With many rural and inner-city locales already suffering from severe physician shortages, the gap between the supply of and demand for primary care physicians in the United States will likely exceed 50,000 and could reach 200,000 by 2020, according to various estimates—unless medical schools can produce more graduates who pursue family medicine, general internal medicine and general pediatrics.

"Many medical schools state that they are committed to the goal of more primary care physicians," notes Kenneth J. Veit, DO, the senior vice president for academic affairs and dean of the Philadelphia College of Osteopathic Medicine (PCOM).

Because of its traditional focus on primary care, the osteopathic medical profession can stand at the forefront of alleviating the physician shortfall by opening new schools in underserved areas and by expanding class sizes, Dr. Veit says. But first, he insists, the profession needs to rekindle student interest in primary care and line up enough high-quality training sites to prepare future primary care physicians.

While a greater percentage of DO graduates compared with MD graduates choose careers in primary care, osteopathic medical graduates increasingly select non-primary-care specialties. Between 1998 and 2006, the proportion of DO graduates planning to practice family medicine and internal medicine declined from 47% to 37%, according to the American Association of Colleges of Osteopathic Medicine (AACOM), which annually surveys fourth-year osteopathic medical students on their career plans. During the same period, the proportion of MD graduates intending to practice family medicine and internal medicine dropped from 34% to 25%, notes Tyler C. Cymet, DO, AACOM's associate vice president for medical education, citing unpublished data from the Association of American Medical Colleges.

Measuring the need for and declining numbers of primary care physicians is difficult because primary care is not well-defined, Dr. Veit maintains.

"We normally think of primary care as a patient's first contact with the health care system, including a certain level of comprehensiveness and continuity of care," he says. "The primary care physician is the doctor you think about calling when you're not feeling well or when your children are not feeling well. It might be a family physician, a general internist or a pediatrician.

"However, many women of child-bearing age use their obstetricians and gynecologists as primary care physicians. On the other hand, some family physicians today specialize in sports medicine and pain management and might not really be delivering primary care."

While the exact number of graduates going into primary care may be impossible to determine, osteopathic medical educators tend to agree that student interest in primary care has noticeably waned.

A number of osteopathic medical schools have intensified their efforts both to recruit students who will likely practice in primary care specialties and to keep those students interested in primary care during their training. While some schools emphasize primary care throughout their curricula, others have established special programs just for students interested in primary care or rural medicine.

Altering perceptions

"Encouraging students to enter primary care is getting harder all the time," emphasizes Kendall Reed, DO, the dean of the Des Moines (Iowa) University—College of Osteopathic Medicine (DMU-COM).

Dr. Reed contends that lower reimbursement for primary care services is the main reason more students are going into non-primary-care specialties. "There is such a discrepancy in pay between primary care physicians and specialists," he notes. "On average, primary care physicians make 40% to 50% of what specialists make."

Paul Evans, DO, the dean and chief academic officer of Georgia Campus-PCOM (GA-PCOM), agrees that reimbursement is a major motive for not entering primary care. "Family physicians make $155,000 on average, while urologists, for example, make $350,000 to $400,000 on average," he points out. "Primary care physician incomes have remained stagnant."

With DO graduates shouldering an average student-loan debt of more than $160,000, many students believe they cannot afford careers in primary care medicine, Dr. Evans adds.

But money isn't the only influencing factor, Dr. Veit insists, noting that prestige is also important. Medical schools need to convince students that primary care is intellectually stimulating, as well as emotionally fulfilling, and pivotal to reforming the U.S. health care system, he says.

"We need to show students all that primary care involves," Dr. Veit explains. "Primary care is not just about humanistic values. It's about evidence-based medicine. It's about implementing electronic health records to better care for patients and better manage populations of patients who have chronic conditions, such as diabetes mellitus and cardiovascular disease."

Dr. Veit notes that among medical students, "primary care was hot" 25 years ago, when managed care organizations promised to be the future of health care.

"The medical community expected that anesthesiologists and other specialists would have to retrain," Dr. Veit recounts. "But that didn't happen because of the public's reaction. Patients said, 'I don't want to have to go to a gatekeeper primary care physician to get to see a specialist.' "

But now as the U.S. Congress and President Barack Obama's administration weigh health care-reform proposals, primary care is once again taking center stage. A number of health care-reform stakeholders, including the AOA, agree that the best way to both improve health care quality and reduce costs is to adopt the patient-centered medical home model of care. In this team approach to care, primary care physicians establish personal relationships with each of their patients and coordinate care with all needed medical specialists and nonphysician clinicians.

The proposed America's Affordable Health Choices Act of 2009, currently the leading health care-reform bill under consideration in Congress, contains several provisions that would benefit primary care physicians, including the establishment of medical-home pilot projects.

"The patient-centered medical home concept offers a ray of hope for primary care," Dr. Reed observes. Ideally, under this approach to care, a primary care physician would not have to see 30 to 40 patients in a day to make a good living, he explains. Instead, the physician could see just eight to 10 patients a day, spending more time with each patient, while other members of the medical home team—such as physician assistants, advanced nurse practitioners, registered nurses, physical therapists and psychologists—would provide quality ancillary care under the physician's supervision.

1. Daniel Good

   July 2, 2009, 2009, at 11:12 a.m.

   Dear Sirs,

   I am retired after 35 yers in State and Lcal Law Enforcement.
   I have a B.A. From The University Of South Carolina
   I volunteer at the VA Hospital.
   I want to Obtain a Certificate in D.O. ,bcome a D.O. or a PA.
   I am 61 .

   Can I fulfill My Desires Or I Just Dreaming?

   Thanks, Dan Good

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