I have been hearing a lot regarding this. Is Family medicine really a dying field? I have heard that nurse practitioners and physician assistant are going to take over the jobs of family physicians. Is that true?
I have been hearing a lot regarding this. Is Family medicine really a dying field? I have heard that nurse practitioners and physician assistant are going to take over the jobs of family physicians. Is that true?
Ten Biggest Myths Regarding Primary Care in the Future
Introduction: This article is by Robert Bowman, MD, of the AT Still College of Osteopathic Medicine in Mesa, AZ. Dr. Bowman is a long time scholar of primary care and rural health workforce issues. He identifies and comments upon 2 important workforce concepts. The first is primary care forms of training, which include 3 physician forms (family medicine, general internal medicine, and general pediatrics), and primary care nurse practitioners and physicians assistants. The second is the Standard Primary Care (SPC) year, which allows us to look at the success of the different forms in terms of how many SPC years they provide per graduate. This takes into account the percentage of graduates who enter primary care, the portion of their practice that is primary care, at what rate they leave primary care for another area, the number of years they practice, and the percent time (part time/full time) they practice. Thus if a form of training has 100% of graduates entering primary care who practice full-time for an average of 35 years with 100% primary care practice, that form would produce 35 SPC years per graduate. If another form had only 50% of its graduates entering primary care, who averaged 50% primary care practice, practiced for an average of 20 years with an average of 75% FTE, that form would produce an average of only 3.75 SPC years per graduate (do the arithmetic: 20 years x 75% FTE x 50% of grads in primary care x 50% of practice is primary care). This is important in comparing projections one cant just say, for example nurse practitioners will take care of our primary care needs without doing such a calculation.
Myth Number 1: Primary Care has collapsed. Primary care internal medicine has collapsed with lowest production and lowest primary care retention levels. Those associated with internal medicine primary care perceive collapse. But primary care remains. Existing dedicated primary care practitioners continue to deliver primary care despite insufficient support. There are 5 training sources of primary care. Some are remaining steady and some are dropping. The ideal primary care provider would contribute 35 Standard Primary Care (SPC) years: a 35 years career, actively in practice 100% of those years, and 100% remaining in primary care and 100% or top volume of primary care. Among the 5 forms of primary care training, family medicine remains steady in primary care with over 25 Standard Primary Care (SPC) years per graduate. Pediatrics is also steady, but with only 16 SPC years per graduate. The other 3 forms have more graduates who are inactive or part-time, have fewer years in a career, retain a lower percent of graduates in primary care (retention), and have a lower volume of primary care. They thus make limited contributions with fewer SPC years per graduate. Internal medicine, nurse practitioner, and physician assistant forms have declined to less than 4 SPC years per program graduate. Collapse of primary care is found for forms that depart primary care during training, at graduation, and each year after graduation under the assault of poor primary care support. [1]
Myth Number 2: Nurse practitioners will take over more primary care duties. Nurse practitioners will continue to supply less than 12% of the primary care supplied by the five primary care training forms using past measures as well as future estimates.[1, 2] Increasing departures to hospital and specialty careers, lowest activity (inactive, part time), lowest volume of primary care, and greatest delays in entering primary care limit nurse practitioner primary care contributions.
Myth Number 3: Physician assistants will take over more primary care duties. Less than 30% of new physician assistants enter primary care and active physician assistants will dip below this level in the next 3 years.[3] Physician assistants will continue to supply less than 12% of the primary care supplied by the five training forms. Increasing departures to emergency medicine and subspecialty careers, lower activity (inactive, part time), and lower volume of primary care limit physician assistant primary care contributions.
Only if physician assistants or nurse practitioners were required to stay in the family practice mode of care would they be able to increase share of primary care, rural primary care, and underserved primary care duties.
