Addressing the Primary Care Crisis

John Geyman, MD was asked various questions about the Primary Care Crisis. I recommend his book Breaking Point - How the Primary Care Crisis Endangers the Lives of Americans.
But I also have some variations of my own from the answers that he has given to the folks at Health Workforce News.
What is the primary care crisis, and how did it come about?
The last time that the United States supported primary care was 1965 to 1980. Before that and after that, the US has failed. Only from 1965 to 1980 did the US double primary care by designs that doubled the number of MD, DO, NP, and PA graduates that served in primary care. It is important to remember that in the United States design based on flexible primary care training, primary care graduates ofen fail to go into primary care. Only from 1965 to 1980 did graduates remain consistently in primary care in all the 6 primary care sources. Only from 1965 to 1980 did US health policy and training result in top primary care retention. Since 1980 five sources have claimed to be primary care but only family medicine delivers on the promise of primary care consistently.

From 1965 to 1980 the US doubled primary care and also doubled non-primary care  by design. Only from 1965 to 1980 did any intervention for primary care work. Since this time and increasingly to the present, the United States policy has driven primary care graduates away from primary care.

Each 15 years since 1980 the US had doubled non-primary care but primary care has remained static in a policy design that favors non-primary care and forgets primary care. A design that sends so much more each year to non-primary care sets up far too much for patchwork programming to overcome. It is not possible for any special programming or intervention to succeed in delivering on primary care promises short of a permanent choice - of which only family medicine is representative. Voluntary choice plus US health policy fails for the purpose of primary care, rural, and underserved workforce. The existence of special programs actually distracts the US away from understanding the failure of policy plus voluntary choice. Health and political leaders fail to act in the best interest of the entire nation, 70% of rural populations, and 60% of urban populations as well as elderly, poor, near poor, disadvantaged, lower income, middle income, less insured, uninsured, less employed, less educated and less health literate populations. All except those most advantaged in multiple dimensions lose out.

The reason for primary care failure, basic health access failure, and most health care failures for most Americans is flawed designs.
How is this crisis affecting the health care that Americans receive?
The primary care crisis is only a symptom of total failure in the American health care design. Only those who have been healthy or those that are most urban, highest income, and top occupation are untouched by the poor American design for health care. What is most apparent to academic, political, media, government, and foundation leaders is not what is happening to most Americans and solutions such as innovation and reorganization are not going to fix massive shortages of primary care RN, MD, DO, NP, and PA - the result of defective designs for policy and training.
Words no longer can describe the daily experience of those who should be accessing care but cannot, those who avoid care due to barriers, those who do not understand the need for care when they should, those who do not understand the care provided, those who get too much care and are injured, those who get testing that results in their poor health,

and all Americans who are experiencing recession in no small part because of a design that cripples nearly all businesses and all levels of government with far too much health care cost for far too little health care result.

The designs are so bad that school districts must cut teachers and marginalize education due to health care costs, health systems marginalize nurses, state and local government must cut public servants to balance budgets, states must minimize public health and primary care with too few, and government looks to accountants for cost cutting designs rather than working closely to develop a real plan for best health for nearly all Americans and a health care workforce to match this plan - one that will not defeat our nation by costing too much and delivering too little for too few. 
For primary care to recover, the entire health system must be redesigned not for primary care, but for better health and better health care for nearly all Americans. Primary care and basic health access cannot survive a black hole that sucks all health spending into 1% of the land area with 50% of workforce and 60% of health spending.
What changes would you make in medical education to encourage students to go into primary care?
The time for encouragement, passive methods, and voluntary choice is over. It is time for the workforce design to work for 65% of Americans left behind in 30,000 zip codes. After nearly two decades working on pipeline designs that have failed to work because of policy failure, my resolve follows the evidence of success – not more promises that fail. It is not possible to improve the delivery of care where needed until there is workforce where needed. To change patterns of health spending, the US must begin to shift where workforce is located and what careers are chosen. MD, DO, NP, and PA students not willing to choose the needed careers and locations will need to find other occupations.
Many if not most MD, DO, NP, and PA schools and programs must offer the following options. The following example is the physician trianing example. Private schools must also be convinced to contribute to the physician workforce needed for all Americans, not just health care delivered to a few Americans a few years of their lives delivered in a few locations.
Limited Choice Options
  1. Choose to go elsewhere for training where you can find voluntary choice options.
  2. Choose to serve in basic health access with a signed obligation.
  3. There are no other options as the focus is upon most Americans, not just a few.
Medicine is not a pathway to serve you or to serve your desire to stamp out some disease. Medicine is a pathway to serve those in need of better health. Designs to train physicians and to deliver health care must contribute to an efficient and effective nation, not burden a nation.

Basic Health Access Admission and First 25% of Your Career Served Where Needed
To become a physician you must serve in practice in a zip code in need of workforce for at least 8 years after training. The obligation design will commit enough graduates for a sufficient amount of time needed to reduce the deficits. This is entirely different than send me more money and we hope we can convince enough to serve where needed.

