In my day job and my organization work I hear cries to increase the production of primary care physicians. Internists decry the small numbers of residency graduates who join primary care practices. Family physicians blame everyone for the meager interest in family medicine residencies.
Increasing numbers of internal medicine graduates, and now family medicine graduates, are taking hospitalist jobs. Internal medicine graduates enter subspecialty training in droves.
Many well meaning internists blame the training programs. This line of reasoning blames the clinic experience contrasted with the hospital experience as the reason the residents no longer choose primary care jobs. If we could just give the residents a better primary care experience, then they would rush to primary care jobs.
Family physicians blame the medical schools for discouraging students from choosing family medicine. They point out true observations – the hidden curriculum against primary care and the snobbery of academic subspecialists.
But all these sincere critics miss the main point. The job has deteriorated.
Could we produce more primary care physicians? Possibly we could trick a few more graduates to taking primary care jobs, but we would still have an ongoing stampede away from primary care. Many internists leave their practices to take hospitalist jobs. They make more money, have more predictable hours, and have decreased hassles in their new jobs.
Primary care is a wonderful noble calling. I did primary care for 20 years. The job deteriorated over time.
The patient centered medical home is a bold attempt at reinventing the job. Retainer medicine is a successful attempt at reinventing the job. Cash only practices are another successful option.
Until we (society) willingly pay our valuable front line physicians a fair wage, without excessive administrative hassles, we will have too few good primary care physicians.
The problem is one of value. We who have done primary care and work with excellent primary care physicians understand their value. I do not think the insurers understand. I am sure that the politicians do not understand.
They do not understand the complexity of the job. They do not understand the value proposition, that is how greatly excellent primary care physicians improve health at lower cost. They think that non-physicians can do the job because they have no respect for primary care.
We must do everything we can to fix the job. If we fix the job, we will have full residencies, and hospitalists leaving their jobs to come back to primary care. To paraphrase James Carville, “it’s the job, stupid”.
