Is the primary care market shrinking?

As some struggle to find work, there is talk about an oversupply

From the December 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

For much of the past decade, educators have been encouraging physicians to go into primary care. In light of predictions from work force experts that the nation faces a glut of subspecialty physicians, educators have chatted up generalism and urged students and residents to take a serious look at primary care practice.

Now, some analysts are wondering if those efforts have been too successful. They worry that anecdotes from residents having trouble finding work as generalists, combined with other work force and training data, may be harbingers of a coming glut in primary care.

One compelling piece of evidence that may support that hypothesis appeared in the Sept. 2 issue of The Journal of the American Medical Association. A survey in the issue found that 7% of the residents looking for work had not found a job, and that 22% of physicians who had found clinical positions had experienced significant difficulty finding work. The survey, sent out in May of 1996, showed that nearly 5% of family physicians were unemployed at that time and just over 9% of pediatricians were out of work. Internal medicine led the primary care specialties with the most new physicians—11%—looking for work.

While these numbers appear daunting, some analysts say that fears of a coming primary care oversupply are overblown, and that other factors such as location and nationality play a part. According to Rebecca S. Miller, lead author of the study and director of research and data analysis in the AMA's division of graduate medical education, the high number of generalists having difficulties finding a job may be directly related to the problems that international medical graduates (IMGs) have finding work in this country. Of the internists in the study who reported having problems getting work, two thirds were IMGs.

Ms. Miller explained that the surveys were sent to all residents in the sample, including those who were in the United States on visas that would make them ineligible to work in this country after finishing their training. "Some of those people should be leaving the country and aren't eligible for work," Ms. Miller said, "but instead they may be reporting that they are having difficulty finding a job."

In addition, Richard A. Cooper, FACP, director of the Health Policy Institute at the Medical College of Wisconsin in Milwaukee, said that job surveys often fail to consider whether the applicants were willing to relocate or what factors, other than job availability, influenced their answers. "It may not mean they don't have a job to go to. It may be they are considering two or three jobs or waiting for a spouse to find a job first," Dr. Cooper said. "They all have their own stories: One's going to have a baby, some can't move from their current location because their spouses are in the middle of their residencies or in law schools. If there is any surplus, this particular analysis exaggerates it."

Even those who accept the fact that some residents are having trouble finding work in primary care argue that the problem is not that the market is saturated with too many generalists, but that the market is changing. Physicians, they say, have not yet learned to adapt.

The numbers

A look at federal work force data indicates that the U.S. health care system should be able to absorb more generalists. According to the Council on Graduate Medical Education (COGME), which is charged by Congress with assessing the physician work force, the country needs between 60 and 80 primary care physicians per 100,000 people. As of 1995, the latest year for which data are available, there were 68 generalists for every 100,000 persons.

Robert Politzer, ScD, chief of work force analysis at the Bureau of Health Professions, the office that runs COGME, said that estimates place the number of generalists per 100,000 in 1996 at 70. That ratio is nothing to worry about, said Dr. Politzer, adding that "the current hype about an oversupply of primary care physicians is much ado about nothing."

But other analysts are concerned that the proportion of generalists to the overall population has been steadily inching up (it was 63 in 1989). They also point out that residency programs are training a growing number of generalists. The number of first-year internal medicine residency slots filled through the Match grew 5.7% to 4,433 between 1994 and 1998, while the number of filled primary care track slots jumped 24% to 528 during that same period. The number of filled family practice slots grew 14% to 2,614, and the number of filled pediatric slots grew 10% to 2,047.

These numbers don't take into consideration other primary care providers such as osteopaths, more than half of whom go into primary care. The number of graduates from osteopathic medical schools rose to 2,020 last year from 1,534 in 1990, and that doesn't account for three schools that have opened since 1995 but have yet to send their first classes to training programs.

Finally, fewer internal medicine residency graduates appear to be planning to subspecialize. Historically, about 60% of young internists subspecialize, but in states like New York, for example, only about 40% of 1997 residency graduates planned to do a fellowship, according to a survey by the Center for Health Work Force Studies at the State University of New York in Albany.

Edward Salsberg, director of the center, said he believes the rest of the nation is experiencing a similar shift. "That has an enormous impact on primary care numbers," Mr. Salsberg said. "You're taking 20% of the largest specialty and switching it from becoming specialists into staying in primary care."

Jonathan Weiner, PhD, a professor of health policy and management at the Johns Hopkins University School of Hygiene and Public Health, added that internists and other primary care physicians might also have to compete with "hidden" primary care practitioners: specialists who, when faced with empty appointment books, are likely to expand the scope of their practice to include primary care patients.

"Any way you slice the numbers, you have in most locations an ample supply of providers, particularly when you add to the mix the large cohort of nurse practitioners being trained and the so-called 'hidden cohort' of primary care physicians," Dr. Weiner noted.

