Rural Primary Care: Has the Canary Stopped Singing?

Dr McCue is Clinical Professor of Medicine, University of California, San Francisco, and Chief Medical Officer, Tuolumne General Hospital, Sonora, Calif.

Last year was not a good one for primary care in our town. Two general internists moved out of state, one retired, a cardiologist cut back on his practice in preparation for retirement, two family physicians and a physician's assistant took jobs in the desperately understaffed California prison system, and two general internists decided that they were too old to take hospital call for unassigned patients. Two family physicians are actively looking for greener pastures, where they would not have to take call and can balance their personal and family obligations better.

Adding to the turmoil, the county has concluded that it can no longer afford to operate what may be the oldest public hospital in the state. This county hospital is a busy place, supplying a large amount of primary care through its clinics and emergency room. Maybe some of the services for the uninsured and underinsured can be preserved in another, more rational system. But I am worried. Not only is the track record for how well the underinsured fare when public institutions close not at all encouraging, but when well-insured, employed patients have trouble finding a primary care physician, what do you think will happen to those without jobs and insurance?

And that's not all the bad news. The specialists and subspecialists are aging and starting to feel the effects of decades of night call and emergency department coverage. For example, the four general surgeons work too many long, hard days, often operating into the wee hours of the night when they are on call; the pulmonologist, gastroenterologist, and neurologist are solo practitioners, without weekend coverage, and the latter two are getting older, and retirement seems increasingly attractive. The local private hospital has been desperately trying to recruit primary care physicians: Two years ago they recruited two family physicians (the ones who are now looking for jobs elsewhere), and they have given up trying to recruit a general internist. At present, there is nobody to take over the practices of the physicians who have left town.

This is not a tale from dust-bowl Oklahoma (where I was born) or the frozen borders of Maine. It is a snapshot of medical care in 2007 in a charming, historic community of about 25,000 or so, depending on how far you extend the hospital's catchment area, in the gold country foothills of the Sierra Nevada, a short drive from Yosemite National Park.

Until recently, most of the patients in the United States could compensate for spotty physician coverage?they could just drive to the next suburb or brave the chaos of the university medical center for specialty care. Our patients, however, do not have that option, because the nearest medical center is more than an hour's ambulance ride away, university centers are three hours away, and for better or worse, we do not have suburbs.

It is no longer just a rural America issue. Now even those living in metropolitan areas are starting to feel the shortfall in availability of primary and specialty care?but it is nearing a crisis in the rural communities of the United States and Canada. Are these communities our canaries dying in the coal mines? (Canaries are especially sensitive to the toxic mine gases methane and carbon monoxide. As long as the canary that miners brought into a coal mine kept singing, miners knew their air supply was safe.)

How did we get into this mess? More to the point?Where is our great unkept, unplanned medical care system headed?

1. There is simple arithmetic. Our nation is growing, and will continue to do so for at least a couple of decades; our supply of medical school graduates is not growing. Since 1980, US medical schools have graduated the same number of physicians. Osteopathic medical schools have multiplied and tend to graduate physicians more interested in primary care, but they constitute a relatively small fraction of the overall number of medical students. We have imported international medical graduates to fill 25% of the residency positions, but my experience is that the residents tend to prefer non?primary care specialties and prefer to settle in metropolitan areas. International medical graduates are, moreover, not a reliable resource; as conditions improve in the countries that we mine for talent, the best are more likely to want to stay home. And neither is a planned or adequate response to the needs of a nation whose ratio of first-year medical students to 100,000 population is projected to fall to about 5 in 2020, from about 7.5 in 1980.¹

2. It is simply demographics. We are an aging nation, and our physicians are aging. In 1985, 49% of physicians were aged 45 years or older; in 2005, 57% were 45 or older (a 15% increase). My guess is that physicians are retiring at a younger age today than 20 years ago. If you don't believe it, just ask my (or your) hospital administrator.

3. We don't make 'em like we used to. In general, current graduates of residency programs are interested in a sane, balanced life, and are less interested in working long hours and taking night call. About half of medical students are now women (up from about 10% in 1980), who are more likely to be in a 2-professional household, and, for a variety of good reasons, they prefer to work fewer hours than male physicians. More than a decade ago, I and my medical educator colleagues clearly saw this irreversible change in lifestyle preferences occurring, and predicted that the effective physician supply would be less than the numbers suggest.

4. It is not a secret that the enthusiasm for the overworked, underpaid, and underappreciated primary care disciplines are of less interest to current residency graduates. To a large extent, primary care has become the second or third (or desperation) choice, mostly for graduates who cannot get into a subspecialty residency or specialty fellowship. This has contributed, I believe, to a very palpable fall in the morale of primary care physicians, who not only feel undervalued, but many of whom did not necessarily want to be in primary care in the first place.² It is simply a fact that medical students in the top half of their class are a lot less likely to be interested in primary care than those students who are less well endowed with great test scores.

5. The move to hospitalism in internal medicine is a mixed blessing. The attractiveness of inpatient acute medicine is undeniable. It is an opportunity to do what you have been well taught as an internal medicine resident; jobs are salaried (very important if you have high medical school debts); hours are fixed, predictable, and often include generous time off; and the hospitalist jobs pay better. There is an enormous demand for well-trained hospitalists, and as a result salaries and benefits are rising. And because of the obvious benefits to hospitals, hospital administrators are willing to pay well to give themselves control over hospital quality and utilization programs, and to ensure availability of physicians to take unassigned patients, especially at those inconvenient hours. So, what's wrong with this picture? Actually, not much, except that these are the same residents who used to go into primary care. Our understandable appetite for hospitalists is now cannibalizing our supply of potential primary care internists.

6. The American appetite for medical care is increasing. You have probably noticed that old people use more medical care resources and need primary care physicians who can skillfully balance their complex chronic medical illnesses and need for preventive medical care. And you have probably noticed that there are more old people than there used to be (a considerable comfort to those of us who are of a certain age). There will be about twice as many Americans older than 65 in 25 years; the average >65-year-old averages 130% more ambulatory care visits than those <65 years old.¹

But enough of the problems. What are the solutions? Short-term, there are none. We are tumbling headlong into a primary care crisis, and the canary is clearly dyspneic and desaturating. Long-term, you know the solutions as well as I. We need rational planning for medical care that includes increasing the numbers of physicians and increasing the attractiveness of primary care (ie, money, love, respect, and an attractive lifestyle). Complaining that the good old days are gone won't resuscitate the canary. In the meantime, we may need to invest in some respirators to get us through the next two decades.

References

Acad Med

1. Salsberg E, Grover A. Physician workforce shortages: implications and issues for academic health centers and policymakers. . 2006; 81: 782-787.

2. West CP, et al. Changes in career decisions of internal medicine residents during training. Ann Intern Med. 2006; 145:774-779.