United Stand for Primary Care or Getting the United States to Understand Primary Care?

About Proposals to Merge Primary Care - A Critique of Academic Medicine May 2008

Robert C. Bowman, M.D.

It is not a surprise that yet another major change to family medicine has been proposed from academic leaders. The problems with family medicine are most prevalent in the locations where the nation has the lowest priority in primary care and family medicine - in the nation's academic centers. Not surprisingly family practice and primary care percentages in the United States are the lowest in the nation in medical school locations. In addition the low priority placed on primary care is also illustrated by the the Dysfunctional Primary Care article also in this May 2008 Academic Medicine Issue.

From the perspective of a united primary care front, a primary care merger appears to be attractive. A united primary care front would be helpful for the purposes of real primary care funding for training and for support of primary care physicians, for united accreditation focused on primary care not hospital care, and for sufficient support so that the nation (and those who think they are primary care) can actually begin to understand primary care and health access.

Of course primary care is about as fragmented as it has ever been. From a practical standpoint, what will all of this controversy and additional effort produce? The answer is - no solutions at all. As one who watched the last Association of American Medical Colleges effort involving Rural Health break up over this "merger of primary care" issue in 1990, the effort is not worthwhile. (Talley presentation)

The problem with primary care is not a matter of discipline; it is a matter of poor priority and poor understanding. The major arguments are not logical; they are practical.

The other forms of primary care, including nurse practitioners and physician assistants, are bowing out of the primary care health access role. At the current rate of change, only family practice will truly remain a primary care specialty graduating at least a majority into primary care. Fortunately for the nation about 90% of family practice residents remain in primary care, a level double the levels of pediatric residents remaining in primary care, triple the levels of nurse practitioners and physician assistants remaining in primary care, and quadruple the levels of internal medicine residency graduates remaining in primary care.

Family physicians do not claim to be a superior breed of primary care, but they do tenaciously hold on to family medicine emphasis at 98% levels with 90% remaining in primary care. Family physicians remain the most active and deliver the most primary care volume. Family physicians may well have the longest careers.

The changes in other primary care forms have been dramatic over the past decades. Reductions in scope, decreases in rural location, and decreases in underserved location have been prominent. At one point family nurse practitioners and physician assistants in family practice could have addressed all locations and populations, but their various departures no longer allow this capability. Family physicians are the only form of primary care that can address all populations, ages, and locations. When nurse practitioners and physician assistants leave association with family practice, they move toward major medical center careers and locations where 70% of internal medicine and pediatric generalists and 75 – 92% of specialists share location with just 35% of the population in 4% of the land area. 

Family practice is the only primary care form that manages to escape major medical center locations with 53% to satisfy the needs of the 65% of the population outside of major medical center locations. Other physicians, nurse practitioners, and physician assistants distribute according to concentrations of health resources. Family physicians increase in percentage with decreasing income, population, physicians, education, professionals, and health resources. Family physicians are 12% of urban physicians, 23% of physicians in large rural areas, 42% of the physicians in small rural areas, and 46% of the physicians in isolated rural areas. Family physicians are 50% of the physicians in Community Health Centers and this increases to 61% in rural CHCs. (rosen)

Physicians By Practice Location Zip Codes Using Physician Distribution by Concentration Coding: Active Physicians Excluding Residents and Physicians Not Classified, Unknown, Other, or Inactive unless noted

 

Percentages By Type of Practice Location

Physician Concentrations Per 100,000 Population

 

FM

Office Primary Care

FM

Office Primary Care

All Active

Add GME per 100,000

All per 100,000

 

 

 

 

 

669,871

765,444

933,835

All Super Center 200 or More Physicians

6.2%

28.6%

49.6

230.3

804.1

1103.0

1191.3

Medical School

5.0%

26.6%

41.8

222.7

837.5

1313.2

1452.6

Urban Super Center

7.1%

30.2%

55.0

234.9

778.9

954.2

1007.0

Rural Super Center

5.7%

29.4%

67.4

350.2

1189.4

1667.4

1762.9

 

 

 

 

 

 

 

 

All Major Center   75 – 199 Physicians

11.0%

35.2%

35.9

114.9

326.5

409.7

434.6

Medical School

8.6%

33.3%

15.2

58.6

176.0

306.0

346.2

Urban

10.7%

35.2%

35.5

116.7

331.6

415.6

440.9

Rural

14.8%

35.7%

47.8

115.2

322.9

379.9

396.5

 

 

 

 

 

 

 

 

All Marginal or Half Served Locations (Half the National Average in Physicians and in Sufficient Primary Care

19.4%

42.1%

25.3

55.0

130.6

165.6

177.0

Urban Marginal or Half Served

17.0%

40.7%

22.6

54.1

132.7

168.9

181.8

Rural Marginal or Half Served

28.0%

46.9%

37.1

62.1

132.4

162.0

168.3

Isolated Marginal

39.5%

56.5%

32.4

46.5

82.2

112.4

116.5

 

