What will happen for our aging population and women's health care when we face a shortage of primary care physicians?
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This feature is part of our ongoing series looking at the inequities in healthcare.
Imagine an America where infants in towns across the country are struck with a sudden sickness and die. Imagine an America where women suffering from advanced cervical or breast cancer is the new normal. Imagine having to wait months upon months for medical care, or having to travel hundreds of miles to simply see a doctor. This isn’t season three of The Handmaid’s Tale, or a post-apocalyptic America—it’s the possible future of our health care and in many regions, and populations, it’s already arrived.
Americans are facing a shortage of primary care doctors that is only expected to get worse in the next decade. How dire is it? According to a 2018 report by the Association of American Medical Colleges, the U.S. could see a shortfall of between 14,800 and 49,300 primary care physicians by 2030. If you consider that the average primary care physician has approximately 2,300 patients under their care that could mean as many as 1 billion patients left searching for a new doctor, or flooding urgent care centers and emergency rooms nationwide.
Mindy Hoffbauer, a social media director in Dayton, Ohio, has felt the existing shortage firsthand. She was recently having gallbladder trouble when she decided to call her primary care physician. “I was told I wouldn’t be able to see him until mid-October,” Hoffbauer says. She started shopping around for a new physician but discovered that getting an appointment as a new patient takes even longer. “Thankfully, I had a childhood friend who was able to pull some strings for me and get me a new patient appointment in just three weeks,” she says. Others who can’t find appointments aren’t so lucky, and experts say there’s been a surge of patients in urgent care centers and emergency rooms in many rural areas and cities.
Why is the shortage of primary care physicians in a freefall?
There’s a slate of reasons that make up a complicated brew. The trouble starts to bubble up in med school where doctors are encouraged to specialize rather than generalize in medicine; and it stews with an increase in aging Baby Boomers, along with a heavy dose of physician burnout and rural hospitals closing nationwide. Plus, the fact that federal residency funding has remained stagnant for decades.
Monya De, M.D., an internist in Los Angeles, who has written widely about health trends for publications such as ABC Medical News, explains that the shortage’s roots are in medical school. De says it’s common for med school students who choose to go into primary care fields to get mocked by both their peers and advisors. “They are met with this attitude of: Why would you even go into med school if you’re not making the most money you can? Or have the most autonomy that you can? Or the most prestige that you can?,” she says. She adds that in addition to primary care positions being unpopular because of low pay and status, it’s also a field in which burnout is sky high.
“What’s happening with primary care doctors all across the country is that they see patients at breakneck speed during the day, and they can never be going fast enough,” De says. “They may be seeing 20 to 30 patients a day.” Along with the heavy patient load is relentless desk work. “When you sit back down at your desk there are 40 messages in your inbox, and a pile of refills on your desk to review, and five people might want disability and another 10 people want family medical leave so you have to fill out that paperwork, or a sports physical form, etcetera, etcetera,” De says. In addition to the crushing workload and time pressures—and a sometimes chaotic work environment due to emergency health dilemmas—there’s a slew of complex tasks created by health insurance companies. The combination of all these challenges is leading to primary care physicians calling it quits, or seeking alternative work.
Although being a primary care physician is becoming an unpopular profession because of its increasingly lousy reputation, these physicians remain vital to our care. It’s worth noting that primary care physicians often serve as the first, or only, health care available to rural or underserved communities. Primary care physicians have the expertise to answer questions about aging parents’ health, a colicky baby, or a partner’s erectile dysfunction as well as give a routine pelvic or breast exam all in one visit. In fact, according to medical experts, it’s not uncommon for women to bring their kids to their primary care provider so that they can take care of the entire family’s health needs in one fell swoop.
Often, we think of the 1950s as the golden era of the family doctor who would care for the entire household for decades, but it actually wasn’t until the 1960s that the public began to express their concern over the state of medicine (which had been becoming more and more specialized since post-World War II). In 1969 the Medical Boards finally approved family medicine—a keystone of primary care—as a new specialty that provided comprehensive care regardless of sex, age, or gender. Family medicine, which some say was born out of the social consciousness movements of the 60s, then began to flourish starting in the 1970s until the mid-1990s.
Primary care is critical for women because we use it across our lifespans not just for preventative medicine, but also for taking care of our loved ones and families.
“Women serve as the health care decision-makers for their families,” says Katie Martin, the vice-president of Health Policy and Programs for the National Partnership for Women and Families. She adds that it’s also clear that without easily accessible and affordable providers women will just not go to the doctor, which is detrimental to their health.
