The doctor is unavailable. The doctor is late. The doctor is not spending enough time with me.
But the health care system, not the doctor, is to blame.
Twin brothers Matthew and Michael Siegenthaler are family medicine doctors who practice in Madison County, a rural part of upstate New York. Here, for every 2,000 patients, there is just one primary care doctor.
“They think you don’t really care about them, and it kills you,” Matthew said. “When really, you’re thinking, ‘I have five rooms full of people who are all checking their watch waiting to see me right now, as well.’ And they’re all going to be upset with me when I get into those rooms.”
This severe shortage on the front lines of medical care is also found at the Yale School of Medicine. Among the thousands of graduates who are currently practicing medicine, only 72 are primary care physicians.
Unlike specialists, primary care doctors are the home base for health care. These doctors develop lifelong relationships with their patients, who visit them after developing new symptoms of an illness and for regular checkups to prevent new health issues from cropping up.
The Siegenthalers completed their training in family medicine and began practicing on their own just a month ago. The need for primary care doctors in their area was so severe that Matthew already cannot accept new patients, and Michael is booked until next year.
“This is not unique to Oneida or Canastota. Literally pick anywhere in the country and this is what you see,” Michael said, referring to the towns where he and his brother practice.
The scarcity of primary care physicians places burdens on patients as well. Without adequate access to primary care doctors, patients turn to emergency rooms or urgent care services. When this happens, according to Michael, simple tests he could run at his practice will instead cost the patient and the health care system thousands of dollars.
Primary care doctors, regardless of the practice, see a different patient every 10 to 15 minutes. For eight hours. Five days a week. This frequency is necessary in order for primary care practices to stay afloat, Matthew said.
For the Siegenthaler brothers, whose patients often do not have sufficient medical literacy, it is difficult to fully explain health conditions to those they treat. During one visit, Michael gave a diabetes diagnosis to a patient who had no familiarity with the condition. He had to explain the diagnosis, including what medications and diet changes were required, all in 15 minutes.
“I could easily spend an hour with each of my patients,” Matthew said. “But I always have someone waiting in the next room, and I have to keep the financial realities in mind and make sure that I’m getting care to all the people who need it.”
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The U.S. is currently estimated to be short 30,000 primary care physicians, and this number is only expected to rise. The Association of Medical Colleges projected that in a decade, this number could increase to 50,000.
Yale, a medical juggernaut in other regards, does not measure up when it comes to producing primary care physicians. Of the 160 medical schools in the U.S., Yale ranks 142nd for producing primary care doctors, according to the Robert Graham Center, a database that tracks medical school graduates.
“I feel no pressure to produce primary care physicians,” wrote Robert Alpern, dean of the medical school, in an email to the News. “That pressure may come to state schools. Yale is very committed to the need for primary care physicians and understands the need in rural areas, but while Yale has a strong primary care curriculum, we will always be a school whose graduates tend to go into many specialties.”
To become a primary care physician, a medical student can either pursue an internal or family medicine residency. Internal medicine programs train students to provide primary care solely to adults. By contrast, family medicine programs train their students in internal medicine as well as pediatrics and obstetrics and gynecology –– allowing family medicine doctors to provide a wide range of primary care services to their patients.
Yale does not have a family medicine department and is one of three medical schools nationwide that does not offer a family medicine residency.
Though Yale has both an internal medicine department and residency program, research has shown that the majority of doctors who pursue internal medicine will later specialize in a field of medicine instead of practicing primary care.
“Even in internal medicine primary care programs –– ones targeted specifically at primary care –– two-thirds of the residents in those programs don’t go into primary care,” said Ted Long ’06, vice president of ambulatory care for New York City Health and Hospitals, the largest public health care system in the U.S.
While Alpern said that the burden to produce primary care physicians does not fall upon Yale, other private medical schools have excelled in primary care while still maintaining their prestigious research rankings.
Two of these schools, the University of Pennsylvania’s Perelman School of Medicine and Washington University School of Medicine in St. Louis, are ranked in the top 10 for both research and primary care by the U.S. News & World Report.
On those same lists, Yale is ranked 11th in research and 51st in primary care.
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Primary care physicians are the backbone of a healthy society. Yet, the culture in medical practices still views these doctors as inferior to specialists.
“A lot of other physicians [think with] family medicine that there’s too much breadth and not enough depth, so that you’re not trained to take care of really complicated problems and that’s bullshit,” said Peter Mason, a family medicine doctor and professor of community and family medicine at Dartmouth’s Geisel School of Medicine.
At places like Yale, these attitudes still prevail. Julie Rosenbaum MED ’96, professor of general medicine at the Yale School of Medicine, noted that a “hidden curriculum” is woven into the medical school’s training, which ascribes more prestige to specialty medicine practices and indirectly discourages Yale’s medical students from pursuing primary care.
Another factor that deters students from primary care is unfair compensation.
Although primary care doctors see patients with great frequency, they, on average, have the lowest salaries of all physicians. Among medical professionals, they also have one of the highest burnout rates, which affects nearly 60 percent of primary care doctors.
“I get paid far more for spending five minutes injecting somebody’s shoulder for bursitis than I do for spending 45 minutes to an hour counseling them about intimate partner violence. What’s wrong with this picture?” Mason said.
Regardless of what they practice, historically, physicians are paid less for cognitive work like counseling and diagnosing patients – the bulk of a primary care doctor’s day-to-day responsibilities – than they are for doing procedures.
If primary care doctors were reimbursed at a rate commensurate with the time and cognitive effort involved, insurance companies would spend considerably more up front than they do now on primary care, according to Mason. However, this move would decrease long-term health care costs.
“We know that in countries where people fund primary care, the cost to the whole system is far less because primary care involves prevention. You go upstream and you prevent people from having procedures,” he said. “Every country in the world that has emphasized family medicine and primary care does better according to every metric than we do in this country. They spend less money.”
Spain, for example, rapidly expanded its primary healthcare system in 1978. A report found that this expansion led to decreased health care costs and even lower rates of infant mortality, as well as longer life expectancies.
Primary care physicians make a sizable earning of $195,000 per year, according the American Academy of Family Physicians. Specialists, by contrast, earn $284,000 on average.
Both these salaries lead to comfortable lifestyles at face value. In reality, though, most medical students leave their education with massive amounts of debt and earning $89,000 more is enough to dissuade some students from pursuing primary care.
“Most of my medical students now are coming out with two or three hundred thousand dollars in debt,” Mason said. “How do you buy a house? How do you raise a family?”
New York University School of Medicine made headlines in August after the school announced that it would go tuition-free.
NYU is the only top-ranked medical school to date that is tuition free. It is unlikely that Yale will consider adopting this model in the near future.
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The demand for primary care physicians will only increase as the U.S. population swells and older demographics grow. The Association of American Medical Colleges reported that within the next 10 years, the U.S. population over age 65 will rise by 50 percent and that this demographic utilizes far more health care services than younger patients.
If systemic changes are not made to medical training and to the workplace conditions of primary care doctors, the supply of these physicians will not increase, and the U.S. health care system will not be able to keep pace with its patients’ needs.
Yale’s missions are to produce great research and excel in education and patient care. Historically, according to Rosenbaum, the medical school has seen its role as creating physician-scientists who will go on to be internationally known leaders within specialty medical practices.
She lamented, “Arguably [Yale has] said, ‘We will allow other medical schools to train primary care doctors who will go out into the community and actually take care of patients.’”
Marisa Peryer | marisa.peryer@yale.edu