failed promises of primary care as in multiple times in the past. In fact there is no way that more of the same can deliver more primary care at the current time. Out of 28,000 annual primary care graduates from five forms, the nation can only count on 2500 permanent primary care graduates from family medicine (out of 3000), 800 from internal medicine (out of 8000), 1500 from pediatrics (out of 3000, 2100 from nurse practitioners (out of 7000 but less than 1000 physicians worth of primary care), and 1600 from physician assistants (out of 6500, but less than 1000 physicians worth of primary care). An expansion plan that does not result in permanent primary care fails in primary care as departures from primary care of 1 to 3 percentage points have continued for NP, PA, IM, and PD steadily for over a decade and for non-physicians steadily since their creation.

A lesson in Basic Workforce 101 is required, even for physician workforce leaders. These basic lessons require learning that it takes about 50 years to change a design, especially one involving over 1 million individuals. It takes 40 – 50 years to recover from a bad design – about 10 years to increase to the design level and 35 class years to replace the physicians from the old design. It takes two generations of work to prepare the way for the next generation in basic health access as in education and in child development and in opportunity for advancement.

Primary care recovery requires about 95 - 100 primary care physicians per 100,000 (likely 110 due to aging). With 400 million people in 2040 and according to HRSA using the census and calculations by age groups, the US needs 400,000 primary care physicians. It has had 220,000 to 240,000 in 1980, about the same in 2000, and will have the same or less in 2020 and in 2040 under the current design. Even the expanding non-physicians will actually not be able to keep up with the internal medicine losses. Also primary care is 60% inside of saturations with 40% attempting to cover 65% of the population. The workforce design needs to cover enough primary care and primary care in the right places.

The major reasons for the stagnation of primary care are the four major failures in health care

·         The design fails lower and middle income Americans in basic health access insurance coverage

·         The design fails to graduate permanent primary care with 25,000 of 28,000 primary care graduates flexible forms that can go either way to specialty or primary care careers (also fails in locations of primary care).

·         The design for support of primary care fails with a small fraction of 2 trillion annual dollars going to support basic health access for most Americans left behind with small fractions for primary care, for rural health, and for underserved care.

·         The design fails in coordination as illustrated in primary care in the three above critical areas.

Many consider that the United States really has no design. I would go one further and say that the safety net patchwork of programs actually gets in the way of a real infrastructure design for basic health access with enough primary care in the right places with enough support.

Market forces do shape American health care. But physician leaders do influence the design for health care reimbursement that has distorted market forces and the balance needed for efficient and effective health care via basic health access as a priority.

Primary care recovery requires all three areas (workforce, funding for people, funding for primary care) to be addressed and fixed in place as infrastructure so that the United States can have the health system that meets the basic needs of all Americans, especially the elderly and the complex populations that will be granted financial access and have so many needs from pent up demand backed up for decades of neglect.

So why should you contact Congress and tell them to vote no and tell organized medicine to come up with a better plan

·         First the easiest proposal is to limit or terminate entry of foreign origin international medical graduates. This is an easy one as the same GME cost applied to US origin results in double the workforce for the same cost. It also does not squeeze out United States graduates or United States citizens attempting to enter the workforce. This alone is worth holding out for a better plan for all Americans and medical students. Medical education does not want to do this due to some powerful influences that have grown dependent, but with expansion of United States medical schools the time has come. Is there any in Congress that wants to pay more to get less and compromise the opportunity of American citizens?

·         Second the current design fixed in place by the expansion of GME also fails you in the most important area of future career choice and support. It risks too many competitors in a variety of specialties. Do you really want deficient primary care with patients with primary care needs attempting to access care from you as a specialist? Do you as a primary care physician want insufficient support and insufficient colleagues? Also you cannot make the decision for your career because debt, tuition, and a poor training design limit your options. For example if you crowd into internal medicine or pediatrics to preserve your option to specialize, there is not a guarantee of more positions in your desired specialty, or even a need for more in that specialty in the future. The plan needs to go back to the drawing board and you need to participate. Medical education needs to be honest with medical students about this prior to medical school. It needs to have more details on the design for graduate medical education worked out for medical students and most Americans.