 

 

 

 

 

 

 

All Underserved

22.1%

46.6%

18.5

37.0

83.7

92.3

98.7

Urban Underserved - One-Fourth Served - or fourth priority

16.2%

42.7%

11.9

31.3

73.3

88.4

95.7

Rural Underserved or One-Third Served, or Third Priority

26.5%

50.4%

30.2

57.4

114.0

115.3

121.0

Isolated Underserved

37.7%

62.6%

23.3

38.7

61.8

55.3

58.7

 

 

 

 

 

 

 

 

Military Base

20.9%

32.2%

55.7

85.8

266.8

318.1

342.7

Military Super

5.6%

16.7%

108.6

325.9

1955.1

2839.2

3043.9

Total

12.0%

35.1%

29.5

86.6

246.4

320.6

343.5

Marginal or Half Served locations have half of the nation's 300 physicians per 100,000 and half of the nations recommended 100 per 100,000 primary care physicians. One-Third Served locations have one-third of the national average and one-third of the primary care recommendation. One-Fourth Served is seen in the urban underserved locations with the lowest physician and primary care physician concentrations. This is also seen in rural iunderserved areas that are lowest poverty or isolated.

The lowest percentages of family physicians are found in super centers, especially medical school super centers. Despite lowest percentages, family physicians are the most likely to be found as medical teachers with about 1.8 – 2.2 times odds ratios as compared to other forms of primary care with 1.3 or lower odds ratios. Holding steady in primary care and in generalism is not enough. Family physicians also must prop up medical education in the nation.

Family physicians assume greater and greater roles in primary care in the locations in most need of primary care. Internal medicine and pediatric physicians are predominantly found in major centers and super centers where primary care levels are saturated. This is yet another reason for more to leave primary care. NPs and PAs leaving family practice and primary care are moving toward super centers, major centers, and higher income urban locations. Each departure from primary care is rewarded by increased salary and benefits, in some cases massive increases in salary and benefits. Those choosing "the right careers" to serve the nation where it most needs help in health care are penalized at every turn.

The aging of the United States population is also a major concern. Again pediatrics is out of the equation. Internal medicine graduates have moved away from generalist careers where they serve significant levels of elderly patients and have moved into major medical center careers and locations where the populations have the youngest adults, not the oldest. Geriatric populations avoid the highest costs of health care and the highest costs of living found in major medical center locations. Geriatric populations concentrate in lower and middle income locations, the locations where family physicians concentrate. At the county level the family practice percentage increases along with the percentage of the population over age 65 with a 0.2 correlation that is highly significant (using only 2500 counties with at least 2 physicians).

The current solution for geriatrics for a top ranking medical school is 1 geriatrician (actually only half), 2 family physicians, and 3 remaining in general internal medicine produced from a class of 130. The geriatric solution is very different in Duluth, the consistent leader in family practice percentage of graduates in the nation. The Duluth solution is no geriatricians, 27 family physicians, and 4 internal medicine generalists out of a class of 60. These are graduates that have consistently located in the urban and rural lower and middle income locations with concentrations of people over age 65. Duluth also manages to produce higher levels of rural specialists, women’s health, general surgery, and neonatology. Any real workforce assessment of the nation's health needs would have guided the current expansion in very different directions. The current expansion will only intensify physician concentrations and will fail to address health care for the 65% and growing populations left behind.

The Duluth admissions process is specific for family practice and rural health. The Duluth training includes 30 of the 60 third year medical students each year who take the Rural Physician Associate Program for 9 months in rural Minnesota. The hands-on medical careers apparently are a top choice of Duluth graduates who get the opportunity for hands on training in rural locations. The Duluth model appears to be a solution for most of the nation’s top workforce needs, but the national decisions move in other directions. Osteopathic public models have similar outcomes, yet the only 6 were created also during the 1970s.  The Duluth contributions are consistent with other distributional medical schools that focus on different admission, different training, and specific outcomes serving lower and middle income patients. In the past 100 years the Historically Black and osteopathic medical schools have made top contributions. In each case, the family practice component makes significant contributions to health access.  

Now what would happen if a medical school graduated 100% family physicians? Only 3 - 4 times more primary care for the same cost compared to Duluth or osteopathic, 8 times more for allopathic public, and 14 times more compared to allopathic private. Of course the nation has realized its severe and growing primary care and health access problems and is rapidly moving to graduate more of the physicians most needed in the most efficient and effective manner. Sadly no. Or perhaps the needs for rural specialists, women's health, general surgeons, and primary care could be met by expansions limited only to the Duluth or Osteopathic Model? Sadly again no. The current expansion is a pure strain of medical students admitted from the most concentrated origins, trained in the most concentrated locations, and incented by policy to choose the most concentra