The Collapse of Primary Care

On the first day of my internship in primary care internal medicine at the Massachusetts General Hospital in 1981, one of the gastroenterology professors had a welcoming party for the new interns at his home, a beautiful manor located on several acres of land, in one of the wealthiest suburbs of Boston. In-between bites of the gourmet food he provided, one person asked the professor, "How are you able to afford all this?"

"Scoping for dollars," he replied. He spent much of his time performing endoscopies, a then new procedure in which a fiber-optic scope is threaded down the esophagus of a patient, thereby allowing the doctor to visualize the stomach, duodenum, and other parts of the upper gastrointestinal tract.

"But can't most patients with ulcers be diagnosed just on the basis of their symptoms and history?" one intern asked. "What's the added value of doing an endoscopy?"

"What's the value of not knowing?" he replied.

I chose primary care medicine because many of its leading advocates then, mentors such as Mass General's Dr. John Stoeckle and Dr. Alexander Leaf, saw it as part of a larger social and political movement toward more equitable health care. Also, as I conducted research showing what a powerful difference counseling patients to eat healthier, manage stress, quit smoking, and exercise could make in their lives, primary care provided the ability to follow patients over time and support them in making healthier choices.

However, at that time, anyone choosing to enter one of the primary care fields such as general internal medicine, pediatrics, geriatrics, or family medicine was looked down upon as having less prestige and power than those entering a sub-specialty such as gastroenterology or cardiology. Since then, it's gotten even worse.

A study just published in the Journal of the American Medical Association found a strong, direct correlation between the starting salary of physicians in a specialty and the percentage of medical school graduates choosing those specialties. Because those in primary care fields are the lowest paid—the average salary of a family physician ($185,470 for working 60-70 hours/week) is less than half that of an interventional cardiologist or surgeon—it's not surprising that the number of interns and residents choosing a career in primary care has decreased by more than 60 percent in the past decade, whereas the number choosing to be sub-specialists has increased by almost 40 percent. Already lower to begin with, salaries for primary-care doctors actually decreased 10.2 percent between 1995 and 2003.

This study was directed by Dr. Mark Ebell, a professor at the University of Georgia. He conducted the research to draw renewed attention to the role of salary disparities and the primary care shortage and to encourage policymakers to enact meaningful reforms to increase the percentage of primary care physicians. "The problem of salary disparities is not something that anyone is going to solve locally," Ebell said. "This is something that will require reform at a national level."