Because of this shortage, even fully insured Americans find the act of securing a generalist to be problematic: Almost 1 in 5 of us live in a federally designated primary-care-shortage area (see Figure 1).3 It is estimated that our current training programs will produce 40% fewer PCPs than will be needed to keep pace with the baby boomers and the insurance expansion of the Affordable Care Act. Attempts at using GME subsidies as a lever to increase the number of generalists have failed for decades. Almost 30 years ago, Dan Quayle petitioned Medicare to forgo any subsidies to training programs that did not commit to graduating at least 70% of trainees to primary-care careers, to no avail. Years later, the Institute of Medicine appealed to the federal government to reduce the training of specialists, and increase the training pool for generalists, to no avail. To reduce the financial burden of GME training, about 15 years ago, Congress threw in place a stop-gap measure, putting a freeze on the total number of residency slots that would be funded, but it did not put any measures in place to ensure that the allocation of slots would match what the U.S. health-care system needs. This has left us in a global shortage of physicians, the most grotesque of which is among generalists in regions of greatest need.
The Good News
So where does this leave hospitalists? Fortunately for our specialty, hospital medicine remains very appealing to new graduates and to the health-care system. For new graduates, it offers a competitive salary and work-life balance, without additional fellowship training. For the health-care system, we are generalists who can enhance the “value equation,” having proven to enhance quality while simultaneously reducing cost. As generalists, our specialty remains relatively undifferentiated and flexible to meet the needs of the system, including caring for patients at many stages of an acute or chronic illness; pre-operative care; post-discharge transitions of care; and assisting in some stages of “specialty care” (e.g. the medical care of the neurologic emergency, the pregnant patient, comanagement with a variety of surgical subspecialists).
As a progressive specialty, we should continue to focus on the pipeline, not only to ensure we recruit our “favorite picks” to hospital medicine, but also to support the reform needed to enhance the appeal of generalist practices and reduce the irresistible appeal of specialty care. In this way, we can add yet another meaningful contribution to meeting the needs of the U.S. health-care system.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
References
- Longman P. First teach no harm. The Washington Monthly website. Available at: http://www.washingtonmonthly.com/magazine/july_august_2013/features/first_teach_no_harm045361.php?page=all. Accessed Aug. 4, 2013.
- Association of American Medical Colleges. Physician shortages to worsen without increases in residency training. Association of American Medical Colleges website. Available at: https://www.aamc.org/download/150612/data/md-shortage.pdf. Accessed Aug. 4, 2013.