There were 13 doctors in my internal medicine residency class. We produced 2 cardiologists, 2 oncologists, 2 nephrologists, 2 gastroenterologists, a pulmonologist, a rheumatologist, and an infectious disease specialist. Amazingly, there were 2 that stayed in general internal medicine.

Many general internists who do not specialize now are becoming hospitalists. It may only be a matter of time before it becomes its own recognized sub-specialty. The days of the internist working as a primary care physician in the office setting appear to be ending.

The number of medical school graduates choosing primary care specialties (internal medicine, family medicine, pediatrics) has been falling for some time now. This is complicated by the facts that physicians are aging and by 2020 we are projected to be producing only 5 doctors per 100K of population.

There are studies that show primary care physicians can save the system money. Primary care physicians often know their patients better and can make decisions that are tougher to make in acute settings. Acute problems decrease in frequency with good primary care as well.

Reasons that students go into specialties go well beyond money. Still, it is hard to ignore the money factor when 75% of students graduate with over $100K in debt.

Specialists are trained to be zebra hunters when a horse cannot be found. They do more extensive work-ups. If you take the primary care physician out of the equation you get far more zebra hunts. It is expensive to hunt zebras.

The other problem with zebra hunts is that all the horses hanging around tend to get ignored.

A savvy primary care doctor is needed as a gatekeeper instead of a scope jockey stomach dude. Of course, either is better than some pinhead running a phone in an insurance or government office. So how do we do it?

Routine annual visits need to be reimbursed at a premium. Capitation has been used to try and address the issue but it has frustrated physicians and actually can encourage witholding necessary care. A better option is a “gatekeeper fee” where a primary care doctor would be given an annual fee not subject to penalties. The AAFP has put forth similar ideas in the past.

Another thing to do is to rework the coding system and give the primaries higher reimbursement for visits. The justification would be overhead and the money saved with excellent primary care.

Insurance programs should also be encouraged to have patients see a primary care physician regularly. Depending on age, a routine visit should be covered at 100% at least every 1-3 years. This is a mandate that would make sense. It increases the chances of problems getting caught, be a nice revenue producer for the primary, promotes health, and would save money over the long term.

Primary care physicians should not have to see a patient every 10 minutes. If they are going to be gatekeepers, they need time to make the decisions. One way to help is to use physician’s assistants and nurse practitioners to extend their abilities. The magnitude of the role of extenders is a debate in itself which is a topic for another day.

Registered nurses, nutritionists, and other professionals should also be utilized at the primary care level. There needs to be better ways for these services to be reimbursed so it can be offered with greater ease. The burden relief on the physician could be substantial.

Medical students need better exposure to the primary care setting. Students still get more exposure to inpatient medicine and complex cases. The exposure to the basics is often with residents that want to rush back and handle inpatient issues.

The rise of hospitalists has allowed many primary care physicians to have more regular hours. Students should be exposed to this reality. There also could be a role for primary care residencies and rotations that almost completely ignore the inpatient side. Primary care needs to be attractive in both pay and lifestyle.

Changes have been made over the years and it is improving but the numbers still show the system is not peaking interest.

There are things being done now such as loan forgiveness and other incentives for choosing primary care. The problem is no amount of incentive is going to help if primary care remains substantially lower paid and unattractive in other ways.

We need other changes to keep primary care physicians in control.

There need to be rules to keep a patient from becoming a “pinball.” If a patient is referred to specialist and needs another specialist the primary care physician should be in the loop. Sometimes patients can bounce around for a year or two before circling back to primary care.

Specialists need to return cases to the primary care system. There are hospital patients that may have avoided admission had had a primary care physician. It is a problem with insured patients even more than with the uninsured. All patients should be steered a primary care physician in these cases.

Public education is a necessity. Too many patients do not have faith in the primary care system. This is a big difference between the US and the rest of the world. Patients want to see the specialist for every problem. The expectations need to change. There are some exceptions like the management of a complex disease but even then the primary care doctor should still help manage other issues.

The list of things that may help to improve the primary care situation is extensive. There are a few things in the present bill that might help and some that might hurt.

You can put together a great game plan but if you do not have a point guard, it may not matter.

Primary care doctors are the point guards. Investing in them will pay dividends and save the system money.

(I have a brother who was a point guard and is a family medicine physician so this analogy was switched from basketball from football for him)

If we do not fix the impending primary care crisis, no reform program has a chance.