Myth Number 4: Internal medicine graduates from international medical schools will make significant primary care contributions. Internal medicine residency program graduates from foreign origins and international medical schools will contribute the fewest years of primary care averaging 1.3 SPC years per graduate. The limitations are substantial with lowest primary care retention after graduation, loss of 8 years due to delayed entry into the United States workforce, and losses after graduation including 20% departing the United States for home nations, 8% chronic unemployment, and increasing fractions departing for other nations.[4, 5] Lowest primary care also means lowest rural primary care and underserved primary care. A family practice residency graduate contributes greater than 30 times the rural or underserved primary care per graduate. Changes in the J-1 Visa waiver program and increasing uses of international graduates by the military and teaching hospitals will further limit primary care, rural, and underserved contributions.
Myth Number 5: The United States is unable to produce enough primary care. Through policy, medical education efforts, and statewide efforts, the US has been consistently successful. The US was able to quadruple primary care graduates in the 1970s. The US increased primary care production 50% during the span of a few years in the 1990s. Historically Black, osteopathic, and many allopathic public schools have been successful for over 100 years. Primary care contributions are maximized when schools and states focus together on health access in birth to admission preparation, admission preferences, training curricula/faculty/locations, and health policy.[6]
To sum up: the only way that the United States can fail to produce primary care is to admit the most exclusive students (lowest probability primary care), train in locations with the least health access emphasis (lowest influence), fail to graduate enough family physicians (permanent form), and create a health policy that rewards the most exclusive careers and locations. This, of course, is exactly how US health care is structured.
Myth Number 6: Generic expansions of medical school, nurse practitioner, or physician assistant graduates can increase primary care. During the current time period with the worst health access policy in decades, fewer students are choosing primary care and those that can move away from primary care are leaving. Osteopathic (DO) graduates will more than double from 2004 to 2017 but, with the current steady declines in family practice percentages, the end result will be only a gain of 100 more family physicians or a 20% increase despite a 100% increase in graduates. With primary care retention rates dropping steadily at 1 or 2 percentage points each year in the large and growing nurse practitioner and physician assistant pools (over 230,000 combined), new graduates entering the workforce in primary care are not able to keep up with losses of active primary care plus departures from active practice. Only specific expansions of family practitioners that remain in the family practice mode (physicians, nurse practitioners, and physician assistants) can address primary care and health access needs. Retention in the family practice mode is much less likely for NPs and PAs since they can and do depart the family practice mode at any time.
Myth Number 7: Nurse practitioners make substantial rural primary care contributions. Rural primary care requires both rural location and primary care contributions. While 20-25% of nurse practitioners are rural, they do not have the primary care component. Nurse practitioners contribute 1 rural Standard Primary Care year per graduate (4 SPC years times 25% rural) in rural workforce whereas family physicians contribute 5 Standard Primary Care years per graduate (25 SPC years x 20%) in rural locations.
Myth Number 8: Primary care is not marketable to the American consumer.[2, 7, 8] It is very hard to understand how respected authorities in leadership positions could make such statements. Only a severe lack of awareness explains their comments. Workforce experts, trainers and educators in major medical centers and medical schools, leaders in the Council of Graduate Medical Education and the Association of American Medical Colleges all live in areas with the highest concentrations of people, physicians, and medical schools. These experts have spent their entire lives in locations that employ the fewest primary care physicians and support primary care at the lowest levels. They have tolerated the training of medical students and residents in dysfunctional primary care settings.[9] It is not surprising that primary care does not appear marketable to those clustered in the 3,300 US zip codes which make up 4% of the land area with 75% of physicians and 95% of medical schools. This limited perspective ignores the 38,000 zip codes in which 65% of the American population and 70% of the elderly are cared for by the remaining 23% of total physicians. In these locations, 30 100% of the total physicians are primary care physicians.
