Sunday, June 5, 2011

Guest Blog: Production of Primary Care Doctors

John Delzell, Jr., MD, MSPH is an Associate Professor of Family Medicine and Assistant Dean for Graduate Medical Education at the University of Kansas Medical Center. Dr. Delzell is also an assistant medical editor on the journal American Family Physician. The following post first appeared on his blog, Education in Medicine.


COGME has just released its 20th report, Advancing Primary Care. Unless you are a real geek like me, you probably don't know what COGME stands for. COGME is the Council on Graduate Medical Education. It was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues and financing policies, and to recommend appropriate federal and private sector efforts to address identified needs. The legislation calls for COGME to advise and make recommendations to the Secretary of the U.S. Department of Health and Human Services (HHS), the Senate Committee on Health, Education, Labor and Pensions, and the House of Representatives Committee on Commerce. The Health Professions Education Partnerships Act of 1998 reauthorized the Council through September 30, 2002. Since then, the Council has been extended through successive annual appropriations governing the Department of Health and Human Services.(1)

Now, there is some history here. In January 1994, COGME released its Fourth report, Improving Access to Health Care Through Physician Workforce Reform. In that report the authors took the position that the physician workforce was not meeting the needs of the US healthcare system and the public need. The report concluded that we needed more generalist physicians. Their recommendation was that 50% of all graduates should enter practice as a generalist physician (Family Medicine, General Internal Medicine, and General Pediatrics). Their goal was to attain this by 2000. As we know that did not happen. In fact, it went the other direction.

But interestingly, in their Sixteenth report, Physician Workforce Policy Guidelines for the United States, 2000-2020(2005), COGME reversed themselves and said that market forces should determine the proportion of students in an in specific specialty. The exact recommendation was: The distribution between generalists and non-generalists should reflect ongoing assessments of demand; therefore, COGME does not recommend a rigid national numerical target. Wow, what an amazing mistake that was. Since that time, the proportion of students choosing family medicine and primary care in general has continued a downward trend. In 2008, the total proportion was down to 32%. Clearly market forces are not working.

Dr Jerry Kruse, Chair of Family & Community Medicine at Southern Illinois University who I wrote about in a recent blog, was Chair of one of the writing groups for the COGME report. According to Dr. Kruse, market forces didn't work because there is not a traditional supply and demand market in the US healthcare system. What we have is really a supply and supply market. We have a virtually unlimited amount of care that can be delivered (whether it should be is a different discussion) and a funding pot that rewards doctors, hospitals, DME companies, etc for doing more (See Dr. Lin's post at the Common Sense Family Doctor). The rewards are financial and huge. So, the market is designed to reward doctors financially in specialties that do more technical and procedural things. (A more detailed discussion of this can be found in a recent post by Matthews and McGinty on the Wall Street Journal Health blog.) These are specialties such as, Radiology, Orthopaedic Surgery, Anesthesiology, and Dermatology. The "ROAD", as some medical students have taken to calling it.

Medical students are not stupid. They figured out that the financial rewards of practicing in the higher paid specialties were extraordinary. The median lifetime income gap between a student choosing primary care versus a specialty is 3.5 million dollars.(2) Currently, US primary care doctors earn about 55 percent of what specialists earn on average. When primary care doctors' salaries dropped as a proportion of specialists' salaries, interest in family medicine and other primary care areas also drop. The key number seems to be around 70 percent. If the income of primary care doctors as a proportion of the income of specialty physicians goes up then student interest goes up as well. The Altarum Institute estimates that increasing primary care income to 80 percent of specialty income would double medical student interest in primary care. This would increase the percentage of students choosing primary care to about 40 percent.(3)

Canada had the same problem. From 1998 to 2004, they had a 25% drop in students choosing family medicine and it worried the Canadian health ministry.(4) In a country that has universal coverage, it is vital that the primary care base is adequate. In Canada, they understand and believe that they need a specific number of family doctors in order to be able to take care of the populace. To address this national crisis (their words, not mine) they invested in student interest by building up and supporting medical school family medicine interest groups (FMIG). And they raised the salary of family physicians. They did not make family medicine and specialist salaries the same, but they raised the proportion to 87%. By 2006, the median income of Canadian family physicians was $212,000 per year compared to the median annual specialty income of $245,000.(4) That was enough. Interest started going back up. Medical students choosing family medicine has increased by 27 percent each year since 2004.

Why can't we do that in the US? There are so many reasons that I don't think I could even begin to cover them all, but let me hit some of the highlights. We don't have a national universal coverage system. Doctors are mostly self-employed or work for large healthcare organizations (like hospitals). The government does not directly decide how much doctors are paid. (For more on this, read Dr. Freeman's post Outing the RUC: Medicare reimbursement and Primary Care.)

The most important reason is probably that we don't see this as a national crisis. Most people think that we have the best healthcare system in the world. Unfortunately, the data does not support that. We have a mediocre healthcare system compared to the rest of the world by any measure. The primary care base is the key to the system. We need to and should adopt the COGME recommendations. If we don't have enough primary care doctors (translate=enough students choosing family medicine), the US population will be less healthy. There is no question. Our population will be less healthy, people will die prematurely, and it will cost more.(5)

(2) Wilder V, Dodoo MS, Phillips RL Jr, Teevan B, Bazemore AW, Petterson SM, Xierali I. Income disparities shape medical student specialty choice. Am Fam Physician. 2010 Sep 15;82(6):601
(3) Altarum Institute. (2009). Updates to BHPR phy­sician supply and requirements models. Presenta­tion to COGME, p. 15. Rockville, MD, from COGME 20th report
(4) Canadian Institute for Health Information. (2007, December 13). Physicians in Canada: Average Gross Fee-For-Service Payments, 2005-2006. Re­trieved May 11, 2010, from cihiweb/products/FTE_APP_2005_Eng_final.pdf
(5) Phillips RL Jr, Bazemore AW. Primary care and why it matters for U.S. health system reform. Health Aff (Millwood). 2010 May;29(5):806-10


  1. On a related note, an article in last month's issue of Academic Medicine found that barely 1 in 4 residents who enrolled in training programs in primary care medicine or general surgery were still committed to providing primary care (that is, not subspecializing) 2-4 years later:

    What this means is that the current expansion of the physician workforce is actually decreasing the percentage of graduates who become family physicians, general internists, general pediatricians, or general surgeons. As Dr. Delzell notes, that's not a recipe for good U.S. population health.

  2. It is actually not possible with current designs to resolve primary care deficits. The retention rates of primary care graduates within primary care are so low that the nation does not have enough bodies to enter training and the cost is more than can be afforded.

    This contrasts with a specific design such as permanent primary care family medicine where primary care retention is two to four times higher and half as many annual graduates can do twice the primary care work. This is 14,000 annual FM graduates that can do the twice the primary care workload of 28,000 from six current sources.