Those accepting the commitment must be prepared to use all of their training to prepare for such a career. A career as a health professional is substantially individual in implementation. Each day of training for years must prepare for an 8 year or longer commitment to serve where the obligation indicates. Failure to do this will result in loss of the ability to practice medicine. Those entering should not even consider an option to buy out this obligation.

If you sign on to become a physician under this plan, you will honor this commitment. If you are not sure about this, go elsewhere. If you fail to honor this contract at any time, you will pay the entire cost of training a replacement. This is not a penalty. This is entirely about health access for people in need of health access. You will provide health access or you will pay for another in your place or you will not practice medicine. The intent of this program is an entire lifetime served as much as possible on the front lines delivering basic health services to those most in need of services.
Choose as a condition of admission to become a family physician remaining instate for 15 years at your choice of practice in all zip codes except the most saturated with primary care (increasing the instate primary care workforce maximally due to top retention in primary care and highest probability of remaining in primary care and highest probability of remaining instate in primary care, especially after 23 years or more of instate life experiences including all training and practice experiences).
Choose as a condition of admission to become a family physician serving where needed for at least 8 years in a zip code that has insufficient primary care (all but 4% of the land area with top saturations, serving where 53% of family physicians are found already).
Choose as a condition of admission to become part of the surgical workforce in this state where needed in a rural area for at least 8 years serving in general surgery, general ob-gyn, or another general career. (area short of surgical workforce but able to sustain such workforce, definitely not in 3400 zip codes with top concentrations where 75 - 80% of such workforce is found, but not in the smallest locations where such workforce cannot be sustained).
Choose as a condition of admission to become a mental health professional remaining instate in a needed location for at least 8 – 10 years. (any child psychiatrist, psychiatrist in small urban or rural area, just not a psychiatrist in a location in 4% of the land area with top workforce saturations).
Your training will involve as much time as possible spent in a health access location (preferred method will be entirely health access in location in a continuity team) working with health access physicians as clinician-faculty. You will not be spending your time living in places with top concentrations of physicians and training in such places. Your training will be active not passive. Your training will be clinician specific, not basic science and research in focus. Even the purpose of your training is to facilitate more and better health care services where needed. You will become an active part of the local health care team.

You will recruit the next generation of health access professionals and you will train the next generation – inherent in the design. You will facilitate health access before admission, during training, and after training by design.
Your best preparation to gain admission is to demonstrate that you are interested in becoming a servant clinician. You must demonstrate at least adequate academics but your people skills and patient care skills must be consistently superior. Those who have already served on the front lines as part of a basic health access team will have preference in admission.You must be aware of the health needs of those you will serve or you must become aware of these needs before graduation. You should choose carefully as your commitment involves the next 14 – 18 years of your life. This will also include consideration of those closest to you in life. Those connected to you will need to be willing to make the same commitment.
You should not worry about being taken advantage of during your obligation. Sites that even appear to take you for granted will lose your services and the services of any obligated physicians for a period of years in duration with a period of probation to follow afterward.
Communities, practices, hospitals, and others who employ obligated physicians will do all possible to take good care of the servant clinicians on the front line – something America has failed to do for teachers, nurses, primary care, public health, and basic health access professionals for quite some time.
The above example is a state design specific to physicians. Designs can also be set up for any health professional for primary care associations, for all Community Health Centers, for predominantly African American or Hispanic or Native American or low income counties that are rural counties, or a similar population. The more specific populations will need the most specific commitments and results as this is a design that begins before training and extends until retirement - anchored by commitment alone.
How can we get more primary care physicians to practice in rural America?
The above program design takes care of primary care physicians in more than rural America. The design is specific for rural and urban populations left behind in primary care as well as basic health services in women’s health and surgical care and mental health. This is not about just primary care or just about rural America. This is about the basic health services needed by 65% of Americans.
Japan has a design for front line health access workforce in rural areas. The design has worked for 40 years and is being expanded. Such a design that results in specific workforce needs being met indicates what the United States should do to be specific.
What are the barriers to implementing these changes?
The barriers are quite simple. Most Americans suffer in silence under failed designs. To address their basic health needs, the United States must have designs that are Specific, Measurable, Achievable, Realistic, and Timely.
The barriers are lack of awareness and lack of understanding of what works and has worked for 40 years. The barriers are designs that result in specific gain for a few with consequences for those left behind.
The long term commitment extending from before training and encompassing all training and extending after training is the only design that is SMART. All other designs result in the funding, emphasis, faculty, training, or other components benefiting someone else. Rather than increasing the funding before training, at each year of training, for recruitment, for retention, and for locums and their brokers, the United States must have an efficient and effective design – a SMART design.
Thanksgiving is over. We should indeed be thankful for what we have in health care - but so should most Americans not just a few.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at and he is the author of the World of Rural Medical Education, and Physician Workforce Studies


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