The total elimination of health care for millions is unconscionable and this is what is suggested by the statement that primary care is not marketable. The locations that depend upon primary care are also locations that offer better primary care salaries, better primary care support, better practice options to generate more revenue, lower costs of delivering health care, and lower costs of living. Those designing health care for an entire nation must place much more emphasis on care for the 65% of the population left out of the current health care design. All of medicine and medical education will pay dearly for the choices of a few leaders. Current leaders appear to have abandoned Butlers call to a season of accountability and social responsibility for medical education.[10 ]
Myth Number 9: The nation needs more pediatric graduates to meet primary care needs. More pediatric graduates will not meet primary care needs. According to pediatric leadership, pediatric primary care is saturated in the locations where pediatricians choose to locate, at the same time that the United States has fewer children. Even though 15% of white female medical students remain committed to pediatric residency choices, they and other pediatric graduates will compete with all other primary care graduates already delivering pediatric primary care. This is likely to result in more practicing in part time, specialty, hospital, urgent, and emergent pediatric care settings.[11]
Myth Number 10: Care for Age 65 and Up Will Be Provided By Geriatric Specialists. Geriatricians are a small fraction of new physicians, they are less likely to be found in locations with concentrations of older Americans, they have limited support, they have lower volume of patients, and they have some of the most complex patients. Older patients move toward locations with lower costs of living and health care and they move away from concentrations of internal medicine physicians, geriatricians, geriatric training programs, stroke centers, and heart attack centers.[12] They move steadily toward locations served predominantly by family physicians.
National studies confirm patterns of care for the elderly and for all seeking ambulatory care in the United States in 2004. About 62.5% of age 65 and older patients saw a family physician compared to internists for 29%, and somewhat less than 19% seeing a nurse practitioner.[2] This is not what numbers of graduates predict since both internal medicine graduates and nurse practitioner graduates are about twice the number of family practice graduates. In 2004 family physicians led in all but one ambulatory category. In addition to seniors, family physicians were seen by 43.4% of adults seeking care, and 39% seeking womens health care. The family physician share of 20% was second to pediatricians although family physician percentages increased for children over age 4 and for the 65% of the population beyond concentrations of pediatricians.[2] This is why increased family physicians can address pediatric care needs while more pediatricians cannot.
Myths persist unless they are compared to reality. Primary care must be measured according to a standard and the standard is set by forms of primary care training that produce providers who remain for 35 years of a career, who continue to provide primary care, who remain in the wide range of most needed locations, who continue to serve the populations most in need of care, and who continue to do so whether the current policy era is supportive or unsupportive of primary care. For physicians, nurse practitioners, and physician assistants, the standard is set by those that remain in the mode of care known as family practice.
1. Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural Remote Health. Jul-Sep 2008;8(3).
2. Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.
3. American Academy of Physician Assistants. Data and Statistics. http://www.aapa.org/research/index.html. Accessed October 26, 2006, 2006.
4. International Medical Graduate Section of the American Medical Association. Report on International Medical Graduates. Chicago 2007.
5. Quick Views. J-1 Waivers on the Decline. amednews.com. January 22, 2007.
6. Bruce TA, W.R. N. Improving Rural Health. Little Rock, Arkansas: Rose Publishing Company; 1984.
7. Philibert I. An interview with Carl Getto, MD. ACGME Bulletin. 2004;Spring:10-11.
8. Salsberg E. Physician Workforce Policy Guidelines for the U.S. for 20002020. Presented to the Council on Graduate Medical Education. Bethesda, MD. September 1718, 2003.
9. Keirns CC, Bosk CL. Perspective: the unintended consequences of training residents in dysfunctional outpatient settings. Acad Med. May 2008;83(5):498-502.
10. Butler WT. Academic medicine's season of accountability and social responsibility. Acad Med. Feb 1992;67(2):68-73.
11. Committee on Pediatric Workforce. Pediatrician workforce statement. Pediatrics. Jul 2005;116(1):263-269.
12. Perrotta BL, Perrotta AL. Access to state-of-the-art healthcare: a missing dynamic in consumer selection of a retirement community. J Am Osteopath Assoc. Jun 2008;108(6):297-305.
