Why Is There An Imbalance Between Primary Care Doctors And Specialists?

Nov 14, 2013

Dr. Rick Kellerman points out blue bags on a map of the US. Each bag stands for doctors trained at KU Med School in Wichita. Without these bags virtually the entire state becomes under-served.
Credit Aileen LeBlanc / KMUW

Credit http://rtdna.org

Winner of a 2014 Edward R. Murrow Award for Investigative Reporting. 

System Breakdown

There is a crisis in healthcare in this country and it’s not directly involved with the Affordable Care Act. There is a larger problem. With the population numbers as they stand right now, there are just not enough physicians to take care of them.

Doctors that are being trained in the current system, are not going into private practice in their communities. They’re going into specialties and sub-specialties, which are housed in large research and teaching hospitals located in major cities.  These major hospitals have expensive machines to do MRIs, CAT scans and cardiac catheterizations amongst other high-tech testing.

There is evidence that there is an association between the specialists and the imbalance, says Dr. Andrew Bazemore of the Robert Graham Center in Washington, DC.

“That helps explain where the system broke down and left you with an abundance of highly compensated sub-specialties whose procedures and whose outputs are highly lucrative to the hospitals.”

White Follows Green

Back in the ‘60s when Medicare and Medicaid were being legislated, Congress was concerned that there needed to be a way to insure that there were enough outlets for the care of people covered by the new programs. Funding was designated for Graduate Medical Education. The money was given to teaching hospitals for the training of new doctors. Some $13 billion tax dollars go into this program annually.  But there never was a system to direct exactly how the dollars were used.

Bazemore says that the hospitals were left on their own to decide what to do with the resources. And, without any measurement of the program in place,  they chose what would benefit them locally, often within their own buildings.

Things got out of balance. The large hospitals were grooming doctors for their high-tech expensive units, and the doctors saw the specialties and sub-specialties as being a good choice: more money, less work and a quicker way to pay off  hefty medical school debts.

Rural Rotation

KU Med School student Rachel Svaty examines Belleville, Kan. resident Mr. McChesney's sore hand.
Credit Aileen LeBlanc / KMUW

Belleville, Kan. has a population of about 2000. It is named for Arabelle Tutton, wife of A.B. Tutton, who founded the town in 1869. Belleville sits at the “Crossroads of America” and it has the “World’s Fastest Half-Mile Dirt Track” for racing. The track’s operator, Mr. McChesney, is in the clinic and his hand is very sore.

Student Doctor, Rachel Svaty, examines his hand, searching for the cause of the pain. Svaty studies at the KU School of Medicine in Wichita and is in Belleville doing a month of study with Dr. Cayle Goetzen. The students are required to do a rural rotation as part of their training. Svaty examines the patient, then consults with Dr. Goetzen about possible causes of the illness and ideas about treatment.

Dr. Goetzen quizzes her, challenging her to use what she has already learned in med school in an actual situation. They then go back into the patient's room and present a plan for his care.

She says that a lot is learned through this process.

Dr. Goetzen and hundreds of doctors across Kansas volunteer their time for the program.

Students often tell Dr. Kellerman, chair of the Department of Family and Community Medicine at Wichita's KU School of Medicine, that these rural rotations are their best.

“That’s the (rotation) that they remember as the one where they could put all of the things that they’ve learned into use," he said.

The Family Doc

“Family Doctor” is not just a shingle word, it’s a whole discipline. It is based on a concept that patients aren’t just a body part, according to Kellerman.

“We don’t take care of just a heart or just a lung or just a brain, but rather you’re taking care of a patient who has these organs, but also has disease processes, that has illnesses, but is still a patient,” he said.

Family doctor, A. Patrick Jonas agrees with that concept, “We may know that the elbow happened to be at a little league baseball game on Saturday and the context is the important part.”

Family doctors are more likely to prescribe aspirin and ace bandages than CT Scans and other expensive tests. They are more in the business of keeping people out of the hospital than of treating them once they are admitted. Jonas says that the reimbursement system, set up through Medicare, places a higher value on technology than on a physician's ability to use his brain for preventative care.

“The people with incredibly detailed, complex thinking that saves a lot of money were not getting as much credit as people who thought a lot less but had an expensive room or an expensive piece of technology,” Jonas said.

How does the system discourage young would-be doctors from going into Family Medicine?

  • The fee for service pricing.
  • Time investment is less for many specialists – once they get into practice (more time off.)
  • Higher pay.
  • The large teaching hospitals are encouraging their decisions , which can help the hospitals' bottom lines.

The Study

Wichita ranks #6 in the nation for total grads who stay in primary care after med school on the "Toward Graduate Medical Education (GME) Accountability" study.
Credit Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions, Academic Medicine, Vol. 88, No. 9 / September 2013

A recent study, "Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions," ranked 161 institutions that produce medical school graduates and also accept federal

Credit Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions, Academic Medicine, Vol. 88, No. 9 / September 2013

tax dollars. Wichita ranks #6 in the nation for percentages of grads who stay in primary care after med school. And KU Med School also ranks very high for placing doctors in under-served rural areas.

“Only about eight percent of graduating medical students (nationally) go into family medicine,” Kellerman said. “That is not going to cut it. That is not going to meet the needs of our country. And it doesn’t matter whether it’s Kansas or some other state, we don’t have enough family physicians, we don’t have enough primary care physicians who are taking care of society.”

The Fix?

All are fast to emphasize that we need the high tech hospitals and their programs. It is the imbalance that is the concern. 

Dr. Atul Grover, Chief Public Policy Officer for the Association of American Medical Colleges argues that the study, in a sense, proved what it set out to prove. The association is the parent group to the GME study. He also points out many pilot programs which have been put in place to address the concerns.

“We’re all having active discussions in Washington, and I’m sure you’re doing it at the state level too," Grover said, " About how to reward (those who are) keeping people well just as much as we reward (those who) take care of people who are sick. And that’s going to come through a whole lot of new payment systems that are being tested out now, whether that is medical homes, or accountable care organizations or bundle payment projects.”

The fixes, he said, are in the works. But the problems are right here and right now. So beware of a sore elbow if you have been playing baseball all weekend. You may just need a quick visit down the street. Look for the shingle which says: “Family Doctor.” Thanks to the KU Med School in Wichita, Kansas has a few.


For more on primary care visit our public television partner KCPT:

Is it hard for you to get in to see your family doctor? Primary care, experts say, is the key to making America healthier and, just as important, making health care more affordable.

But, even though we need primary care physicians more than ever, there’s a shortage…and not enough in the pipeline. And as KCPT special correspondent Sam Zeff reports, in Kansas, a recent round of massive tax cuts that now impacts higher education funding may make the problem even worse.

KCPT, our Kansas City public television partner.