John Dillon
April 27, 2023
Imagine sitting in your local barber shop and, while waiting your turn, getting your health care taken care of right there.
It’s already happening to a certain extent. And the COVID-19 pandemic helped further untether the primary care visit from the doctor’s office, empowering patients to demand access to their doctors via video or other virtual means. Experts took notice, and they say they’ll need to focus more on reaching patients where they are.
As the primary care landscape evolves, patients can expect a team approach to their care – helped greatly by artificial intelligence (AI), electronic patient records, and, often, their own devices. What patients can’t count on in the near future is the ability to see a primary care doctor at a time of their choosing.
Experts say technology and the team approach will continue to open avenues to treating patients and identifying patients who need primary care treatment. (The barber shop experiment, in which pharmacists successfully treated hypertension in an underserved patient population, is an example.) The biggest challenge that health care professionals face is the alarming shortage of primary care doctors and a lack of incentives to produce more.
“The pipeline is problematic,” said Barbra G. Rabson, president and CEO of Massachusetts Health Quality Partners, a nonprofit group of health care stakeholders that attempts to improve the quality of medical care in the Bay State. “It’s pretty dismal.”
In 2021, the Association of American Medical Colleges projected that the U.S. will face a shortage of between 17,800 and 48,000 primary care doctors by 2034. By that time, the population of Americans 65 and older – a demographic that will rely the most on these providers – will grow by 42.4%.
Meanwhile, the existing supply of doctors is itself going gray. Rabson said a third of Massachusetts primary care doctors are 60 or older. The Association of American Medical Colleges predicts that in the next decade, two-fifths of active doctors nationwide will be at least 65 years old and eyeing the exits.
The warning is no surprise to doctors or patients, who have witnessed a rush of doctor retirements in the COVID era. Sang-ick Chang, MD, a clinical professor of medicine specializing in primary care and population health at Stanford School of Medicine, has watched it unfold in his neighborhood.
“People who have moved to the area seeking a [primary care doctor] struggle, and are put on a long waiting list,” he said. “I feel terrible that there are no doctors available.”
Replenishing the pool of providers won’t happen easily, experts said.
“We can’t produce all these doctors tomorrow,” said Atul Grover, MD, PhD, executive director of the Association of American Medical Colleges’ Research and Action Institute. Many of the nation’s top medical schools have no family residency training programs. “They don’t even attempt to train primary care doctors,” Rabson said.
Money plays a big role in medical school students’ career choices, according to experts. Primary care is “the lowest-paid, lowest-filled specialty in the entire field of medicine,” Chang said.
Although a primary care doctor’s salary of roughly $250,000 a year is plenty for most people, med school students – especially those from low-income backgrounds – see that a career in orthopedics or dermatology can earn two or three times that.
“There are people who want to do primary medicine,” Grover said, but “income expectations make a difference.”
“I went into primary care because I like patients,” said Kirsti Weng Elder, MD, section chief of primary care at Stanford School of Medicine. She wanted to make a good but not necessarily “fabulous” salary for her work. But she sees people leaving medical school today with $500,000 in debt, five times what she left with, and “you need to pay that debt.”
There are also 10 times as many medical specialties as there were in the 1960s, said Grover, and the reimbursement payment system favors procedures over generalists.
“We undervalue primary care, and it is reflected in reimbursement,” Abraham Verghese, MD, a professor of internal medicine at Stanford, said in an email. “In American health care, we put great premium on doing things to people rather than doing things for people. … It is much more challenging to find primary care for one’s aging parent than it is to find a specialist willing to change their heart valve.”
The decline in private primary care practices, also made worse by the pandemic, extends to hospitals, Rabson said. The advent of hospitalists means that primary care doctors are less likely to spend time in a hospital consulting about their patients, further disrupting the continuum of care doctors would prefer.
“The private practice is kind of dead,” said Baldeep Singh, MD, a professor of primary care and population health, also at Stanford.
In its place is a team-based system owned by hospitals or private companies such as Optum (owners of Harvard Vanguard), CVS (which runs Minute Clinics), Amazon (which bought One Medical in February), and virtual-first providers like Teladoc Health. Even Meta, Facebook’s parent company, is getting into virtual care through the “metaverse.”
These companies, offering same-day appointments, appeal to potential patients with no patience for a 3-month wait to see a doctor.
“You go to Amazon because you can find a thing you want to buy and get it tomorrow,” Lee Schwamm, MD,chief digital officer for Yale New Haven Health, said at a recent Massachusetts Medical Society conference addressing challenges to health care. “We are going to see a lot of companies who have not traditionally been in health care want to play that role because they know how to do that kind of thing very well.”
The proliferation of social media platforms has trickled into primary care as well, especially for younger patients. “People really want instant access all the time, and people are not used to making appointments,” said Weng Elder. “My children don’t know what that means.”
