What's on the horizon for primary care?

If you're looking for a job, these are better days. But demand for generalists is still simmering, not boiling over.

By Ken Terry
Managed Care Editor

Three years ago, because of intense competition, graduates of the FP residency program of St. Joseph's Medical Center in Paterson, NJ, had to look hard for high-paying jobs in northern New Jersey. Half of them are now practicing in the area, but the rest had to go elsewhere.

The latest batch of six grads did "extremely well, though," says residency program director John DeGhetto Jr. Four of them took area jobs, all paying $125,000 or more; the remaining two married each other and went into practice in Rhode Island.

Mark Korsten, director of the internal medicine program at the Bronx (NY) VA Hospital, agrees that the job market for generalist physicians has improved. "Any graduate can get a primary care position in the New York area now," he maintains.

The easing of the primary care job pinch in some cities appears to be related to a major change in managed care. As HMOs have retreated from the gatekeeper model and cut restrictions on referrals and procedures, the demand for specialists has boomed, and residents have flocked to the higher-paying specialty fields. Korsten notes that nine out of 10 recent graduates of his program got fellowships in subspecialties. Three years ago, when there were fewer opportunities for specialists, half his graduates went straight into private practice, most outside the New York area.

Meanwhile, patient demand for primary care doctors hasn't fallen off significantly. Since fewer physicians are entering primary care practice and some are leaving it—including internists who are seeking subspecialty training, and subspecialists who no longer provide primary care—openings for generalists have increased in some areas that used to be saturated, including New York and Chicago.

Job prospects vary from one city to another

The employment situation varies markedly across the country. In Dallas, primary care jobs are abundant and high-paying, says internist Joshi Alumkal, chief resident in the internal medicine program at the University of Texas Southwestern Medical Center. "There's no shortage of people calling—whether they're hospitals, groups, or recruiters—to try to get our graduates to join their practices." Starting salaries, he adds, range from $100,000 to $150,000.

If you want to practice primary care in the San Francisco Bay Area, on the other hand, you'd better think twice. Some jobs are available, but you won't live well there on a doctor's starting salary. One big group reportedly won't hire new primary care physicians unless they have spouses who earn more than they do.

In Washington, DC, similarly, fewer primary care jobs are being filled than in the past, because young physicians can't afford to live there, says Joan Damsey, head of a consulting and recruiting firm in Norfolk, VA. But FPs and internists are being actively recruited in the suburbs, she says.

In fact, across the country, the suburbs and outlying areas are the places to look. Starting salaries are higher there than in large metropolitan areas. So if money is the goal, young physicians may need to reset their sights: A recent survey of third-year residents by recruiting firm Merritt Hawkins & Associates in Irving, TX, shows that 80 percent would prefer to practice in communities of more than 50,000, and none wants to work in towns of 10,000 or less.

Nationwide, average salaries offered to both new and experienced primary care physicians haven't increased much in the past three years—just 3 percent for FPs and internists, and 11 percent for ob/gyns, according to another Merritt Hawkins study.

Primary care jobs pay less on the East and West Coasts than in the Midwest and the South, says Geoffrey Staub, director of marketing for Cejka & Co., a recruiting firm based in St. Louis. The reason is the continuing maldistribution of physicians.

"You have a ton of internists who want to work in the East, but there's a limited number of patients there," he says. "So they have to work harder for less. Some of them go to three or four different locations to see patients."

Pediatricians seem to be adequately supplied in most areas. Cejka is conducting searches for only "a handful" of pediatricians, says Staub, and the field didn't make Merritt Hawkins' list of the 10 most-recruited specialties. Family practice is on the list, but it's a less-sought-after specialty than internal medicine—a reversal of the situation only a year ago.

The aging population could alter the job equation

As the population ages, internists will be even more sought after because of their focus on complex conditions in adults, says Mark Smith, executive vice president of Merritt Hawkins. Family physicians will also play a key role in serving the growing population over 65, he adds.

But there's some debate about just how much the aging of America will affect the demand for physicians in general, and primary care doctors in particular.

Recent studies show a decline in the percentage of elderly people suffering from chronic disabilities caused by such conditions as stroke, dementia, and diabetes. A Duke University study indicates that the incidence of these disabilities is dropping at an accelerated rate.

Another paper, out of Harvard, postulates that falling disability rates can be explained by improvements in medical care, better health habits, and increased use of mechanical aids. Both studies predict that seniors' increasing independence and improved health status will mean lower-than-expected increases in health care costs.

