VOL. 7 | NO. 40 | Saturday, September 27, 2014
SPECIAL EDITION Health Care
Searching for Doctors
By Don Wade
So here’s the offer: lower salary – meaning it will take longer to pay down your student loan debt – less prestige, and perhaps even a questioning of your intelligence and skill.
In 2014, that’s what comes with the decision to become a primary care physician. Recently, a fourth-year medical student at the University of Pennsylvania, Mara Gordon, wrote an article for The Atlantic explaining her decision to become a primary care doctor.
Strangely, this put Gordon in the role of apologist. She described herself and two classmates who also decided to go into primary care as “anomalies,” adding, “We were an unofficial support group for a rare condition: becoming a primary care doctor.”
And this is a problem for, well, pretty much everyone.
“It’s what keeps all of us up at night,” said Michael Ugwueke, president and chief operating officer of Methodist Le Bonheur Healthcare, and president and CEO of Methodist Healthcare Memphis Hospitals.
If the system for delivering primary health care in 2020 is essentially the same as it is now, a primary care physician shortage of 20,400 is projected nationally by the U.S. Department of Health and Human Services.
(Memphis News/Andrew J. Breig)
How this has come about isn’t all that surprising.
“Not only is the physician population getting older, but the regular population is getting older as well,” said Bill Jolley, vice president of rural issues for the Tennessee Hospital Association and executive director for the Tennessee Rural Partnership. “It’s probably going to continue to get worse.”
The Tennessee Rural Partnership analyzed 2012 data from 21 West Tennessee counties. The findings show that 85.7 percent of primary care physicians are age 50 or older.
“My great-grandfather was a country doctor,” Jolley said. “He made house calls on horseback.”
But no doctor is pulling into a patient’s driveway on horseback now, and probably not showing up in a Ferrari. In fact, the family physician/general practitioner – especially as we used to think of that doctor – is becoming endangered.
“The traditional Marcus Welby doctor going to the hospital and back to the clinic, and then back to the hospital that night, and hanging out a shingle is no longer part of our environment,” said Jim Boswell, vice president of physician services at Baptist Memorial Health Care Corp. and CEO of Baptist Medical Group. “I don’t know if it’s all economic, but there are certain realities.”
Boswell says his son, who is in medical school, is facing anywhere from $250,000 to $300,000 in debt when he gets out.
“The question becomes, ‘What can I do to pay that off?’” Boswell said. “In his case, he wants to be an emergency room doctor.”
Going into a lucrative subspecialty offers the most direct path to free oneself from debt. Profiles, an online database surveying graduating physicians, reported the median starting salary for family medicine at $138,000, and the six-year national average did not break $200,000. By comparison, the median starting pay for a general surgeon was $225,000, for an anesthesiologist $265,000, and for a diagnostic radiologist $330,000.
“When I came out of medical school 30 years ago, I had very little debt,” said Dr. David Jennings of the Church Health Center. “Now, basically, you’ve got a nice home mortgage without the home.”
Gordon, in her article for The Atlantic, said just 12 out 162 students in her school’s past graduating class have started primary care residency programs. And at the other end of the spectrum, dissatisfaction among primary care physicians appears to be running high. A 2012 Urban Institute study of 500 primary care physicians found that 30 percent of those aged 35 to 49 intended to leave their practices within five years. For those older than 50, the rate spiked to 52 percent.
Boswell says because the young doctors are carrying so much debt, it’s difficult for the older doctors with private practices to bring them on and pay them enough so they can pay down the debt in a timely manner.
“Smaller practices can’t compete,” Boswell said. “We (Baptist) have acquired a lot of those practices and we’re bringing young new doctors into them.”
Matchmaker, matchmaker …
To address the shortage of primary care physicians in rural areas, the Tennessee Rural Partnership has developed what amounts to a dating website hoping to match new doctors with communities in need of primary care. A three-year commitment to an underserved rural community can mean as much as $35,000 a year in help paying for school.
Dr. Marc Courts looked at the offer several years ago as he was plotting his future.
“I was a little skeptical, to be honest,” he said, adding that he had believed he would practice in one of Tennessee’s larger cities.
Ultimately, he brought his family to Loudon County, between Chattanooga and Knoxville, and went to work for Loudon Pediatric Clinic.
“On our first visit to the community they were having a Christmas parade,” he recalled. “Everybody knew everybody and there was all kinds of natural beauty in the area. And the community responds to the service you provide. They’re so thankful you’re there.”
In Courts’ case, he has been there for six years now.
Meanwhile, over the last 12 months, Jolley says three West Tennessee hospitals have closed, including two in Gibson County.