·         Third, the current flaws in the designs, if etched in stone, will also impact you as an aging American. You will still have the same plan when you become old, older, and oldest – one that fails for you and possibly for your children. You will have to compensate for this during your income earning years, to compensate for what will not be in the future. What even Boomers do not know is that the current designs will fail them when they need them the most. As they age and lose mobility and transportation and need coordinated care, they will little or no local primary care available to them. Current elderly, Boomers about to become elderly, and those not 65 after 2040 will all have failures in basic health access. The same is true of stroke and heart attack care where rapid care access could save lives, disability, and dollars. The design is broken for most Americans in most areas of need. The lack of true unlimited health access with arguably universal health access, is a devastating commentary on a flawed system. And to maintain solvency, further compromises continue for the elderly, the physicians serving the elderly, and the locations with concentrations of elderly – what a mess that will be promoted and continued.

·         Fourth – the current proposals bring the nation closer and closer to forced choice of career and location. I am a believer in courtship and marriage in career and location so that physician, family, employer, and patient needs are best met. But continued flawed designs may force government and others to act.

·         More of the same still puts 85% or more of health care dollars into 3400 zip codes clustered together with top concentrations of physicians. Health care actually helps divide the nation into rich and poor. Health care funding forces medical students and residents into the most expensive places to live and learn. These are also locations where every other health profession tries to train.

·         More of the same health care funding also concentrates health care into vulnerable locations, as demonstrated by Katrina and Ike (remember forgotten Galveston) and as will be illustrated by earthquakes, floods, hurricanes, civil unrest, and disasters to come in the future.  Health care funding concentrates people – a very bad plan for public health. Spreading people out results in less disease and less risk of poor outcomes in the future. Health care is a way to accomplish this but only from 1965 – 1978 did health care funding accomplish this in workforce design and in funding design and we have not progressed since this point in either.

·         Financial assess for most Americans still fails and since we have not addressed the other two designs, increasing financial access cannot deliver on the promise made. Again coordination is necessary, not manipulation.

·         The funding design is so flawed that it has already has converted 70% of nurse practitioners and physician assistants to specialists with more to come. Easily 80% of 400,000 to 500,000 non-physicians age 30 – 65 will be specialists in future workforce. Do you really want to compete against someone that can generate 30 – 40% of the same revenue for 15 – 30% of the cost at a time when fewer and fewer physicians control the reins and more and more physicians are employees? Studies by the Lewin Group posted on the AAMC site already demonstrate that hiring a non-physician increases revenue as in about $300,000 for cardiology. This hiring does not decrease revenue for existing specialists as there are various efficiencies including higher paying billing codes going to physicians. Now when the cardiology groups hire a physician this does increase revenue by $700,000 but this results in decreased revenue for existing cardiologists. With non-physicians well on the way to 400,000 to 500,000 age 30 – 65, this should be a concern. Current surveys of medical students (AAMC GQ) also indicate the expectation of lower salaries for physicians and factors such as employment status and non-physicians and too many specialists are just a few of the reasons.

What if there is too much expansion?

How many specialists will be produced in the new design? It is impossible to tell as the design is not set. Usually you can calculate the number entering a specialty times the average length of the physician career to get an estimate. For example 2500 entering the family medicine form of primary care from 1976 to 2009 results in 2500 times 35 class years or 90,000 to 100,000 in family medicine as we currently have.

It is not possible to calculate specialty workforce. Percentages of specialists from each source of workforce keep increasing. Other than nurse practitioners, each source of specialty workforce is increasing in annual graduates at 50% or more in the past decade. Primary care is stagnant and continues to decline with each passing year. Specialty percentages increase steadily. With steady increases in numbers entering and higher percentages entering specialties, the final outcome is not known. What we do know is that primary care physicians are stagnant and primary care delivery is declining in the face of increasing population and an increasingly older population. This means that any expansion is entirely about specialty workforce in both physicians and non-physicians. New developments also loom on the horizon. Few specialists replaced by various developments, technologies, and other specialists anticipated these changes when they made their choices.

Few understand that graduate medical positions have been increasing. Systems, specialists, Veterans funding, and even individuals have continued to expand positions. This form of expansion results in a more limited and more appropriate expansion. Wholesale government funding places funds in the hands of people that think that more is better rather than deciding the best priorities first.