Patients got a glimpse into the future of the primary care visit when the pandemic lockdowns, like Toto in The Wizard of Oz, pulled the televisit curtain open on a system that wasn’t quite ready. Weng Elder said she was one of the first doctors to use telehealth several years before COVID. “We were excited to try it, and it was very very poorly adopted,” she recalled. “People thought it was strange.” But before they knew it, doctors were forced into it, and “suddenly people realized it was a good thing.”
“Video invites you into your patient’s home,” she continued. “You can see if they have a cluttered house or a neat house. You can ask them to open up their refrigerator, show me their meds, let me walk around.” Family members can also be invited to the conversation.
Video visits, which doctors say now account for 20% to 30% of primary care visits, also spare patients the time and expense of getting to the hospital or office – a boon for patients with limited mobility or who live far from their provider.
Doctors go by the rule that 80% of a diagnosis comes from the patient’s history – helped greatly by algorithms and artificial intelligence – while the rest comes from a physical exam. “Chest pain requires an electrocardiogram,” Chang said. “We can’t do that on a video visit.”
Patients without a regular doctor lose out, and Grover sees a burgeoning problem. “Patients are getting older, they have multiple medical illnesses, and what we’re seeing is that patients in the hospital are sicker.”
A condition that could have been controlled with the help of a primary care doctor becomes one that is treated in urgent care.
Doctors said that electronic health records, which allow them to see how the patient was treated in an ER halfway across the country, have improved to the point where different recordkeeping systems now communicate better with one another. But another approach, they said, is one of a primary care team – sometimes omitting the doctor unless necessary.
“It’s a much better team sport,” said Singh. “I have a pharmacy team that helps me. I have a social care worker to help me with patients who are depressed.” Also on the team are nurse practitioners, case managers, and physician assistants.
In such an environment, in a few years, “I can see primary care doctors as being a manager of people,” Wang Elder said. “They end up seeing people who have critical conversations that need to be had.”
Yale’s Schwamm described it as reaching people who shop at Walmart as well as Bloomingdale’s. Conditions like diabetes and atherosclerosis are not “infectiously contagious,” he said, but “socially contagious” and need to be addressed sooner rather than later.
The barber shop study said a scaled-up program reaching 941,000 Black men to help control blood pressure would avert 8,600 major (and costly) cardiovascular events. And the program didn’t even use primary care doctors at the start.
“Pharmacists are incredibly well-trained and talented,” Grover said. “They understand what falls outside their expertise.”
The trick is to convince insurers to buy into such programs. “Payers need to be more creative and flexible in the way they reimburse for the kind of care we expect.”
The digital divide threatens to widen. Doctors expect that in the next few years, more and more patients will be able to upload information from their phones, Fitbits, and blood-pressure and glucose monitors.
Niteesh K. Choudhry, MD, PhD, a professor of health policy management at Harvard T.H. Chan School of Public Health, said at the Massachusetts conference that devices give patients more control over their own care while requiring less work from providers.
“Self-management led to better blood pressure control than primary care management,” he said. “We need to imagine that there’s lots of health care which we take responsibility for, which patients might actually be better at.”
They give doctors a better look at how patients are faring “where they are – not with us in our offices.”
Rabson said such devices are far likelier to be used if a patient has a primary care doctor. And Weng Elder added, “If you have money, you can get a Bluetooth BP monitor. If you are poor, you do not. That will be a disparity.”
Grover said devices will help people in rural areas only if there is decent broadband. But disparities also happen in urban areas, where life expectancies can vary many years, depending on where in that urban area one lives.
Primary care doctors care for an average of 1,500 patients a year, and increasingly spend more of their time answering patients’ electronic queries.
“The crisis of manpower means you’re much more likely to be offered a nurse practitioner or a nurse’s assistant than an MD because there won’t be an MD,” Chang said.
“The alternative solution is well, maybe we don’t need MDs in primary care. Maybe we’ll just give up.”
Sources
Sang-ick Chang, MD, clinical professor of medicine specializing in primary care and population health, Stanford School of Medicine.
Barbra G. Rabson, president and CEO, Massachusetts Health Quality Partners.
Atul Grover, MD, PhD, executive director, Association of American Medical Colleges Research and Action Institute.
Kirsti Weng Elder, MD, section chief, primary care, Stanford School of Medicine.
Massachusetts Medical Society: “Future Health: Best Practices for Advancing Care,” March 31, 2023, Waltham, MA.
Abraham Verghese, MD, professor of internal medicine, Stanford School of Medicine.
National Academies Press: “Primary Care: America’s Health in a New Era,” “Implementing High-Quality Primary Care: Rebuilding the Foundation of Healthcare.”
Baldeep Singh, MD, professor of primary care and population health, Stanford School of Medicine.
American Association of Medical Colleges.
Circulation: “Scaling Up Pharmacist-Led Blood Pressure Control Programs in Black Barbershops: Projected Population Health Impact and Value.”
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