Primary care is a calling, not just a career, for many physicians like Dr. David Richard.
“Practicing family medicine has been the highlight of my life. I never want to retire,” said Richard who is vice chair of education in the family and community medicine department at Penn State Health in Reading.
Yet, for many medical students, family medicine has little appeal. Fear of lower earnings and the lack of prestige associated with general medicine keep doctors away from the practice. So much so that the nation is facing a shortage of primary care providers.
Currently, 13 percent of Americans live in an area with less than one primary care physician per 2,000 patients, according to a 2018 report from the UnitedHealth Group, a national health insurance provider.
In fact, only one in six medical school graduates chooses a primary care residency, according to the same report. Many larger medical schools do not even have a primary care department.
And, as time wears on, existing primary care practitioners are aging into retirement. By 2025, one third will be over 65, according to the Association of American Medical Colleges, a nonprofit medical research organization based in Washington, D.C.
Match these numbers with aging baby boomers who need more health care and the shortage is expected to grow.
“This is not a new phenomenon,” said Dr. Jeffrey Zlotnick, a primary care physician based in Reading. “Family medicine was looked down upon when I was in medical school. There was a sense that if you chose that route, you were a hippie, a leftist.”
“And as far as society at large, in America we value specialists and procedures, surgery, not primary care,” he continued. “What people don’t see is that primary care is the heart of the system. It feeds everything. If primary care were valued more, more doctors would pursue it.”
The heavy student-loan debt borne by medical school graduates also overshadows the primary care route. New doctors carrying $250,000 to $500,000 in loans want to enter a field that will be financially lucrative enough to ease the burden.
Many primary care doctors recommend student-loan forgiveness programs as a way to bring more physicians into areas where there is a primary care shortage
“Cardiologists don’t need loan-forgiveness programs; primary care doctors do” said Zlotnick.
Doctors in the Penn State Health Family and Community Medicine residency department report that physicians who are drawn to a career in primary care are often looking for something more than financial gain.
“If you are looking for the three Ps – power, prestige and possessions – don’t go into primary care,” said Dr. Mack Ruffin, chair of family and community medicine at Penn State Health,
A large number of those who are drawn to the primary care track are non-traditional students, according to Ruffin. The field draws more women, minorities, and older and second-career students than other specialties, he said.
What makes primary care satisfying to those who practice it? The relationships between patient and doctor. The ability to treat a wide range of conditions. The problem solving and detective work.
“There is a lot of detective work to find out what the source is of the patient’s problem,” Zlotnick said. “You really have to be Sherlock Holmes as a primary care physician.”
To draw more medical students into primary care, Penn State Health in 2018 launched a campaign for primary care that is part of a larger nationwide campaign undertaken by the Association of Family Medicine Residency Directors. Called “25 by 2030,” the campaign seeks to ensure that by 2030, 25 percent of medical school seniors select family medicine as their focus.
Right now, less than 10 percent of medical students at Penn State Health go into family medicine. By emphasizing the way in which primary care encompasses all fields of medicine and the satisfying patient-doctor relationships that can come out of it, Penn State Health hopes to increase the number of recruits to their family medicine track.
“We have primary care physicians meet with medical students, connect with them, develop a mentorship, and showcase their scope of care,” said Ruffin.
In addition, the residency program at Penn State Health Milton S. Hershey Medical Center offers a three-year accelerated program that shaves one year off a primary care student’s schooling.
“It effectively reduces their student debt by a quarter of a million dollars,” said Dr. Shou Ling Leong, director of the accelerated residency program.
Penn State Health also offers a physician assistant primary care residency program. Physician assistants practice medicine directly under the supervision of doctors.
Leong, Richards and Ruffin all believe that physician assistants, often referred to as PAs, are another solution to the primary care crisis.
