Breaking the backbone of primary care
American Academy of Family Physicians
Press release
March 20, 2003
Medical Student Interest in Primary Care Continues to Decline
In the United States, graduating medical school seniors pursuing careers as doctors are more apt to choose a non-primary care specialty in 2003. Preliminary information released today by the National Resident Matching Program indicates that the 2003 initial fill rate for family practice residency programs is 76.2 percent or 2,239 positions filled out of 2,940 positions offered. This represents a 5 percent decrease from last year's initial fill rate and continues a six-year trend that began in 1997.
James C. Martin, M.D., FAAFP, President, AAFP:
"This continuing decline in the number of future family physicians will be devastating to the health of the American people. Family doctors conduct almost 200 million office visits each year - that's 75 million more visits than any other medical specialty. Family physicians are the backbone of the American health system."
"The current U.S. health care system does not appropriately value the essential function of family physicians. This undervaluation is especially apparent in two areas: the system's inadequate reimbursement for patient services, including those provided by the federal government to Medicare patients, and a negative medical school educational environment."
"The AAFP identified this trend of declining fill rates for family medicine more than five years ago and funded major studies from 1998 to 2000 at the University of Arizona, Tucson, to determine the cause."
"Results of the Arizona University studies indicate that medical schools need to address the important role the following factors play in whether medical students pursue a family practice residency: medical school admissions policies, poor faculty role models, and a medical school culture prone to disparaging family medicine. Initial results from the FFM research point to extraordinary hours worked for inadequate reimbursement, a limited scope of practice, and the general feeling that family physicians, with their breadth of training, are not as highly valued as a sub-specialist with a very narrow scope of practice."
"With the health care needs of millions of Americans at stake, our medical schools must provide a positive training environment for future family physicians. The federal government can help by supporting programs that enhance medical school and residency educational efforts, and patient care initiatives. Such support would require a reversal of current proposed budget cuts - the Bush Administration's proposed 2004 budget slashes federal funding for primary care training programs by an alarming 96.28 percent. These are the only federally funded programs designed to address the shortage of primary care physicians in America."
"As noted by Barbara Starfield, M.D., M.P.H., 'There is no longer any doubt of the importance of primary care as the key to an effective and efficient health service. In a major cross-national comparison..., countries with strong primary care systems were found to have lower health care costs than those countries with weaker primary care infrastructures... States in the U.S. that have more primary care resources have better health outcomes for just those indicators that would be expected to respond to primary care alone, even when income inequalities within the states are taken into account.'"
http://www.aafp.org/x20089.xml
Comment: This problem should not be formulated as a conflict between specialization and primary care. Specialized care has its own set of issues which include proper allocation of our finite resources, access to advanced technologies, fragmentation of services, inequitable compensation, isolation from the rapidly expanding body of knowledge in general medicine, and other deficiencies that can result from being isolated in a small niche of medicine. An integrated health care system can more readily address these issues, providing guidelines to improve the role of specialists within the global health care system.
On the separate issue of primary care, Dr. Starfield is absolutely correct when she states, 'There is no longer any doubt of the importance of primary care as the key to an effective and efficient health service." Every effort must be made to sustain the primary care fields, including family physicians, general internists, pediatricians, nurse practitioners and, in some instances, obstetrician-gynecologists. Once we are ready to transform into an integrated system we must have in place the substrate and foundation of a primary care system.
As a first step, we should adopt a universal, publicly-administered system of funding health care. Under the single payer model, regional allocation of our resources would ensure the support a strong primary care system.
Don McCanne, M.D., FAAFP Charter Fellow, American Academy of Family Physicians Charter Diplomate, American Board of Family Practice Life Member, American Academy of Family Physicians
(Although I have revealed my past bias for family practice, my current bias in my work on health care reform is for an affordable, efficient, effective, accessible, high-quality, universal health care system. That system needs a strong primary care base supported by appropriate specialized services.)