Physician burnout and shortages: The challenges facing primary care

Key takeaways

• Russell Phillips, MD, said that primary care should be considered “a common good,” like fire departments and access to public schools.
• Among its strengths, primary care physicians have the “unique ability” to improve population health and prolong life, he said.
• Challenges like physician burnout, workforce shortages and payment systems that devalue primary care pose challenges to the field.

Complex challenges like physician burnout, workforce shortages and insufficient resources are some of the most prominent issues facing primary care today, but transforming the field is possible, a speaker said.

“Whether it is burnout, COVID, the recognition of the impact of institutional racism, the desire for instant access on the part of our patients, the aging of our patient population, the development of new treatments, or the incorporation of artificial intelligence and machine learning in clinical practice, we need to be able to constantly evolve our work that we do in primary care,” Russell Phillips, MD, director of the Center for Primary Care at Harvard Medical School, said in his keynote presentation at the Primary Care Transformation Summit.

Common good

Phillips, who is also William Applebaum Professor of Medicine and a professor of global health and social medicine at Harvard, said there are four strengths to primary care that make it “a common good,” like fire departments and public schools, “suggesting that it should be available to all and thought of separately” from other health care practices. These include a “unique ability” to:

• improve population health and prolong life;
• improve quality of care;
• improve health equity; and
• reduce medical costs.

Primary care’s impact on community health and lifespan has been documented in previous research. In a confirmatory study published in JAMA Internal Medicine, Phillips and colleagues showed that the number of primary care physicians per 1,000 community members increased life expectancy for the community. They also found that counties with fewer than one physician per 3,500 people had an average life expectancy that was 1 year lower than other counties with a higher density rate. Phillip said this direct impact on life expectancy was unique among medical specialties.

For the second strength, Phillips said that people in a system with strong primary care orientation or those with a usual source of primary care have a higher quality of care than other patients, “as indicated by better control of chronic illness,” the fact that these patients are more likely to get cancer screenings and that they rate their health care experience as higher than others.

“These factors are very important, as it turns out that primary care clinicians save lives primarily by reducing mortality from cancer and cardiovascular disease, which likely relates from higher rates of screening and better risk factor management,” he said.

Notably, PCPs better the health of everyone in the community. Phillips said that primary care access is able to reduce differences in life expectancy based on race or socioeconomic status.

“Most experts agree that access to primary care is an important determinant of health equity,” he said.

The final strength has been “difficult to show on prospective studies,” Phillips said, but in areas of the country that are better resourced with PCPs, health care costs are lower. Patients who live in areas that have a higher density of PCPs typically see lower costs as well, he said.

But even with these, “there is no question that primary care is in need of a transformation,” he said.

Primary care can offer “endless rewards,” but insufficient resources can infringe upon the opportunity to do more, Phillips said.

“I must admit, primary care has been exhausting and we often lacked needed resources,” Phillips said of his own experience. “I feel stretched by the number of patients I need to care for and the time I have available, and too often I'm frustrated by the difficulty in finding a social worker who can take on a new patient with anxiety or depression or my inability to address basic social needs such as housing or food insecurity.”

The state of primary care today, he said, is connecting with patients and influencing the course of their lives, but in health care systems “that often devalue the work of primary care physicians and team members by not providing sufficient resources to do the work.”

“That lack of resources often leaves primary care practices without the resources to offer critical and effective services such as behavioral health integration, population health, medication-assisted treatment for those with opioid use disorder or help from community health workers for patients who face social barriers to health,” Phillips said.

‘Critical shortage’  of primary care providers

Currently, there are not enough primary care clinicians in the U.S., “and the shortage is predicted to grow worse,” according to Phillips.

“Anyone who has tried to get an appointment with a primary care clinician will understand that,” he said.

By 2034, the Association of American Medical Colleges estimated that there will be a shortage of between 17,800 and 48,000 PCPs. Physicians, physician assistants and nurse practitioners “are being lured away from primary care by higher paying options, which are available in the offices of highly paid sub-specialists or in the hospital, working with surgeons,” Phillips said.

Medical students are also more likely to choose a higher paying specialty, he said. Although “primary care career choices have been shown to be affected by the inequity in available compensation,” Phillips said there is a solution.

“We have the capability to address the primary care compensation issue by learning from other countries that have made progress in this area,” he said. “Canada addressed inequities in salaries between primary care clinicians and those working in higher paying specialties by increasing primary care salaries from 50% to 80% of other physician salaries, and this change attracted the needed physicians to primary care.”

Phillips said that a physician’s training experience can also affect decisions to pursue careers in primary care. When exposed to “the satisfaction of caring for patients over time while offering comprehensive care,” students are more likely to enter the field. Additionally, he said that “students are eager to address issues of inequity in care.” So, providing opportunities for students to care for disadvantaged patients encourages them to enter primary care.

“We need to give more thought to school culture and the training opportunities we provide to our students and residents,” Phillips said.

Payment

Challenges in payment do not come from how much individual physicians are paid, Phillips said, but instead with “how much we have to invest in the services we offer in primary care and how much we have to invest in innovative approaches to primary care that we know improve health, save lives, improve quality, improve work life or improve equity.”

The current fee-for-service model “undervalues primary care,” Phillips said, “resulting in delivering only 5% to 6% of the total medical spend to primary care services.”

“It's clear that there are not enough resources to do the job. We know the solution to this issue. We can address this challenge by investing more in primary care,” he said, noting that countries that spend more on primary care have better health outcomes and lower overall costs.

Burnout

Physician burnout has been a top concern, especially with the added stressors of the COVID-19 pandemic. It is a critical challenge to the workforce’s health, Phillips said, as “at least half of primary care team members are facing burnout and its consequences, which include depression, anxiety and suicidal feelings.”

“The core issue is that primary care jobs are often unmanageable. Care systems are dysfunctional, and the electronic health record is not designed to simplify work,” he said.

There is no easy solution to the complex issue of burnout, Phillips said.

“While learning personal skills and resilience is important, reshaping the work and supporting primary care is vital. We need to create primary care jobs that are doable and meaningful because we have the resources and training to attend to patients’ physical, behavioral and social needs,” he said. “We need systems that are functional to assist in meeting those needs in reliable and effective ways. As we consider remaking the work of primary care, my own view is that we need to ensure that physicians are focused on caring for the most complex patients in a way that complements their training and that they are able to lead ongoing efforts in practice transformation and improvement.”

Broad goals

The final challenge Phillips discussed is that the goals of health care are broad and include “improving health, quality of care, reducing costs, enhancing system and personal resiliency, and addressing racism and inequity in health care and outcomes.”

With those goals in mind, he said, “it's clear that there's much to be done” because primary care “is failing to reach segments of our population.”

“Primary care should help patients to optimize their function and health in order with whatever ways that patients value and prefer,” he said.

References:

• AAMC report reinforces mounting physician shortage. https://www.aamc.org/news-insights/press-releases/aamc-report-reinforces-mounting-physician-shortage. Published June 11, 2021. Accessed Aug. 26.
• Basu S. et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2018.7624.
• Phillips R. Keynote address: Primary care in the United States. Presented at: Primary Care Transformation Summit; July 25-July 29, 2022 (virtual meeting).