There once was a time when PAs were viewed as the primary care providers of the future. Indeed, in the minds of many, the central purpose of the creation of the PA profession was to take the place of the old general practitioner. Our social and policy mandate was to team with physicians to augment the supply of primary care providers.

For several decades, PAs fulfilled this role effectively, with a large number of annual graduates entering the primary care specialties (family medicine, general internal medicine and general pediatrics) and a good proportion locating in practices in rural and medically underserved communities.

Things, as they say, have changed.

Primary Care in Decline

Modern workforce realities have markedly changed the face of primary care, and these forces have affected PAs as well as physicians. The difficult statistic is that the proportion of PAs working in the primary care specialties in 2007 was down to 34%.¹ PAs also are no longer seeking practice settings in underserved regions. PAs and physicians perceive primary care as a less than desirable specialty, despite strong marketplace demand for primary care physicians. The No. 1 physician recruitment category in 2006-2007 was primary care physician, according to one of the largest U.S. health care staffing firms.²

Yet physicians continue to avoid primary care. This is most obviously apparent in the numbers from the "Match," the National Resident Matching Program process by which senior medical students select residency positions. A total of 2,299 of the 2,603 positions available for residency training in family medicine in 2007 were filled by 87 U.S. physicians who were prior-year graduates of U.S. allopathic medical schools, nine graduates of the Fifth Pathway, 335 U.S. citizens who were graduates of international medical schools, 538 non-U.S. citizens who were graduates of international medical schools, 227 osteopathic physicians and 1,096 U.S. citizens who were allopathic senior medical students.³

That only a bit more than a thousand of 16,262 graduating allopathic medical school seniors selected family medicine is a sad and telling commentary on how future physicians view a career in primary care. Between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50%.⁴

Why the Primary Care Flight?

Another factor is the rise of new and attractive roles for physicians such as hospitalists. The growth in the number of hospitalists means that fewer physicians enter primary care. In 1998, half of internal medicine residents chose primary care; today, about 80% become subspecialists or hospitalists.⁴ Because hospitalists are primarily drawn from general internal medicine or family practice, the growth of hospitalists further exacerbates the shortage of primary care physicians. The hospitalist trend also is affecting the PA profession, with increasing numbers of new graduates attracted to such positions, which are becoming more plentiful in many institutions.

Debt from education is a major driver of these trends. Many PA students and medical students graduate from their programs with large loans to repay. By working in the higher-paying specialties and subspecialties, they are capable of paying off these loans sooner.

One can argue that a root cause of this circumstance is the failure of the federal government to maintain subsidies for health professions education. By cutting programs such as Title VII and similar programs that support health professions education, there is no counterbalance to the market forces that attract graduates to the specialties and the cities. With funding cuts, PA programs no longer have significant incentives to orient PA education to primary care or to promote PA employment in rural and medically underserved communities.

From Bad to Worse

These trends are occurring at a time of growing need for primary care for an aging population with an increased prevalence of chronic disease. Primary care should be the backbone of our future health care delivery system. That the American health system has allowed patients to seek care directly from specialists has led to increasing cost, fragmentation and inefficiency in service delivery. It has been shown that higher numbers of primary care providers are associated with lower overall mortality and lower death rates from cancer and cardiovascular disease.⁵ Since primary care providers tend to be the main providers for the poor, minority groups and people in underserved areas, shortages of these providers have a greater effect on these populations.

What are possible solutions? Most view increasing physician payment as the answer to the problem of primary care shortages. While many other approaches could be considered to promote primary care practice and make it easier for clinicians in this field, increasing the reimbursement for primary care physicians is seen as the only realistic way to attract physicians to primary care.⁶ Would that strategy work also for PAs?

Since the early 2000s, we have been told that primary care is in crisis. Things only have become worse and have moved from crisis to disaster. One would like to think that PAs could once again rise to the occasion to fill the gap in primary care. But because they are hampered by the same barriers and circumstances that affect primary care physicians, we will have to search for more-comprehensive solutions in the future.

James F. Cawley is professor and interim director of the PA program at the School of Medicine and Health Sciences at The George Washington University in Washington.

References

1. American Academy of Physician Assistants. Number and percent distribution of clinically practicing respondents by general specialty practiced for primary employer. 2007 AAPA Physician Assistant Census Report. http://www.aapa.org/research/07census-content.html#3.6. Updated October 15, 2007. Accessed March 17, 2008.

2. Merritt Hawkins and Associates. 2007 Review of Physician and CRNA Recruiting Incentives. http://www.merritthawkins.com/pdf/2007_Review_of_Physician_and_CRNA_Recruiting_Incentives.pdf. Accessed March 17, 2008.

3. National Resident Matching Program. Results and Data: 2007 Main Residency Match. http://www.nrmp.org/data/resultsanddata2007.pdf. Published April 2007. Accessed March 17, 2008.

4. Bodenheimer T. Primary care-will it survive? N Engl J Med. 2006;355(9):861-864.

5. Shi L. The relationship between primary care and life chances. J Healh Care Poor Underserved. 1992;3(2):321-335.

6. Pho K. Shortage of primary care threatens health care system. USA Today. March 13, 2008.