“We need to embrace a new health care team model,” said Leong. “Having a team of people behind everyone’s health care will ease stress and burnout for each individual provider and help the shortage. Even with PAs, more are going into other specialty areas. The number of primary care PAs can’t match the need.”
Nurse practitioners are also working to meet the primary care provider shortage. Nurse practitioners are advanced practice registered nurses. In Pennsylvania, these nurses must work with a collaborating doctor, though that doctor does not have to be working in the same clinic as the nurse practitioner.
Some see the increasing number of physician assistants and nurse practitioners in primary care as a threat to primary care physicians.
Zlotnick, who said that he has worked with and respects nurse practitioners, maintains that a family medicine physician should be the go-to for the majority of people when it comes to primary care.
“A physician just has more training,” he said. “Nurse practitioners can miss some of the nuances when it comes to diagnosing and should have someone supervising. PAs and nurse practitioners have a niche, but the better ones know when they are getting out of their league.”
Dr. Karen Bensinger, certified nurse practitioner and assistant professor of nursing at Cedar Crest College in Allentown, argues that all primary care
providers can sometimes miss things.
“It can be true of physicians,” she said. “It’s not a competition. You know what you know and what you don’t. We work better together; it doesn’t have to be adversarial.”
Right now in Pennsylvania, lawmakers are working to pass a bill that would allow nurse practitioners to practice without a collaborating physician.
Similar legislation has passed the Pennsylvania Senate twice before dying in the House of Representatives, including in 2017. In June this year, the Senate voted 44 to 6 in favor of allowing nurse practitioners to practice independently. Twenty-two states currently allow nurse practitioners full practice authority.
If the bill eventually passes in Pennsylvania, nurse practitioners who have three years or 3,600 hours working with a physician will be able to practice alone. This will free up nurse practitioners to serve patients in rural areas where it is difficult to find a collaborator and where patients either lack care or need to drive long distances for a medical visit.
“People need primary care from prevention and screening of disease to managing chronic disease states and this is where nurse practitioners are most needed,” said Dr. Adele Caruso, president of the Pittsburgh-based Pennsylvania Coalition of Nurse Practitioners. “The best case scenario is to have NPs and physicians work together as a team, but we do not need a collaborative agreement to best serve our patients.”
Opposition to the bill is frustrating to many nurse practitioners.
“The time is now,” said Kathy Gray, a certified nurse practitioner and director of the master of nursing studies program at Moravian College in Bethlehem. “Regardless of who provides primary care, doctors or nurse practitioners, patients have a great need. The wait to get in to see physicians is too long.”
Cedar Crest’s Bensinger said nurse practitioners have a unique approach to treatment that some patients prefer. They focus on the whole patient, putting the patient before the disease, she said. They are also able to spend more time with patients than a traditional doctor, which allows them to focus more on the overall health of a patient, rather than just the symptoms that send them into a medical office in the first place.
“We have a scope of practice,” she said. “As long as we are working in our scope of practice, we don’t need supervision. We can refer, and there is no reason we can’t prescribe medications. All of my collaborative physicians have been of the mindset of ‘I trust you.’”
Nurse practitioners interviewed by LVB spoke emphasized that while nurse practitioners and physicians may have different approaches, the outcomes are the same.
In fact, no significant differences are found in patient outcomes whether treatment is by a nurse practitioner or a physician, according to studies published in the Journal of the American Medical Association, a peer-reviewed medical journal.
While in the past, patients often were apprehensive about seeing a physician assistant or nurse practitioner instead of a doctor, it is rare today for a patient to say “I don’t want to see the NP,” according to Gray.
The Pennsylvania Coalition of Nurse Practitioners’ Caruso is hesitant to pit physicians against other types of primary care providers.
“I work with several physicians and we respect each other’s skill set,” Caruso said. “Nurse practitioners are out there right now serving the poor and underserved populations. There are 12,347 NPs in Pennsylvania and that number is steadily increasing. We are already here. We are already filling the gap in the primary care shortage.”