Appreciate the article. The SPC calculations are really interesting. The acceleration (velocity of the velocity) of midlevels may lead one to believe a future closer to present day anesthesia. I am not making a prediction but I don't feel confident about anything.
Not to be a stickler, but acceleration is the change in velocity per unit time....
agree- I regularly receive job announcements for rural positions. 2 of my current 3 jobs are at rural/critical access hospitals, the other is at a small inner city facility.the future is in RURAL MEDICINE. I know for myself there is nothing very enticing about urban or suburban medicine. I have much more fun practicing rurally and feel truly needed there. Now add in relocation and loan repayment and I am so there....
I think you should confirm before making assumptions. I am a resident pathologist and will be starting my residency in July. I applied to internal medicine and pathology but i got matched to pathology. I like family medicine because of its diversity and outpatient medicine but i did not apply because i was told about its poor job prospects. If you did not like my thread you should just refrain from posting.I am not convinced that most if not all these dramatic threads where supposed students interested in FM are concerned that "FM is DYING!!!" are not really just trolling by dumb bored medical students who have no interest in pursuing general medicine. After all FM is a specialty that is probably the most in demand specialty there is right now based on recruiting. I don't see why these threads aren't just deleted by the moderator. They contribute nothing and are completely inane.
I think you should confirm before making assumptions. I am a resident pathologist and will be starting my residency in July. I applied to internal medicine and pathology but i got matched to pathology. I like family medicine because of its diversity and outpatient medicine but i did not apply because i was told about its poor job prospects. If you did not like my thread you should just refrain from posting.
Yeah, I have also heard about poor job prospects of pathology but I did not know that beforehand otherwise I might have tried to avoid it . But I guess after doing 2-3 fellowships one is able to get some kind of job in pathology. Same goes for family medicine. I do not think that family medicine is going to die any time soon. They will continue to work in rural ares.Here's a funny twist:
I love pathology but won't apply because I have read how dismal the job prospects are. Also I need more patient contact but pathology would serve me well as a medical educator down the line. I'm just trying to learn as much as I go 🙂
I wish you the very best in residency. Hope you find your niche and land a job somewhere that makes you happy.
As for the asinine comment about bad medicine = job security above (not yours!), I've been a PA for 13 years and grew up in lab medicine before that. MedicineDoc, you should use those situations as teachable moments--likely that PA didn't understand what "failed outpatient treatment" meant (or more likely her lazy supervising physician said "just admit her"...happened to me more times than I can count). We all get better with experience. As for the multiple K-sparing drugs and supplemental K, well, that's just bad pharmacology and a weak/defective knowledge base. You won't find that in most PAs because we have very standardized pharm education requirements. NPs do not.
Yeah, I have also heard about poor job prospects of pathology but I did not know that beforehand otherwise I might have tried to avoid it . But I guess after doing 2-3 fellowships one is able to get some kind of job in pathology. Same goes for family medicine. I do not think that family medicine is going to die any time soon. They will continue to work in rural ares.
Yeah, I have also heard about poor job prospects of pathology but I did not know that beforehand otherwise I might have tried to avoid it . But I guess after doing 2-3 fellowships one is able to get some kind of job in pathology. Same goes for family medicine. I do not think that family medicine is going to die any time soon. They will continue to work in rural ares.
Current evidence is mixed regarding actual primary care production for NPs and PAs. RWJ will make you believe their contribution towards the primary care workforce is exploding. So do deans at medical schools publishing "50+ percent of their graduating class entering primary care." It's all fluff. Other sources are showing that NPs are specializing at rates approaching medical student/resident sub-specialization rates.(I am posting for my own interest and not making a specific point.)
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source: http://www.amednews.com/article/20120702/business/307029951/6/
"The nurse practitioner population will nearly double by 2025, according to an analysis published in the July Medical Care, the official journal of the medical care section of the American Public Health Assn.
