The New Health Dialogue

"How will I know that the government won't let us down this time?"

This was the question posed to me from a family medicine doctor after a talk I gave to the American Academy of Family Physicians this week on the role of primary care in health reform. His tone, and his question, reflected years if not decades of false starts and unanswered promises that have been made to him and his primary care colleagues.

Estimates from academic experts point to a shortage in the primary care workforce and most notably, a problem with the distribution of our workforce.

Provisions in the American Recovery and Reinvestment Act (last year's stimulus package) as well as the recently signed health reform law have intensified resources directed to primary care including:

• Increased payment for services in Medicaid to match Medicare rates (at least for 2013-14)
• Expansion of the National Health Service Corps, which encourages training and practice in underserved settings
• Loan repayment programs in primary care
• Grants and incentives for the development of primary care based medical homes

These are resources that have been long needed, but often ignored. Challenges still remain. Med students who enter primary care face a culture that has regarded specialty training as superior. The sheer numbers reflect this. Hospitals, which remain the focus of  medical education and training, are building more towers and wings dedicated to specialty care. Those are the beds that bring in higher revenues. The upper echelons of medical school leaders, such as the deans, are usually filled by specialists. And then there is the money. While finances are certainly not the only driver for professional choices, it is hard to argue with the fact that I, a primary care physician, am still paying off medical school loans. My colleagues who chose to specialize have not only paid their loans off but are purchasing their second homes. 

We also still have a culture of hierarchy amongst our team members. Nurses, pharmacists, nurse practitioners and other members of the health care team are often not regarded as essential -- at least not by the physician. We want patients to perceive us as having interdisciplinary teams, but doctors themselves don't always acknowledge the importance of the team and often have an "I am better than you" attitude toward the nurses. Patients, as well as medical and nursing students, witness this.

I fully sympathize with the sentiment of my questioner. In order to not disappoint him, the House of Medicine will need to unite and work on the cultural and contextual barriers. Only then will we see the many pieces of health care reform start to take shape.