Debt relief, reducing administrative burden: Primary care shortage needs several solutions

Key takeaways:

• Of 61,991 residents, only 9.4% planned a career in general internal medicine from 2019-2021.
• Experts say the shortage of PCPs is driven by financial concerns, administrative burden and more.

A projected shortage of primary care physicians is one of the field’s top concerns, according to experts.

The Association of American Medical Colleges estimates that, by 2034, there will be a shortage of between 17,800 and 48,000 primary care physicians in the United States, and patients are already feeling the effects. Recent data from the Health Resources and Services Administration show that, as a whole, the U.S. has less than half of the PCPs its citizens need; about 99 million people are in a primary care (PC) professional shortage area.

A national scorecard from February offered further evidence that the PCP workforce is shrinking — between 2012 and 2020, just one in five medical residents entered PC, compared with one in three physicians in 2010 — while gaps in access to care are growing.

“We’ve been seeing locally as well as speaking to colleagues nationally that recruiting trainees to go into the field of PC is getting harder and harder. We've had a number of open spaces in our division, and other academic medical centers have had the same,” Lauren Block, MD, a general internist and assistant professor at the Feinstein Institutes for Medical Research in Manhasset, New York, told Healio. “Throughout health care and the service profession since the pandemic, there has been an additional flight of people from direct patient care.”

In a recent analysis published in JAMA Internal Medicine, Block and colleagues used deidentified, limited data from the 2019-2021 surveys given at the ACP’s national training exam to learn more about residents across the country and the fields they intended to pursue within internal medicine (IM).

They found that, of 61,991 residents who participated, just 6.4% were in PC programs. From 2019 to 2021, the bulk of total residents surveyed — 67.9% (42,102) — planned on a career in a subspecialty, whereas 15.1% (9,370) intended to work in hospital medicine (HM) and 9.4% (5,832) wanted to pursue general internal medicine (GIM).

Among the relatively small percentage of residents in PC programs, the majority (40.8%) chose to move on in a career in a subspecialty, 23.6% chose HM and just 31.8% chose GIM. The percentage of graduating IM residents who are planning to pursue a career in GIM, compared with 10 years prior, has dropped by nearly half, whereas HM has risen in popularity: there was a 7.8% decrease in GIM career choices among PC residents during the 10-year span and a 20.1% rise in HM career choices.

“It’s already hard to find a PCP,” Block said. “I’ve certainly heard that from colleagues, from friends, family members, and I’ve seen it as a PCP myself where our [patient] rosters have been getting bigger and bigger, and I think there is only going to be a further shortage of PCPs in the future.”

Reasons why

Block and colleagues hypothesized that factors like work-life balance, stress and the burden of administrative tasks may have played a role in their findings.

“I think this relates to reimbursement, since PC usually is reimbursed at a lower rate than other subspecialties. I think it relates to the high cost of medical education — people often come out with $200,000 or $300,000 worth of debt, sometimes more,” Block said. “And I think it also relates to the demands that we place upon PCPs in terms of documentation and patient care responsibilities and just the sheer volume of work — particularly administrative, nonclinical work. That is leading our trainees to see what their preceptors are doing in outpatient medicine and saying, ‘that's not necessarily what I want to do.’”

Dustin Arnold, DO, an osteopathic physician specializing in IM and a member of the American Osteopathic Association, told Healio that, “as a practicing internist for the past 24 years, the results of this study were no surprise to me,” citing “the burden of documentation with declining reimbursement” as factors that influence residents to avoid PC.

Arnold, who was uninvolved in the study by Block and colleagues, said “a pair of influential factors are student loan debt and competition with allied health providers. Significant student loan debt pushes graduates to the higher paying subspecialties and allied health providers continue to expand scope in the primary care environment. Primary care is a rewarding career, and action must be taken to increase its attractiveness to graduating residents.”

