What's Behind the Shortage of Primary Care Doctors?

[AUDIO LOGO] Welcome, everyone. I'm Dr. John Whyte. I'm the chief medical officer at WebMD. Have you tried getting a doctor's appointment lately? It can be hard. You might have to wait several weeks to see your primary care physician. And that's because there aren't enough primary care physicians around.

People are not going into it. People are retiring early, concerned about burnout, how much they're compensated, the prestige of the profession. So how do we fix it? So whenever I have a difficult question, I go to my very good friend, Dr. David Nash, the founding dean emeritus, The College of Population Health at Jefferson in Philadelphia. David, thanks for joining me.

Hey, John. Thanks so much. I really appreciate it. Great to be together.

You and I were chatting a few weeks ago, and I said to you, David, why would anyone go into primary care right now? We say it's the backbone of our healthcare system. But then we don't financially reward them. We don't give them the prestige. So why would anyone go into it?

Yeah. Well, let's start with some of the research evidence. If you look around the world, here's what's so uncanny and why I have such a hard time with this whole question. In every developed nation that we aspire to be like in terms of improving health status, there are three primary care doctors to every specialist, right?

In America, the ratio is uncannily exactly the opposite, three specialists to every primary care doctor. Primary care doctors are not just the quarterback and the coordinator. As you said, John, they're the backbone, meaning they are the patient educators. They are the folks who keep the specialists on track, who connect the dots for patients, who are the early warning system, who do the follow-ups, who talk with families.

Look, I've been around a long time, and I've been a patient. My family, everybody I know, it is a difficult situation. I don't know a single doctor who says that, oh, accessing healthcare is easy for them and their family, and in part because there aren't enough primary care doctors. But I want to establish the research basis for this conversation, which says primary care doctors lower costs and improve health.

You referenced at the beginning the role of primary care. But let's admit, there really is an identity crisis right now for PCPs. What are they? Are they the backbone? Are they the jack-of-all-trades which isn't celebrated? Are they the gatekeeper? Some people feel like they're the gatekeeper in their insurance system to actually see the doctor they want. So what's their identity, and how do we elevate it?

It's a crazy thing, isn't it? You and I remember when the term gatekeeper first came into our lexicon, right? And it sounded like a pretty good idea that we would control access and so on. And here we are, probably 25 years later, and we're still using that term because it's still applicable.

But I think to answer your great question, there is a big cultural shift at work. We have to reflect on the millennial culture, which is they're not going to do what we did for good reason. So the production function, as you would say in microeconomics, is there's fewer people doing a lot more work in a much more complicated environment.

Also, second change is more technologic, which is care is way more complicated. People are in the hospital way shorter. A third change is our good friend and my colleague Bob Wachter, who invented the term hospitalist.

We didn't have that when you and I--

We didn't have that. Listen, in medical school, there was mythology, which I call it the mythology of the triple threat, right? Office, hospital, research, and teaching, we could do it all. Well, it wasn't true then, and it's not true today.

And so the hospitalist movement was born out of the tactical reality that care was too complicated to leave to old guys and gals who had trained decades ago. And so the birth of the hospitalist movement separated folks who might have then gone into primary care. And my fantastic hospitalist leader daughter is a great example of many-- not the only one, of course, of many young people who said, yeah, I want to be an internist, but in reality, I'm not doing that gatekeeper stuff. I'm staying in the hospital where I'm comfortable. I'd much rather treat septic shock than a scratchy throat.

And it's always about policy. And you've been a policy wonk for 30-plus years, and you think about these things. So the issue is when we think about policy in healthcare, it's usually directed at hospitals, health systems, maybe the specialties.

And it's typically around issues of payment, let's be honest. If we didn't pay for hospitalists, we wouldn't be having people in there. So how do you use policy to drive some of these changes that you just talked about in terms of the culture, the technology, the platforms?

All right, so we got to do a little bit of background because you can't know where you're going until you know where you've been, right? So in America, interns and residents in joint commission and Medicare-approved training programs, where do their salaries come from? Hello, everybody. GME money comes directly from CMS.

So your tax dollars are paying the salaries of doctors in training. And that money goes to the hospitals with a direct payment and an indirect payment. So there's direct GME and indirect GME, and this is in the billions of dollars. Roughly $18 billion from Medicare goes to support the tens of thousands of house officers.

So one policy would be, hey, let's reallocate the dollars away from specialty training to primary care. This mostly has been tried by a federal agency, HRSA, HRSA, Health Resources Service Administration. Very modest success.

Why?

Well, because hospitals resist it. So let's be real. There's a lot of money, and we want primary care house officers to do the grunt work, but we still want to have our cardiology, pulmonary, GI, various--

Ortho.