I find it most interesting that physicians, often conservative in voting patterns and often critical of government programs, are supporting a massive expansion of government programs involving graduate medical education. There has not even been a second thought about taking money away from the care of the elderly during a time when the elderly are being faced with higher premiums for their care, greater out of pocket costs, and no cost of living increases. Also organized medicine has promised more primary care when it cannot actually increase primary care under the plan and when the plan currently fails the elderly.

This entire operation is a very risky operation for organized medicine in the areas of integrity, social responsibility, and accountability. What happens when the elderly and Boomers discover that the plan cannot work for the care that they most need? What happens when Congress realizes that the promises of organized medicine once again mean little? What happens when Americans discover that the elite schools in the nation graduate contribute less than 12% into primary care delivery. What about the deceptions of using the Match to illustrate primary care “success?” What happens when the people, the General Accounting Office, and others realize that projections of 155,000 internal medicine primary care physicians and 21% primary care gains as shaped by organized medicine and replicated by HRSA in 2008 are gross errors with declines in primary care obvious. We already know that over 30,000 internal medicine primary care physicians have left primary care for hospitalist, hospital, and other careers in the past 7 years, yet internal medicine is represented as gaining primary care? We all read the same major literature. How can workforce leaders be allowed to neglect these important studies?

What to do

·         Tell other medical students, your parents, your mentors, your electronic contacts, and others about your concerns. Be respectful.

·         Tell Congress about your concerns.

·         Be sure to inform all that you can that the current plan that favors more of the same does not address primary care, the elderly, or most Americans. The plan will not result in the promised primary care, general internal medicine, or general surgery. Promises of primary care with expansions mainly of internal medicine with 90% of graduates not entering primary care are not in the best interests of medicine now or in the future.

·         Vote the current proposal down that promises primary care but cannot deliver primary care.

·         Force organized medicine to work toward a solution for all Americans, not one that sends more of the treasury to few.

·         Craft a plan that ends reliance upon foreign origin international medical graduates. Each US origin graduate delivers twice the workforce as compared to non-citizens with delayed entry, departures after training, lower productivity, and higher disciplinary rates. We need more secure nations and this involves a decision by the US not to take the best and brightest of other nations. Organized medicine should be leading this effort but in this absence you as future leaders of organized medicine should take the helm.

·         Suggest that graduate medical education and non-physician clinician education be returned to a primary care priority. Nurse practitioners and physician assistants were created for basic health access primary care and at least 50% should be found in primary care to make it more efficient and effective.

·         Suggest that reimbursement be lowered for specialty care involving non-physicians. Non-physicians working as specialists do result in more efficient care and greater revenue for specialists and higher profits for health systems. A better long term solution is better balance in workforce. One way to do this is reduced reimbursement for non-physician care. In the current situation the specialty workforce has the most and best nurses, assistants, and non-physician clinicians. This is all shaped by the funding distribution. Return to balance in workforce requires a change. Also the nation will have a shortage of 300,000 or more nurses in 2020. By 2020 the US will have graduated 300,000 advanced nurses that no longer deliver basic nursing. Rather than truly expanding the nurse model of basic health access to even better health access, nursing leadership has been converted to specialty domination. The money to change nursing into something else all comes from higher specialty reimbursement. Because of nursing success, physician assistants are converting into independent practitioners instead of their past commitment to physician supervision. These represent major failures of current organized medicine with more to come. 

·         OK – I will be brave and say what you are thinking anyway. Yes specialty physicians need lower reimbursement and primary care must receive more. Lowering 75 – 80% of specialty income by some can result in reasonable salaries for primary care. You may be convinced that specialty training that is longer and supposedly more complex, but I can assure you that primary care training, though shorter, is just the beginning of primary care training. Training really starts after graduation. You will find this in specialty careers as well, particularly if you get to do less and less as a resident or fellow as is the case in the current design. Primary care physicians train with each patient, learn about team members, learn about the environments of patients, and more. They learn best with a commitment to primary care and long term continuity of care. Some other day we can debate continuity of care issues, since what the continuity home and continuity of information does not do is provide continuity of care. Continuity of care is about a relationship and one on one interactions - not just an opportunity for funding or for software companies. Trust me, it takes about 8 – 10 years of delivering continuity primary care to capture this most complex concept, something that the designs do not support.

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