The Next Health Care Crisis

Medium. Duke University. April 16, 2020. By Spencer Chang.

While the COVID-19 pandemic has much of the world focused on emergency and ICU medicine — rightly so, there is another crisis that will impact our health care system that we can’t take our eye off of — a shortage of primary care physicians (PCPs). As fewer medical students choose primary care, Americans will be left with even fewer PCPs to look after them, and a surplus of subspecialists in the health care system. The Association of American Medical Colleges predicts a shortage of up to 55,000 primary care physicians by 2032, even as a growing number of baby boomers and increasing obesity rates prompt an expanding need for them. It is known that states with a higher ratio of primary care physicians have better health and lower rates of mortality. Patients who regularly see a primary care physician also have lower health costs than those without one. So why aren’t more medical students going into primary care?

In my view, a big piece of the problem stems form the culture of medical school training.

I can’t remember how many times I’ve been told “good for you” or “well, somebody has to do it” after saying that I’m in Duke’s Primary Care Leadership Track (PCLT). At many medical schools, there is a strong emphasis on lucrative subspecialty fields. From day one, lectures emphasize specialization. As students go through medical school and accrue an increasing amount of debt, there also becomes a subconscious push to pursue a more lucrative field.

Primary care is often painted as a pathway for those who were not overachievers or who failed to get the highest board scores. This is wholly inaccurate, just looking at all of my overachieving peers in the PCLT program. This is why specific tracks dedicated to primary care are essential in medical training.

As a first-generation Asian American, first-generation college student, and the first physician in the family, I even feel a pressure that stems from racial, cultural, and socioeconomic principles of what is perceived as a “prestigious” career path. “Why not neurosurgery or cardiology?” is a question I even defend with my own family. The perception that choosing primary care is a compromise permeates both in the medical and non-medical realms.

I have no regrets in my decision to pursue primary care. Being a part of Duke’s PCLT program, I had firsthand exposure to the challenges and rewards of being a PCP. I look forward to being a doctor for 30 years or more for hundreds to thousands of patients. It is truly a privilege to develop those longitudinal relationships and play such an integral role in patient lives. Now being only a few months away from starting my Internal Medicine residency, I am most looking forward to finally becoming a PCP for my very own panel of patients.

PCPs are at the centerpiece of health care. With a shortage of PCPs that continues to grow, we face the impending issue of an inefficient health care system that further increases the disparity in access to health for marginalized patient populations.

Medicine needs a culture shift so the pursuit of general medicine is the norm, and nobody feels discouraged from making this choice. More specialized niches of primary care tracks like Duke’s PCLT program can help protect trainees from becoming jaded and losing sight of their long-term goals in primary care. Financial incentives for primary care trainees is crucial, but it is important that this carries through from the bottom to top. There must be a shift in graduate medical education and our training system as a whole that is more equitable and reflective of our workforce needs,which will overall help us move towards making the entire health care system more equitable and accessible for all patients of all backgrounds. While we are currently learning about significant vulnerabilities in the US health care system amidst the COVID-19 pandemic, one severe vulnerability we cannot overlook as we rebuild and recover is primary care.

Spencer Chang is a 4th year medical student at Duke University and a 2019–2020 NC Albert Schweitzer Fellow.