Nevertheless, physician workforce experts still believe that the demand for doctors will spike when the baby boomers hit retirement age. "More and more people are having complex procedures done into their 70s and 80s," notes FP Michael J. Scotti Jr., senior vice president of professional standards for the AMA. "A friend of mine just got a new hip at age 80 because he wanted to keep playing golf. That was unheard of years ago."

This upsurge in procedures for the elderly benefits primary care doctors as well as surgeons, says Scotti, because patients who've had surgery must be followed up and maintained on medications.

At the same time, guidelines for preventive care are being applied to increasingly older patients. "It used to be that I didn't bother treating high cholesterol in the 70-year-old, because by the time his lowered cholesterol would make a significant difference, he'd be dead," says Scotti. "But now he won't be."

Other factors besides the aging population also speak to an increased demand for primary care physicians, Scotti says. The redefinition of diabetes, now diagnosed at lower blood sugar levels, is one. So is direct-to-consumer advertising, which motivates patients to seek new prescriptions. "Every one of those DTC ads is specifically designed to create new work," he points out. "It's a new visit by a patient for a new problem. If the drug works, that patient is back every three to six months."

Scotti also notes that some primary care doctors are staking out additional health care turf. The American Academy of Family Physicians, for instance, offers workshops in colonoscopy, bread and butter for gastroenterologists. And Scotti sees an increasing number of FPs offering or even specializing in sports medicine, which was once dominated by orthopedists.

But, over time, other trends are likely to reduce demand for generalists. One is the proliferation of midlevel practitioners. Nurse practitioners now total 82,000, up from about 63,000 in 1996, and 80 percent of them work beside—or in place of—FPs, internists, and pediatricians. There are also 42,700 physician assistants, nearly half of whom provide primary care. In 1996, PAs numbered 29,000.

Open access to specialists, on the other hand, won't decrease the need for primary care, says Herbert S. Waxman, senior vice president of education for the ACP-ASIM. Even if more patients self-refer to specialists, most won't receive their principal care from those consultants, he notes. But if primary care doctors don't want to surrender turf to specialists, they must reassert their role as personal physicians and coordinators of care, argues FP Joseph Scherger, dean of the College of Medicine at Florida State University in Tallahassee.

Is there a primary care shortage in the cards?

It's impossible to predict exactly how many primary care physicians will be needed in the future. Nevertheless, the ACP-ASIM's Waxman believes a primary care shortage could easily develop within the next few years. He cites the increasing percentage of women doctors, who often practice part-time; soaring malpractice premiums; and anecdotal evidence that many physicians are retiring earlier than expected because of managed care hassles and reimbursement cuts.

Waxman also notes that the percentage of US medical school seniors matching to primary care residencies has been steadily dropping. Last year, for instance, 41 percent of US students matched to generalist residencies, down from 43 percent in 2000. (These residencies include family medicine, internal medicine, ob/gyn, and pediatrics.) While international medical graduates filled most of the remaining residency slots, the total number of primary care matches declined 4 percent in 2001.

Osteopathic medical schools are training more and more physicians, and traditionally about half of them choose primary care specialties. But from 1998 to 2000, the number of residents in FP programs approved by the American Osteopathic Association dropped 20 percent.

Most worrisome to Waxman are hints that the shift of internal medicine residents from primary care to subspecialty careers may be accelerating. Internist Alan A. Harris, director of a residency program at Chicago's Rush-Presbyterian-St. Luke's Medical Center, has also detected that trend. A year or two from now, he predicts, the vast majority of graduating residents will go into fellowships, as they did in the early '90s.

There's little indication of a primary care shortage at the moment, though. Between 1995 and 2000, the number of practicing generalists (excluding DOs) grew by 14 percent; by comparison, the total number of MDs in active patient care rose only 11 percent. As of 2000, there were 79.4 primary care physicians per 100,000 people, up 11 percent from 1995. The federal government predicts that that ratio won't start to fall until 2017.

Edward O'Neill, a professor of family and community medicine at the University of California at San Francisco, sees no evidence of an impending primary care shortfall. "Primary care doctors are younger as a group than some of the subspecialties," he says. "So fewer of them are going to retire soon."

Meanwhile, the spate of early physician retirements in all fields has slowed considerably, says recruiter Mark Smith. "Some doctors who thought they might be retiring this year have gotten nervous because of the stock market, and until things improve, they may stick it out a year or two."

Five years ago, the AMA's Scotti thought the country was heading for "a massive oversupply of physicians." But now he believes that doctors are flexible enough to take advantage of whatever opportunities the health care system has to offer. "As long as there's money pouring into the system, the economy will absorb large amounts of new medical services and new medical people."

 

Ken Terry. What's on the horizon for primary care?. Medical Economics 2002;3:26.