Is There a Doctor in the House?

In a 2006 report entitled The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care, the American College of Physicians (ACP) warned that the there is a severe shortage of primary care physicians (family doctors, pediatricians, and internists) in the United States. The situation is equally dire in Canada. According to a November 2, 2006 article from CBC News, five million Canadians, or 17% of the population, do not have a family doctor. Furthermore, nearly two million of those people have tried, and failed, to find a family physician in the past year.

This shortage of general practitioners has widespread implications for patients, doctors, and for the American and Canadian healthcare systems. Not having timely access to a family doctor leads to the overuse of emergency rooms, later diagnoses, difficulty in getting referrals to specialists, and poor management of chronic health problems. Ultimately, it results in poorer health across the country, as well as higher healthcare spending.

Since the baby boom generation will soon be relying on their GPs to care for them in their old age, the problem is expected to worsen. However, family doctors themselves are an aging population. An American Medical Association report found that one-third of US family physicians were over the age of 55, and most of those practitioners were expected to retire within 10 years. Furthermore, there will be fewer new graduates to replace them. According to a study by the American Academy of Family Physicians (AAFP), the number of medical students choosing family medicine has dropped by half between 1998 to 2003. Even as the demand for family doctors increases, medical students are eschewing general practice in favor of better paying and more glamorous specialties. According to an AAFP study, in 1999, the average American pediatrician saw 122 patients per week and earned $137,800 per year, while the average gastroenterologist saw 90 patients per week and earned $299,200. Since the average American medical student is graduating with $120,000 in debt, it's not hard to see why family medicine is losing its appeal.

According to an article published on December 8, 2003 in Maclean's, Canadian "family doctors overwhelmingly feel stressed out, overworked, underpaid, and under-appreciated." In order to generate enough income, GPs are forced to see more patients, which leads to shorter visits and a decrease in the quality of care. A 2001 survey conducted by The College of Family Physicians of Canada found that the average GP worked 52 hours each week, plus an additional 17 hours on call. Some GPs see 50 to 60 patients a day, and a survey of 3,500 Canadian family physicians showed that almost one-third of the doctors believe that the quality of care they give patients has worsened over the past decade. The good news is that nine out of 10 patients still rate their experience with their GP as good or excellent. Similarly, in the US, rising overhead costs and dwindling reimbursements are forcing family doctors to take on larger caseloads.

Solutions

Fortunately, solutions do exist for the challenges that are currently facing primary care. In order to be successful, a coordinated effort is required from doctors, medical schools, healthcare systems, and governments.

In its 2006 report, the ACP recommended sweeping changes to the way that primary care is financed and delivered. Many of the services provided by GPs are currently undervalued, and the ACP suggested that physicians should be paid for email and telephone consultations, and for coordinating patient care with other healthcare professionals and family members. The ACP urged Congress and the Centers for Medicare & Medicaid Services to provide financial incentives for physicians to improve, measure, and report on the quality and efficiency of the care they provide. The report also recommended that Advanced Medical Homes be established to provide patients with comprehensive and coordinated care.

In Canada, many of the problems doctors face were created by the drastic healthcare spending cuts of the mid-1990s. The working conditions of GPs can be improved by increasing pay, easing the burden of paperwork, and embracing information technology. Both American and Canadian administrations can help family practitioners by providing more support for group practices, and by giving doctors the resources to set up systems for electronic recordkeeping and tracking of patients.

Physicians have the opportunity to improve their own working conditions through lobbying and patient education. The 2003 Maclean's article reported that two-thirds of Canadian GPs felt that they were underpaid, while only 13% of their patients shared that view. Canadian patients were also largely unaware of the long hours and large caseloads that their doctors were facing. By educating the general public about their working conditions, GPs may gain many allies in their bid to receive more funding and support from the government.

One key lies in making primary care more attractive to medical students. For example, the Miller School of Medicine in Miami, Florida, aims to expose students early and often to general medicine. The school was one of the first in the US to teach clinical skills to first-year students, and to give students plenty of exposure to general medicine through clinic visits, health fairs, and primary care electives. More family doctors can also be generated by increasing the number of medical school admissions and general medicine residencies, and by making it easier and faster for foreign-trained physicians to become trained and licensed in North America.

Urgent action is needed to improve the working conditions of today's family practitioners, and ensure that enough physicians will be available to meet the needs of future patients.

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