Thursday, May 21, 2009

Primary Care, Pediatrics, and Physician Distribution

As the discussion on health reform proceeds, we are seeing several “specialized” takes on what form health reform should take, what the interests that are advanced should be, and to what degree the current privileges (income) of those who are doing particularly well in the current arrangement (insurance companies, pharmaceutical and medical device companies, many hospitals and subspecialist physicians) should be preserved; this latter is sometimes couched in terms of benefit to the health of the public, but sometimes the argument is even made de facto. In this an a future entry or two, we will discuss some of these issues regarding the physican workforce, physician training, and financial incentives.

In the May 13, 2009 issue of JAMA, Freed and Stockman write on “Oversimplifying primary care shortages”.[1] Citing the literature demonstrating the shortage of primary care physicians, they assert that the real issue is that there is a shortage of primary care physicians for adults, and that the production of primary care pediatricians has not suffered. “The most recent published data regarding pediatric residents completing training in 2008 demonstrate that 40% were planning to pursue a career in primary care, with 10% still undecided.” They warn against increasing the production of general pediatricians, fearing an oversupply, noting that “While the absolute number of children has remained relatively stable, the number of pediatricians has increased substantially. This has resulted in an increase in the number of primary care pediatricians, from 32 to 78 per 100,000 children in the period 1975 to 2005.” They then go on to talk about the “…increase in the number of recognized subspecialties [in pediatrics] and the continuing need to populate those fields with fellowship-trained pediatricians.”; essentially an argument for the need for more pediatrics residents to choose subspecialty training. I will not address that except to say that this statement, unsupported is a tautology – because we have more specialties we need to train people to go into them – rather than a justification (which may well exist) for the need for more pediatric subspecialists.

The fact that the entrance of medical students into pediatrics, and the stability of the choice of general pediatrics among those residents, the first in marked contrast to the decrease in students entering family medicine and the second in contrast to the career choices of residents in internal medicine, is definitely important. It is worthy of more than note; it needs to be studied to identify the reasons. Perhaps these reasons will be unique to pediatrics and not transferable to other primary care (adult) specialties, but perhaps there are important lessons to be learned. However, a gross measure, in this case total number of pediatricians, or even primary care pediatricians, to the number of children misses some important considerations, many of which have been addressed previous in this blog. The most obvious is that Freed and Stockton completely ignore geographic distribution of pediatricians, a point noted by JAMA editor Catherine DeAngelis in her editorial. “…although the number of generalist pediatricians does not appear to be a problem, their geographic maldistribution remain.”[2] Pediatricians, like most physicians, choose to locate in certain areas, specifically in major metropolitan areas. Rural areas especially, and to a lesser degree inner-city areas, do not have enough pediatricians.

Indeed, it is only family physicians that distribute in proportion to the location of the population. Freed and Stockman are correct in asserting that we do not need to simply train more primary care pediatricians, but the reason is that they have saturated the areas in which they are willing to live. This is addressed in Dr. Robert Bowman’s guest column on this blog from January 15, 2009, “Ten myths regarding primary care”. Myth #9 is “The nation needs more pediatric graduates to meet primary care needs.” Dr. Bowman states “More pediatric graduates will not meet primary care needs. According to pediatric leadership, pediatric primary care is saturated in the locations where pediatricians choose to locate, at the same time that the United States has fewer children. Even though 15% of white female medical students remain committed to pediatric residency choices, they and other pediatric graduates will compete with all other primary care graduates already delivering pediatric primary care. This is likely to result in more practicing in part time, specialty, hospital, urgent, and emergent pediatric care settings.”

The fact that pediatricians are disproportionately female may help to explain the relative immunity of this primary care field from downturns in student selection, but, for the reasons Dr. Bowman identifies, may not solve our geographic distribution needs. It may also explain why simply looking at the numbers of doctors entering a specialty (general pediatrics in this case) may overestimate the actual number of FTEs and years practiced (Dr. Bowman’s “Standard Primary Care years). As this blog addressed on March 7, 2009, “The feminization of medicine” is in many ways a very good thing – including the persistent interest in pediatrics – but it has other implications which need to be considered in estimating workforce supply. These include the probability that female physicians, including pediatricians, will work fewer years (including time off for child rearing and earlier retirement) and the greater likelihood of female physicians to work less than full time. In addition, while there are great difficulties in getting physicians overall to practice in rural areas, the issue is even greater for women, because they are even more likely than male physicians to be married to other professionals, frequently physicians in more lucrative subspecialties, who cannot find employment in rural areas.

The challenges of getting physicians to rural areas are enormous, and have been addressed here before. Increasing the number of rural students is critical; paying doctors who work in “less desirable” (and here I want to make clear that this is not by any means a value judgment on life in rural areas, but simply a reflection of physician choice; maybe we should say “less popular”) rural areas more money than those who work in urban areas is essential. But it also requires producing the kind of doctors who can work in those settings, and essentially that means family physicians – and probably general surgeons. If students continue to enter family medicine at rates that won’t even replace the already-too-low percentage of primary care doctors, then all strategies need to be developed to encourage them. It is not sufficient to increase reimbursement for generalists a little, or even some; the entire reimbursement structure needs to be revised to encourage continuity, comprehensive management, coordination of care, and quality metrics rather than production of visits or procedures.

[1] Freed GL, Stockman JA, “Oversimplifying primary care shortages”, JAMA 13May09;301(18):1920-22.
[2] DeAngelis CD, “Commitment to care for the community”, JAMA 13May09;301(18):1929-30.

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