According to a 2017 Kaiser Women’s Health Survey, the majority of women say they currently have a place to go when they need care, and that they have seen a provider in the past two years; however, uninsured women report they are half as likely to see a physician, and Latina, low-income and younger women are far less likely to have regular care.
Susie Carrillo, a spokesperson for the National Cervical Cancer Coalition from Redlands, California, has spoken widely to the media, and in the 2014 documentary film Someone to Love: The HPV Epidemic, about her brush with cervical cancer. Carrillo told SELF magazine, “I was four months pregnant with my first child when my doctor told me I had an abnormal Pap. I thought, I don’t know what that means … I was 19 and had never been to a gynecologist before.” It wasn’t until several years later, during her second pregnancy, that she went in for a comprehensive check-up with her gynecologist. This time she discovered that she had high-grade cervical dysplasia which led her to undergo a procedure to remove the precancerous tissue. It was successful, but she was put on bed rest for four weeks because of excessive bleeding. Since then, Carrillo educates others about how they can prevent what she had to go through.
In Durham, North Carolina, and formerly in rural Iowa, Duke Health’s Viviana Martinez-Bianchi, M.D. has seen women who have limited access to care, and women who don’t routinely see doctors. “They have things like cervical cancer, breast cancer—things that could have been treated had they been caught earlier, advanced diabetes, heart disease,” Martinez-Bianchi says.
She adds that the benefits of seeing a family care physician within your community aren’t simply about taking care of a cold, or other illness, but these physicians can also offer coaching and resources for things like watching weight, quitting smoking, or stopping excessive drinking. “Family doctors motivate their patients,” Martinez-Bianchi explains.
But rural communities are increasingly facing limited access to attentive longer-term care like this, and the coming physician crisis may make it even worse. In fact, more than 80 rural hospitals have closed since 2010, and the National Rural Health Association estimates that rural areas could be short 45,000 doctors by 2020.
A recent New York Times story points to why this is cause for concern with the poignant headline: “It’s 4 a.m. The Baby’s Coming. But the Hospital is 100 Miles Away.” In the article, reporter Jack Healy shines a light on a rural community in Kennett, Missouri, that has been struck by the doctor and hospital shortage. Healy writes: “…this month came the news that [many had been dreading]. Two infant boys, each about a month old, died on opposite ends of the county, one on July 4 and the other the following morning … Their deaths sent a shudder through Kennett.” In both cases, the infants were nearly two dozen miles away from a doctor’s care when they were found unconscious.
As the CEO of Copper Queen Community Hospital in the small town of Bisbee, Arizona, James Dickson is familiar with such chilling stories in his own community; more and more health care centers are shutting down in rural areas such as his. Dickson recently told NPR, “They’re starting to call the rural areas ‘the new inner city’ because we have the same shortages and lack of access to care.”
What, then, is the solution to this increasingly scary physician shortage in both rural communities and cities?
The Association of American Medical Colleges is calling on the medical community to address the shortage with what they call a “a multi-pronged approach.” This involves team-based care that includes nurses and public health professionals working closely with physicians, and in some cases filling in for them when appropriate. The association is also encouraging the federal government to fund residency training programs and limit cuts to Medicare, because without Medicare’s clinical reimbursements teaching hospitals are simply unable to afford residents.
Meanwhile, many physicians agree that telemedicine—in which doctors and patients are often connected by two-way video, or simply via phone—offer promise for helping with wait times and rural patients.
“My take on telemedicine is that it is better than the alternative, which is nothing—how you do a Pap smear via telemedicine definitely remains to be seen,” De says. “But you can initiate the patient-physician relationship, and do health education, which is such an important part of what we do … So many common sense things come from having lived in stable homes, and having gone to school continuously where we learn from our peers and health classes.” She recognizes that not everyone has this privilege. But with cellphone technology becoming more and more accessible to underserved communities accepting telemedicine as one way to address health concerns could be one small step towards better care.
These stop-gap measures alone, of course, will not relieve the primary care physician shortage and its effects. But public awareness of the little-talked-about medical crisis and recognizing the urgent need for more primary care providers is one step towards recognizing the vital care provided by the doctors who serve as the backbone of our medical system. Because without them, who knows how many of us will be left sick, injured, or even chronically ill without anyone to treat or even diagnose the problem.