"Nurse practitioners really are becoming a growing presence, particularly in primary care," said David I. Auerbach, PhD, the author and a health economist at RAND Corp.
Auerbach used modeling to project that the count of those trained as nurse practitioners would increase 94% from 128,000 in 2008 to 244,000 in 2025. The subgroup of those providing patient care as nurse practitioners, rather than filling administrative or other roles, will rise 130% from 86,000 in 2008 to 198,000 in 2025."
"According to the annual census by the American Academy of Physician Assistants, 40,469 physician assistants were practicing in 2000, and that number went up 106% to 83,466 in 2010."
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source: http://www.kevinmd.com/blog/2013/04/match-day-primary-care-aftermath-deans-lie-continues.html
"only about 20-25% of internal medicine residents remain in primary care (this is from the American College of Physicians, confirmed by a JAMA study 2012;308(21):2241-2247, down from over 50% in 1998). Internal medicine residencies should not be considered primary care residencies if an overwhelming majority do not practice primary care."
But "it's DYING!!!!" Are you INSANE!!!!!
As I recall the FM NBME clerkship exam was the most comprehensive detailed and time consuming NBME clerkship exam to study for in medical school. Too smart for family medicine was not the general consensus of my medical school class after taking the NBME clerkship test.
I think you should confirm before making assumptions. I am a resident pathologist and will be starting my residency in July. I applied to internal medicine and pathology but i got matched to pathology. I like family medicine because of its diversity and outpatient medicine but i did not apply because i was told about its poor job prospects. If you did not like my thread you should just refrain from posting.
I like family medicine because of its diversity and outpatient medicine but i did not apply because i was told about its poor job prospects.
The demand for family physicians continues to outstrip demand for other physician specialties and subspecialties, making family physicians the most sought-after physician group in terms of recruitment and retention.
Primary care physicians remain at the top of the wish list for most hospitals, medical groups and other healthcare organizations. For the seventh consecutive year, two types of primary care physicians family physicians and general internists were Merritt Hawkins two most requested physician search assignments.
I do not think that family medicine is going to die any time soon. They will continue to work in rural ares.
Man I asked a question .. I am sorry if my question offended you .. I am an IMG I did not take any nbme clerkship exams. But I must say that FM forum is optimistic about the future of FM. Pathology forum is so gloomy as if pathology is going to die soon. That is why I asked this question ... I might want to switch my residency. I am an IMG with good board scores but failed CS so I know it will be difficult to do that. Still I might want to try it.But "it's DYING!!!!" Are you INSANE!!!!!
As I recall the FM NBME clerkship exam was the most comprehensive detailed and time consuming NBME clerkship exam to study for in medical school. Too smart for family medicine was not the general consensus of my medical school class after taking the NBME clerkship test.
Why stick to path forum only. I might want to switch to FM next year. Also family medicine forums are not your personal property. You sound like you own it.you "got matched" huh? nice. stick to the path forums then.
as for the others with interest in any field... don't let fear be your guide.
Yeah you are right I accept my mistake. I agree that family medicine docs will continue to work both in urban and rural settings.80% of the US population lives in urban areas.
http://www.fhwa.dot.gov/planning/census_issues/archives/metropolitan_planning/cps2k.cfm
The chronic disease burden is increasing worldwide.
http://www.who.int/nutrition/topics/2_background/en/
See the post above this re: recruiting data. Family physicians will have job security for the forseeable future, regardless of location.
Man I am an IMG. I failed my CS. I thought I would never match. I applied to match without even passing CS. I like family medicine because of outpatient medicine and diversity. But I thought given my failed CS I would never get into it. I got 5 pathology interviews and 2 internal medicine interviews. Now I think I should have applied to family medicine too...I might have got a few interviews.You should choose your sources more carefully.
http://www.aafp.org/online/en/home/...ofessional-issues/20110817merritthawkins.html
http://www.merritthawkins.com/uploadedfiles/merritthawkins/pdf/mha2012survpreview.pdf
Man I am an IMG. I failed my CS. I thought I would never match. I applied to match without even passing CS. I like family medicine because of outpatient medicine and diversity. But I thought given my failed CS I would never get into it. I got 5 pathology interviews and 2 internal medicine interviews. Now I think I should have applied to family medicine too...I might have got a few interviews.