“There are some very difficult places to recruit to,” Jolley said, citing locations with high poverty rates, no nearby hospital and an isolated geographical location.
Challenges in certain parts of the city are just as daunting.
“The issue is misdistribution of where doctors are,” said Paul D. Juarez, co-director of the Research Center on Health Disparities, Equity and Exposome, and professor of preventive medicine at the University of Tennessee Health Science Center.
Shelby County, Juarez says, has 726 primary care physicians to cover a population of 939,465. That’s one primary care doctor for every 1,294 residents.
“That’s really quite good,” Juarez said, noting that to be a federally designated shortage area by the Health Resources and Services Administration there must be just one primary care provider for every 3,500 residents.
Each census tract in Memphis has about 4,000 people, Juarez notes, and while some of those tracts have multiple providers, others have none. On a map, one can see the cluster of providers from Downtown and the Medical District through East Memphis. But north and south of Downtown there are few, and they are normally tied to a nonprofit organization.
“There are not many physicians in private practice in those areas,” Juarez said.
“And in those pockets of Memphis where people don’t have access, there’s a much higher emergency room treatment rate,” Jennings of the Church Health Center added.
The same stipend that can draw doctors to the countryside also can apply in the city, as long as the area has federal shortage designation. But it can be a tough sell.
Across the country, including in greater Memphis, there is a growing use of nurse practitioners and physician assistants – known as “physician extenders.”
At Baptist’s Midtown Clinic, Boswell says, they hired two nurse practitioners as part of their medical team. One had five years of experience and the other was fresh out of school.
(Memphis News/Andrew J. Breig)
“We look to physicians to provide the parameters” of what they are allowed to do, Boswell said.
Some industry professionals are more comfortable than others in giving the so-called physician-extenders larger roles. Everyone, however, seems to agree they need to play a part in broadening primary care access with more people able to get care now that they have insurance through the Affordable Care Act.
“They do good work,” Jennings said. “Where you maybe lose something is if you don’t have physicians able to take care of sicker patients and reducing hospitalizations, reducing referrals to specialists. Because the more you refer to specialists, the more in the long run you increase the cost of health care.”
Juarez also has concerns about the nurse practitioners and physician assistants becoming de facto doctors in low-income areas that have trouble attracting full-time primary care physicians, saying the principle of “comprehensive, coordinated, continuous care” could go by the wayside.
“They become familiar with your history,” Juarez said of family physicians and general practitioners. “They know what screenings you are eligible for, mammography or colonoscopy.”
Further, Juarez says if the misdistribution of primary care physicians isn’t solved, and in turn health disparities remain, it will be expensive for all.
“Those costs are kind of shared among everybody in terms of premiums,” he said. “For us to ignore that is to everybody’s economic disadvantage.”
Help is on the way?
To Dr. Guy Reed, chair of the department of medicine at UTHSC, a medical student such as Mara Gordon is not shocking.
“I interview all the medical students at UT that have an interest in internal medicine, and in the last two or three years I’m seeing more of an interest in primary care,” he said. “I think primary care is again going to have an enhanced role in medicine.”
Some of the primary doctor shortfall is expected to be made up by foreign medical school graduates – both nationally and in Memphis, Jennings said.
Another way to address the problem is to increase the number of residency slots in the United States.
“Despite the huge growth in the number of medical students, there hasn’t been any change in the number of residency slots,” Reed said. “By 2016, it’s projected there will be more medical students than slots to train them.”
The lure of well-paying subspecialties always will be part of the primary care physician equation, but with this generation, technology also may be a contributing factor.
“There’s always a new technique, a new technology, and it’s a good thing that there is,” Jennings said. “Colonoscopy was just getting started when I did training.”
But this generation of medical school students also grew up with cellphones and computers, grew up in a time when personal face-to-face communication was considered less vital.
“In primary care, there’s a lot more personal interaction with patients,” Jennings said.
And yes, maybe a lot less glamour. Gordon wrote, “Every time I tell someone I plan to go into primary care, I wonder if they think I just wasn’t smart enough to do something else.”
Said Jennings: “I guess it is what it is. The perception within the medical community and lay community, probably they do place a higher level of respect on specialties.”
Dr. Marc Courts, 39, considered specializing in allergies and immunology before taking up the Tennessee Rural Partnership offer and practicing pediatrics in Loudon County. He has no regrets, even though he sometimes has to break away on a Sunday and drive to someone’s house because their child is very sick.
But he does admit to a little envy for Bill Jolley’s great-grandfather, that country doctor making house calls on horseback.
“That’s awesome,” Courts said. “I want a horse. That’d be so cool.”