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Primary care in the USA
Editorial
Every year US medical schools come to a halt for “Match Day”—the day when medical students learn where they will go for their residency training. This year’s results of the annual National Resident Matching Program, released on March 15, had some good and bad news for the future of primary care in the USA. The good news was that after a long decline, the number of US medical students choosing to go into internal medicine remained steady at 2680, slightly up from 2668 last year. Still, only 56% of training positions were filled by US medical students, the rest being filled by international medical graduates, graduates from osteopathic schools, and other programmes. The number of medical students choosing careers in paediatrics, too, remained steady. But family medicine programmes did less well: there were 100 fewer positions open this year, 500 fewer than were available in 2000, yet only 88% of those were filled, and only 42% of those by US medical school students. The results prompted the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) to issue separate statements warning that unless something is done to make primary care an attractive career for young doctors, the country will be ill prepared to care for its ageing population. The numbers, the ACP said, indicate that it is necessary to “fundamentally change the way that primary care is organised, delivered, financed and valued” in the USA. It is not surprising that US medical students shun careers in primary care. Because of how they are reimbursed, primary-care doctors must see more and more patients in order to stay in business. Visits tend to be short, rushed, and often unsatisfying to both the patient and doctor. In addition, the pay is not commensurate with the value of the services provided. Although robust primary-care systems provide better care for less money, primary-care doctors are among the lowest paid in the USA. In 2004, for example, the median compensation for a family practitioner who did not have an obstetrics practice was US$156 011, and for an internist $168 551. By comparison, the median compensation for a dermatologist was $308 855; for a diagnostic radiologist $406 852; and for an invasive www.thelancet.com Vol 369 March 31, 2007
cardiologist $427 815, according to a 2007 article in the Annals of Internal Medicine. With medical students graduating from public and private institutions with a median debt of $120 000 and $160 000, respectively, it is not surprising that they are opting for careers in specialties that promise higher pay and, in many cases, far easier schedules. How can the USA make careers in primary care attractive again? One solution being advanced by the ACP and the AAFP as well as the American Academy of Paediatrics and the American Osteopathic Association is based on the concept of the patient-centred medical home. The idea is not new; it was first proposed in 1967. But earlier this month those organisations, which together represent 333 000 US physicians, joined together to issue a document called Joint Principles of Patient-Centered Medical Home. The document calls for a system in which each patient has a personal primary-care physician who is trained to provide continuous and comprehensive care, in which each doctor is trained to lead a team of healthcare providers who take collective responsibility for the patient’s ongoing care, and in which that care is coordinated across all elements of the health-care system. But to create such a system and to provide such care, payers will have to be persuaded to pay for more than just time spent in face-to-face visits. Providers, quite reasonably, feel they should be paid for time spent on case management and evaluation occurring outside of patient visits, for time spent coordinating care with other practitioners, for time spent educating patients during visits, and for the time spent communicating with patients by phone and e-mail. They also need financial help to adopt the information technology needed to make the provision of these services efficient. So far, much of the current debate over health-care reform in the USA has focused on how to pay for care, but how that care is provided is at least as important. The medical home proposal advances principles that should be at the centre of that part of the debate, for without a major effort to restore primary care the US health-care system will continue to be overspecialised, fragmented, and wasteful. ■ The Lancet
The printed journal includes an image merely for illustration
For more on the Annals of Internal Medicine study see Ann Inter Med 2007; 146: 301–306 For the Joint Principles Statement see http://www. acponline.org/hpp/approve_ jp.pdf?hp
1055
Robert Harding
Primary care in the USA
Every year US medical schools come to a halt for “Match Day”—the day when medical students learn where they will go for their residency training. This year’s results of the annual National Resident Matching Program, released on March 15, had some good and bad news for the future of primary care in the USA. The good news was that after a long decline, the number of US medical students choosing to go into internal medicine remained steady at 2680, slightly up from 2668 last year. Still, only 56% of training positions were filled by US medical students, the rest being filled by international medical graduates, graduates from osteopathic schools, and other programmes. The number of medical students choosing careers in paediatrics, too, remained steady. But family medicine programmes did less well: there were 100 fewer positions open this year, 500 fewer than were available in 2000, yet only 88% of those were filled, and only 42% of those by US medical school students. The results prompted the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) to issue separate statements warning that unless something is done to make primary care an attractive career for young doctors, the country will be ill prepared to care for its ageing population. The numbers, the ACP said, indicate that it is necessary to “fundamentally change the way that primary care is organised, delivered, financed and valued” in the USA. It is not surprising that US medical students shun careers in primary care. Because of how they are reimbursed, primary-care doctors must see more and more patients in order to stay in business. Visits tend to be short, rushed, and often unsatisfying to both the patient and doctor. In addition, the pay is not commensurate with the value of the services provided. Although robust primary-care systems provide better care for less money, primary-care doctors are among the lowest paid in the USA. In 2004, for example, the median compensation for a family practitioner who did not have an obstetrics practice was US$156 011, and for an internist $168 551. By comparison, the median compensation for a dermatologist was $308 855; for a diagnostic radiologist $406 852; and for an invasive www.thelancet.com Vol 369 March 31, 2007
cardiologist $427 815, according to a 2007 article in the Annals of Internal Medicine. With medical students graduating from public and private institutions with a median debt of $120 000 and $160 000, respectively, it is not surprising that they are opting for careers in specialties that promise higher pay and, in many cases, far easier schedules. How can the USA make careers in primary care attractive again? One solution being advanced by the ACP and the AAFP as well as the American Academy of Paediatrics and the American Osteopathic Association is based on the concept of the patient-centred medical home. The idea is not new; it was first proposed in 1967. But earlier this month those organisations, which together represent 333 000 US physicians, joined together to issue a document called Joint Principles of Patient-Centered Medical Home. The document calls for a system in which each patient has a personal primary-care physician who is trained to provide continuous and comprehensive care, in which each doctor is trained to lead a team of healthcare providers who take collective responsibility for the patient’s ongoing care, and in which that care is coordinated across all elements of the health-care system. But to create such a system and to provide such care, payers will have to be persuaded to pay for more than just time spent in face-to-face visits. Providers, quite reasonably, feel they should be paid for time spent on case management and evaluation occurring outside of patient visits, for time spent coordinating care with other practitioners, for time spent educating patients during visits, and for the time spent communicating with patients by phone and e-mail. They also need financial help to adopt the information technology needed to make the provision of these services efficient. So far, much of the current debate over health-care reform in the USA has focused on how to pay for care, but how that care is provided is at least as important. The medical home proposal advances principles that should be at the centre of that part of the debate, for without a major effort to restore primary care the US health-care system will continue to be overspecialised, fragmented, and wasteful. ■ The Lancet
The printed journal includes an image merely for illustration
For more on the Annals of Internal Medicine study see Ann Inter Med 2007; 146: 301–306 For the Joint Principles Statement see http://www. acponline.org/hpp/approve_ jp.pdf?hp
1055
Robert Harding
Primary care in the USA