Yeah I am getting defensive. I did not want to apply to match. I thought I would never pass CS let alone get residency. My family pushed me to apply for match. Not only that I passed my CS but also I got the residency at a university pathology program. But now I hear that pathology job market is really bad. I don't know if that is true but this is what SDN projects. But I guess even if I am not able to find a job in USA after residency and fellowship which I think is unlikely I can always go back to my home country and work there as a pathologist. I think I will be able to find a job there.Maybe you can switch into it? If its really more interesting don't settle for something less interesting to you unless you don't have a choice. Probably fewer barriers for you now that you matched too. Seems like you keep trying to get defensive and rationalize the choice you made with path.
Yeah I am getting defensive. I did not want to apply to match. I thought I would never pass CS let alone get residency. My family pushed me to apply for match. Not only that I passed my CS but also I got the residency at a university pathology program. But now I hear that pathology job market is really bad. I don't know if that is true but this is what SDN projects. But I guess even if I am not able to find a job in USA after residency and fellowship which I think is unlikely I can always go back to my home country and work there as a pathologist. I think I will be able to find a job there.
in path you will get a solid amount of money for a very easy going schedule, you wont have to bear with many bs.
in path you will get a solid amount of money for a very easy going schedule, you wont have to bear with many bs.
cons- it is pretty much like an office job. You either see parts of people or dead people.
So I am out and about doing my locum thing in Nevada currently as the urgent care overflow/walk-in's provider. I tell you I get asked EVERY DAY if I would consider staying on permanent. I say "no" for personal reasons mostly and lack of close airport since my family doesn't want to move anymore.
Just got off the phone on an interview for the next locum job in Oregon. Was asked if I would consider staying on permanent before the converstation was even over.
Family Practice is HOT right now due to the versatility and huge need all over the country. I don't see it dying anytime soon. There is plenty of work out there. You can pay your bills no problem.😎
Elko, they are desperate for a perm provider.
Elko, they are desperate for a perm provider.
Wow...even hair stylists don't want to live there? 😉
Slightly off topic -- how are the FM prospects for those of us who have no desire to do any inpatient work?
I'm so-so at it but my exposure has been a large, county, safety-net hospital rather rather than a community hospital setting meaning I've often been told that I'll never see patents this sick again as an FM doc....
either way, I have no desire to do inpatient work.
What's it look like?
Cabin,
For a locums FM doc like yourself, what is the reasonable upper limit income for a person willing to work 60 hrs per week?
thanx
😎
Slightly off topic -- how are the FM prospects for those of us who have no desire to do any inpatient work?
I'm so-so at it but my exposure has been a large, county, safety-net hospital rather rather than a community hospital setting meaning I've often been told that I'll never see patents this sick again as an FM doc....
either way, I have no desire to do inpatient work.
What's it look like?
Most clinic jobs do not require inpatient. You just don't have time for that anymore, especially in a busy practice. Inpatient is generally smaller, more rural hospitals. No issue not doing inpatient.
Does it not pay better? (Inpatient only vs. outpatient)
So I am out and about doing my locum thing in Nevada currently as the urgent care overflow/walk-in's provider. I tell you I get asked EVERY DAY if I would consider staying on permanent. I say "no" for personal reasons mostly and lack of close airport since my family doesn't want to move anymore.
Just got off the phone on an interview for the next locum job in Oregon. Was asked if I would consider staying on permanent before the converstation was even over.
Family Practice is HOT right now due to the versatility and huge need all over the country. I don't see it dying anytime soon. There is plenty of work out there. You can pay your bills no problem.😎