By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer
“If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.”
– Albert Einstein
As we emerge from the COVID pandemic, the health care delivery system is not yet recovered.
A point-in-time survey of medium and large primary care physicians (PCPs) in the Partnership HealthPlan of California (PHC) network showed an overall current vacancy rate of 24% of which two thirds were openings for PCP physicians (about 200 openings) and one third were openings for nurse practitioners/physician assistants (about 100 openings). The current PCP openings are in all 14 counties and in all practice settings. The overall need for PCPs is even greater if we want to have sufficient clinicians to do all the preventive and chronic disease care that is recommended by the United States Preventive Services Task Force (USPSTF), the American Academy of Pediatrics, and the Department of Health Care Services (DHCS).
This is not just true in the PHC service area but also nationally and internationally. The United Kingdom is having the largest primary care physician shortage since the start of the National Health Service in 1948. A few clinicians died of COVID, more were disabled by long COVID, and others retired early or stopped doing primary care. As the supply dries up, the demand per clinician remaining in practice increases causing stress and burnout. This leads clinicians to take a break from practice or reduce their hours per week making the shortage worse.
The rise of hospitalists has been a major driver of loss of primary care access. Twenty years ago, about 40% of all internal medicine residents became PCPs. Now that number is about 15% with most of the shift occurring in the rise of the number of hospitalists caring for patients in the inpatient setting.
The number of PCPs plus hospitalists is equal to the number of PCPs needed in a community. The steady decrease in the number of internal medicine specialists in primary care (as older primary care internists retired) was not accompanied by a sufficient increase in training family physicians, nurse practitioners, and physician assistants to overcome this loss. This trend started reversing in the mid-2010s with an increased number of primary care physician residencies as well as a substantial increase in the number of new nurse practitioners and physician assistant graduates.
While the hospitalist movement promised to improve quality and utilization, this has absolutely not happened. Hospital length of stay in the PHC service area is at an all-time high (6.23 days) and increasing steadily over many years. (Part of this increase length of stay is a shortage of skilled nursing facility beds.) Poor continuity of care for discharged patients is now common as compared to when PCPs rounded on their own patients. The major benefit for PCPs was that they no longer had to get up in the middle of the night to admit patients; the hospitalist could take care of it. While this may have made their lives feel better in the short run, the disconnection from hospital care and the loss of collegial relationships with hospital specialists makes PCPs more professionally isolated (and unmentored if they are in small practices), and contributes to a loss of a sense of professionalism. This increases stress and burnout.
If any particular medical system raises primary care salaries, they will recruit away some clinicians from other settings, at least temporarily. This happened in the prison health care system in California and the Permanente Medical Group about 20 years ago. The invisible hand of market forces soon intervenes. Other organizations soon raise PCP salaries in response, to stem the loss of staff. With the nationwide and international shortage of primary care, migration of PCPs to greener pastures will contribute to more severe shortages in other communities.
What Can We Do?
Train more PCPs. First and foremost, we need to train more primary care clinicians who will work in primary care. If all the primary care resident physicians in our service area stay in the PHC service area after graduation (unlikely), it would still take ten years just to staff the current open positions. In the past decade, the number of family medicine residencies in our current 14 county region increased from two to seven, with two additional programs in gestation. Nurse practitioner residencies are springing up in many health centers.
Community connections. Secondly, we need to help new primary care clinicians and their families form deep roots in the community and the clinical setting where they practice. The average length of time that new PCPs are staying at their first jobs is now about three to five years in our service area. Whenever a clinician moves to a new setting, the time they invested in learning the systems of care and learning about the lives and medical histories of their patients is lost. Reducing turnover thus instantly has the effect of increasing primary care capacity where the same number of clinicians can care for heavier patient workloads as they get to know their patients better.
A place-based business or career for a physician spouse can build longevity in the community. A friend from residency moved to rural Alaska to practice for what he and his wife thought would be a three-year stint to repay his substantial medical student loans. His wife liked dogs, and this grew into a hobby of racing sleds driven by Alaskan Huskies. They are still in rural Alaska 30 years later. This is an extreme example of a common phenomenon. Most PCPs who stay in one town their whole career do this because of family connections to the community.
Life-long love of primary care. Third, we need to find ways to help our PCPs feel the joy and pleasure of providing primary care. If clinicians only enjoy their lives outside of the workplace, they will want to work less hours, retire early, and/or change jobs more frequently. Ways to build this joy are building friendships with peers, matching new providers with enthusiastic mentors who love primary care, and finding ways to minimize non-value added administrative activities.
Shake it up. Another tactic that works well is to break up the office practice routine. This could be a clinical activity like becoming the primary care “specialist” in the office for opioid treatment or dermatology or seeing patients weekly in a homeless shelter-based clinic site. The change in routine can also be from working with a team to improve quality outcomes, improving internal operational efficiency, or working on some other special project.
Reduce non-value-added activities. Electronic health records are here to stay, but they are a major contributor to clinicians having less enjoyment in the workplace in the past two decades. The PCP office needs to have support staff off-loading computer documentation activities and adapting the EMR to make it ever more efficient to use and less of a drain on clinician morale. Trying to cut costs by reducing support staff and keeping billable providers will improve the bottom line only temporarily before clinicians start leaving because they don’t feel supported or valued.
As clinical leaders we are all devoting ourselves to this challenge using the five tactics listed above and others. Alleviating the PCP shortage is a long-game imperative for the entire health care delivery system, as well as your individual practices. We at PHC appreciate all you are doing!