However, analysts skeptical of a primary care oversupply say that worries about a "hidden" system of primary care may be exaggerated. Roger A. Rosenblatt, MD, professor and vice chair of the department of family medicine at the University of Washington School of Medicine in Seattle, did a study that found it rare for most specialists in Washington state to stray from the areas in which they were trained. "The hidden system of primary care doesn't really exist," he said, adding that the study did not analyze what happens in areas of high oversupply.

Market forces

While experts argue about the merits of the data, one thing is clear: Even though physician pay has remained relatively flat, the primary care supply is growing while demand has decreased from a few years ago.

At Merritt, Hawkins & Associates, a recruiting firm based in Irving, Texas, searches for specialists increased by 40% while searches for primary care doctors fell 17% this year. Phillip Miller, director of communications for the firm, attributed the drop to several factors: Gatekeeper slots are filling, managed care organizations are making it easier for members to see specialists, older specialists are retiring rather than work in the new managed care environment and groups are adding specialists to make up for the primary care overhead added over the past few years.

While recent pay data do not show major income gains for subspecialists, they do show that pay for generalists is leveling off. According to the Medical Group Management Association's (MGMA) 1998 pay survey, income for specialists dropped by 0.48% while primary care physicians saw their pay rise by only 0.86%.

To be fair, however, generalists have seen huge gains in salary over the last five years, with primary care salary offers averaging $135,000 to $140,000. "Five or six years ago, doctors were getting $90,000 packages," Mr. Miller said. "That's almost unheard of today."

Geography also appears to play a leading role in the difficulties some residents are having in finding work. Many agree that work force issues are often masked by what COGME calls a persistent "geographic maldistribution."

In the past, generalists could usually find a job in almost any town or city. Today, however, more primary care physicians are finding, much like their counterparts in subspecialty medicine, that unless they are willing to work in rural towns or inner cities, where generalists are still in short supply, they are going to have to work harder to get that ideal job in the perfect location.

Though metropolitan areas in 1995 had 35.4 internists for every 100,000 residents, rural areas had only 11.8, according to COGME. The numbers for pediatricians were, respectively, 17.5 and 5.2. Poverty-stricken urban areas with a high African-American and Hispanic population in 1990 (the latest numbers available through COGME) averaged only 24 primary care physicians per 100,000. By comparison, areas that weren't poverty stricken and did not have a high concentration of either ethnic group averaged 80.

"The aggregate number of primary care physicians in this country is adequate to meet the needs of the population, " said Michael E. Whitcomb, FACP, senior vice president of medical education at the AAMC. He noted, however, that the distribution of primary care physicians shows clearly that the country's rural and inner city communities have an inadequate number of primary care physicians for the populations.

To correct that imbalance, COGME supports the training of an increasing number of primary care physicians. Although it advocates cutting the total number of graduate training slots by 20%, it believes half of the remaining slots should be in primary care, up from about 35% now.

Dr. Politzer from the Bureau of Health Professions said that if the ratio of generalists per 100,000 persons "moves from 70 to 75 in the upper range of the band, that's OK because more people without access to generalists will get generalists." He said that more than specialists, generalists "diffuse to areas where they are needed."

However, critics of continued growth in primary care worry that many physicians will put off moving to less desirable areas as long as possible. Consequently, they say, increasing the general supply of primary care physicians is not necessarily the most efficient way to fill rural and inner city needs.

There are real-life situations that back up these concerns. After finishing his residency at the University of Virginia in 1996, Stacy Oshry, ACP-ASIM Associate, took a number of temporary positions. One was with a practice in Hagerstown, a city about 72 miles west of Baltimore with a population base of 39,000. The practice eventually offered him a permanent position, but he turned it down, even though he knew it would not be easy to find a comparable position in a big city.

"Hagerstown is a nice place," said Dr. Oshry, 31, who eventually found a job with a practice in Fairfax, Va., a suburb of Washington, D.C. "[But] everybody my age had three kids. Being a single guy, I couldn't do it."

Or take the case of Julie Mattson, MD. As a former Peace Corps volunteer, Dr. Mattson had high ideals when she started medical school and had even considered moving to a rural area for a job because she knew that was where her services would be most needed. But after finishing her family practice residency through the University of Washington in Seattle in 1997 and staying on for a year as a chief resident, the pull of her social life and her husband's architecture job in the city proved too strong. Instead, she found a job in a Seattle suburb.

"We have a lot of friends here, my husband's job is going well," explained Dr. Mattson, who has not ruled out a move to a rural area in the future. "It's hard to pull up your roots."

Generalists who are looking for work may have to do just that, said Ms. Miller, lead author of the study published in JAMA. "I think what is coming out of this is that people are going to have to move," she said. "States like Texas, California and New York that are training a lot of residents are no longer able to provide work for them later on. We found that people in California were having difficulty finding jobs, and that people in the Midwest were having difficulty finding jobs. I would say that those are probably desirable places to live."

Bryan Walpert is a freelance writer in Denver.

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