Daniel J. Parenti, DO, FCCP, FACOI, program director of IM residency and professor and chair of the IM department at the Philadelphia College of Osteopathic Medicine, was also unsurprised. Parenti, who was also uninvolved in the JAMA Internal Medicine study, told Healio he has personally observed the trend toward careers in HM rather than PC.

He has had 23 residents graduate from his program over the last 2 years, 15 of whom took a position in HM, seven of whom entered a fellowship and just one who took a position in traditional PC IM. HM, he said, “has become an attractive career choice.”

“Jobs are plentiful, salaries are high paying, benefit packages are competitive, lifestyle is predictable, salary bonus incentives are available and significant time off is attractive to young physicians raising a family,” Parenti said. “In HM, young physicians need not worry about managing a private practice including paying for rent, utilities, staff salaries and benefits, and physician coverage during vacations.”

Along with Block and Arnold, Parenti also referenced student debt as a major factor in residents turning from PC. He said HM positions help young physicians pay down the “overwhelming financial debt incurred during education” instead of furthering their debt by joining lower paying fellowship programs.

“There are certainly many advantages of hospitalist medicine, and I think that the number of graduates pursuing this career will continue to grow,” Parenti said. “That said, primary care internists remain very important. Especially in osteopathic medical education, where primary care is often a focus, we should remain committed to addressing physician shortages in primary care settings.”

PC training programs

Some solutions to the PCP shortage have been offered — for example, PC residency training programs have sought to entice more people to the field, Block said. And they work, to some extent.

The study’s findings indicated that more people in PC programs enter GIM than those in other programs, but Block said this cannot be the only solution because “the number of residents from PC training programs going into GIM has been going down.”

“Clearly, there needs to be, I think, multiple solutions proposed in addition to PC training programs, to make PC not only a more attractive career, but also a sustainable career,” Block said.

This year’s Match Day results were encouraging — record breaking, in fact — with 571 more PC positions offered during the 2023 Main Residency Match than last year and a fill rate that remained steady at around 92%.

However, Margot Savoy, MD, MPH, FAAFP, an associate professor of family and community medicine at the Lewis Katz School of Medicine at Temple University and a Healio Primary Care Peer Perspective Board member, said that many students who match into IM get counted as PC because they have not yet chosen a specialty, and “the majority go on to specialize and never actually join the PC workforce.” This can inflate the number while “the reality of not having the doctors on the ground continues to exist.”

“My overall take-home is one of cautious optimism. We have an active PC shortage issue, and it will worsen significantly if we don’t change the trajectory. The good news is we could make an impact if we choose to invest in the specialties that deliver practicing PCPs to communities,” Savoy said.

Seeking solutions

Some major steps forward, Block said, should include debt relief, because it would “play a huge role in helping to level the playing field a little bit given the decrease in compensation” for PCPs, “given inflation and cost of living increases” for their services. Additionally, different service delivery models — besides fee-for-service care — could “address some of the needs that PCPs have.” Homogeneity with common forms patients must fill out would also ensure that some repetitive paperwork does not need to be filled out as frequently, “which often falls on the PCP.”

Block also said using scribes or AI and other technology to help with documentation and “reduce some of the burden of prior authorizations and other approvals that PCPs often bear the brunt of” would help, along with giving them more time to “address some of the concerns that patients have by phone and by messages, to allow PCPs to meet the needs of their patients.”

“If we can address the challenges — simplify the administrative work, adequately fund family physician practices to support patients in their journey towards wellness ... and provide more residency slots, especially in teaching health centers where they can train in communities where they want to practice — we could ensure a future where everyone has access to a family physician and a routine place for whole-person PC,” Savoy said.

References:

• Block L, et al. JAMA Intern Med. 2023; doi:10.1001/jamainternmed.2023.2873.
• The health of US primary care: A baseline scorecard tracking support for high-quality primary care. https://www.milbank.org/publications/health-of-us-primary-care-a-baseline-scorecard/. Published Feb. 22, 2023. Accessed Sept. 5, 2023.