When the doctor will (not) see you now

A friend and colleague recently described their trouble finding a new primary care physician after their physician retired from practice. My friend is an experienced and well-connected internal medicine physician who “knows people and is known by people” in the field and who really should not have had any trouble picking up the phone and getting an immediate appointment. However, it took several phone calls and emails to different colleagues, who eventually managed to find someone who could squeeze them into their already overburdened and closed panel in a couple of months.

Just this last year, I remember attempting to reschedule an appointment with my own physician and finding out that her “next earliest available” was six months away. Fortunately, I had nothing more urgent than a routine annual visit. However, at a recent White House event highlighting medical harm and patient safety, one of the speakers, also a physician, described in horrific detail how she almost lost her life hemorrhaging in the hospital and subsequently bouncing from clinic to clinic. She eventually ended up in an emergency department waiting for more than five hours to be seen while slowly suffocating from cardiomyopathy-induced heart failure.

It is no longer a secret that for many Americans, it is difficult to see a physician for an acute symptom, and almost impossible to get a primary care appointment for routine care in a reasonable amount of time. The mushrooming of urgent care clinics run by nonphysician health care professionals, pharmacy-based clinics, and the unspeakable congestion of emergency departments are symptoms of a much greater problem. The primary care machine is slowly but certainly grinding to a halt. The doctor cannot see you now.

This will not be big news to many readers of this column. For over a decade, ACP has maintained a continuous drumbeat on this issue, trying to raise awareness and action about the threat to the very foundation of our health care system. According to the Association of American Medical Colleges (AAMC), we could be short by as many as 48,000 primary care physicians by 2033, the greatest number for any specialty, amid a projected shortfall of about 140,000 physicians overall. This is happening while medical schools and residency programs are graduating about 30,000 new doctors each year. Why the disconnect?

The crisis has been long in coming, initially precipitated by factors such as physician frustration from declining reimbursements, physician retirements, growth in specialty and subspecialty practice areas, and educational bottlenecks due to static medical school and residency training spots. However, the pace of primary care practice attrition has accelerated over the last decade as private practices are taken over by large health systems and more and more young physicians vote with their feet away from primary care into supposedly more rewarding and less demanding specialties. The growth and attractiveness of hospital medicine over general internal medicine practice have further decreased the proportion of graduating residents who choose to practice primary care as general internal medicine specialists.

While we can all clearly see the problem, the solution is less clear. How do we fix something that intertwines health policy, workforce issues, business interests, personal choice, and societal needs? Moreover, whose job is it to fix it?

The complex dynamics afflicting the practice of “frontline medicine” require a multifaceted approach rather than a silver bullet. Unfortunately, most attempts at addressing the issue have been a hodge-podge of “silver-bullet” solutions, ranging from developing loan forgiveness programs to increasing residency spots, increasing medical school enrollment, hiring physician extenders, or advocating for physician reimbursement reform. All of these are important components of a potential solution, but their application has been haphazard and uncoordinated, with a resultant blunting of their overall effectiveness.

The reality is that this is a national crisis and needs more than piecemeal attempts by a disjointed array of interests and entities to be dealt with effectively. It needs a coming together of like-minded parties with the focused aim of figuring out how to ensure that patients are seen by a frontline physician in a timely, patient-centered, safe, and equitable clinical environment. It also means ensuring that frontline medicine is a satisfying and rewarding practice that physicians gravitate towards rather than away from.

There is a glimmer of hope on the horizon as physicians begin to think outside the box of institutional fee-for-service practice, not only by developing new and sophisticated care models but also by rediscovering old models that previously worked. One example is the team-based patient-centered medical homes and other integrated care models that promise to liberate physicians from the fee-for-service shackles that reduce the joy of practice while increasing efficiency and enabling innovation. Another promising example is direct primary care, a term that evokes old-style patient-physician relationships and describes a practice model that, for a fee, guarantees patients direct access to a physician, much as it was when physicians ran independent practices.

Ultimately, however, there must be concerted action at the national level to address the shortcomings of the current primary care model. Some states have tried to address the problem by legislating independent practice by nonphysician health care staff or licensing nonresidency trained physicians. However, these measures do not constitute an appropriate or feasible long-term solution and are likely to increase cost and potentially harm patients. Federal and state governments must take a serious look at the continued attrition in primary care availability and engage with physicians and other stakeholders to provide concrete and long-lasting solutions. Otherwise, we will all land in the same spot facing the same dilemma: The doctor will (not) see us now.