--all funded. So let's get real. Some of this is we're resistant to increasing the total number of primary care slots. That's one challenge. The other challenge is how the money is allocated at the local level. When the money hits the door, then there's the internal allocation, John, within the academic training institutions. And I'm not picking on any one in particular, certainly not.

But there's 145 major academic medical centers in America, 140-plus allopathic med schools. They all have their own internal allocation formula for who gets the money. Is isn't the chief of surgery, chief of medicine, chief of OB? How's that going? With very little outcome measure connected to the longterm training.

So nobody really is responsible at the training level, understandably, for the outcome at the societal level. So there's a policy disconnect about primary care. And then and now, we have a downstream impact of this policy, which is unionization. Holy mackerel, right?

You've seen the headlines, 400 primary care doctors at the mass general are going to join a union. And in my own city, Philadelphia, five medical schools, 3,000 house officers are going to join a union. Oh, boy. I mean, we could spend a whole program just on that. To me--

Good and bad. There's good and bad on that.

Right. But it's a downstream effect of what we're talking about here.

And part of it is partly because people feel they're overworked, they're not getting paid, they're burnt out, they're not treated with respect. So that's where, often, collective bargaining can come in.

I want to go back to one other policy, explicit and the implicit culture, right? The implicit culture is, look at those poor, bedraggled general internists doing most of the inpatient teaching because their unit opportunity cost is low. You're not going to see typically pulmonary GI, other specialists, doing the bulk of the general internal medicine bedside teaching. Their time is too valuable.

So the opportunity cost of keeping a person who does procedures, letting her teach, that cost is too high. So we have to recognize that there are economic incentives driving the primary care challenge, too.

David, everyone talks about disruption. That's the new buzzword, disruptor. So how do things like AI, digital tools, help disrupt? Is it going to be primarily in primary care, in the sense that it's going to be the role of chatbots, it's going to be augmented intelligence? Is that where we're going to see real disruption, and maybe that can elevate primary care as a profession?

Great question. I have two ideas, but first, let me tell the story because, you know-- look, I'm following ChatGPT. I've even started to pay for ChatGPT 4.0, which is wicked cool stuff. So ChatGPT 2.0 got an 85 on the boards. I got a 79, and I studied my little tail off. That's all to say, holy mackerel, this is a powerful tool.

Its immediate impact on primary care is evolving, right? Because machine learning as a part of AI is really in repetitive areas, reading EKGs, reading X-rays, reading, biopsy slides, right? So we're going to start to see more applications of AI in terms of especially patient communication, that you'll be able to-- AI will be able to write letters to patients, write letters to consultants. That will unburden primary care doctors.

So I don't see it as a job threat in any way. I see it as a primary care enhancement, to answer your question. It will tackle the overutilization issues. I also think, John, AI will give great feedback to primary care doctors.

Let me give you another scenario that I know two companies working on this. Hey, Dr. Nash, primary care doctor, you want to refer your patient to this cardiologist, we don't think that's a good idea. We want you to send to this cardiologist because she, according to our algorithm, returns patients, is a great communicator, doesn't overutilize, has high patient scores, and we gleaned all that with our AI algorithm. OK, that gives me, the primary care doctor, a little bit more information in the marketplace.

So we opened our interview with, why would anyone go into primary care? And you talked about the backbone, all the important things in terms of reducing costs, improving outcomes. So I'm going to end with that again to you, David, but maybe phrase it a different way. What would be your advice to someone who's at the point where they're considering primary care versus one of the specialties? The fourth-year or third-year medical student, what do you tell them, David?

Yeah, great question. Here's what I tell students, you got to do what you love. You got to do what you love. It's too hard a job to say, don't do it because you're going to be working hard or your salary is going to be lower. So my first piece of advice is, you got to find what you love to do, but you have to recognize that it's not a lifetime decision forever, that medicine is changing so rapidly, and tools, like you mentioned, AI and others, changes in the reimbursement system.

But I'll end with this, John, which is I tell every student, whatever you do, if you go to primary care, get the extra training to become a leader. Because what I've been about is training leaders, doctors, nurses, pharmacists, but what we need in our whole $4 trillion industry is more leadership from the people on the front lines. And there's research evidence that clearly shows, you want to reduce burnout in primary care doctors, give them a stake in the operations.

Give them leadership training so that they're a part of how the place is organized, how the resources are allocated, and give them training on how to improve. So I'll close with this, doctors have two jobs every day, primary care doctors especially. We have two jobs every day. Job one, the job of doctoring, doing all that hard work on the front lines. And job two, getting the tools and the learning on how to improve job one. That is how you reduce burnout, and you make primary care primary in our system.

That's why I go to you. That's what I said in the beginning that I always go to you for advice. So Dr. David Nash, thank you for sharing your insights and really helping us rethink about the role of primary care.

Thank you, John. It's a pleasure to be together.

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