By Margaret Newton, M.D.
Brattleboro Reformer, Feb. 23, 2012
Book review: “Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans,” by John Geyman
Dr. John Geyman was a rural family doctor before joining the University of Washington School of Medicine. He eventually chaired its department of family medicine and is now professor emeritus. He has written extensively about America’s urgent need for health care reform. He was president of Physicians for a National Health Program from 2005 to 2007 and is a member of the national Institute of Medicine.
Dr. Geyman began practicing medicine when family doctors knew their patients well and were trusted and overworked community servants. He is a leader in educational and other nonprofit groups that seek solutions to America’s costly and fragmented health care. He has a solid understanding of its conflicting ingredients and politics.
He has witnessed the patient-centered approach of primary practitioners erode over time by forces moving medical care into profit-driven business models controlled by powerful players of the “medical-industrial complex,” a term he likes. (Primary care includes family practice, general internal medicine, general pediatrics and, increasingly, geriatrics.) Primary care, which he sees as essential and central to an efficient health care model, has been diminishing along with America’s health, at an unsustainable cost to all.
Geyman believes that the crux of the primary care provider shortage is the lack of a clear federal policy and oversight for personnel training and funding of primary care and the relative needs of different specialties. There are too many specialists. Training occurs in teaching hospitals and community settings. The national ratio of specialists to generalists varies depending on funding available, priorities of the hospitals and medical centers and choices available to the trainees.
The ratio is also affected by the number practicing doctors who retire, leave clinical medicine entirely or decide to specialize. Many doctors are leaving primary care. Generalists earn by far the least of any doctor groups. Specialists often do primary care but continue to be officially specialists and are paid more accordingly.
Federal Title VII funds a small portion of primary care training and is subject to the usual budget-cutting dialogues. Most funding comes from Medicare payments for hospital care (states may use Medicaid funds). These sources are also affected by federal budget cutting. Medical centers may allocate disproportionate amounts for specialist training despite the nation’s shortage of generalists. There are also periodic bursts of funding to the National Health Service Corps to provide loans to senior medical students who agree to serve in primary care shortage areas. The 2010 Affordable Care Act provides some funds for the NHSC. It is not a long-term solution.
Other educational issues include: insufficient ambulatory care training sites for primary care and the indebtedness of new graduates that lures them toward specialty programs in anticipation of higher incomes and even more manageable lifestyles. Inefficient models for practice groups are another factor. Rural practitioners face additional issues. Providers who are nurse practitioners and physicians now tend to seek specialty jobs versus primary care.
For decades, the primary care doctor to specialist ratio has fluctuated and is now around 30:70, vs. an optimal 50:50. It is getting worse. The laws and appropriations change periodically and lack the flexibility to correlate with regional or national population needs. Funding for residency/fellowship training is influenced by lobbyists, specialty groups, academic medicine, hospitals that train health care providers, equipment manufacturers, insurance companies, federal and state budget-cutting, and more.
Dr. Geyman describes different ways to practice primary care. He outlines his thoughts for reversing the trend of declining primary care practitioners. He is convinced that a single payer model of health care with primary care clinical groups at the core is the best and most cost effective for all. He is committed to a system that is not profit-driven, where the patient comes first, and which serves everyone.
Margaret Newton, MD, is a retired internist and geriatrician. She lives in Brattleboro.