The Forgotten Specialty: Primary Care

April 22, 2020

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

As the COVID pandemic devastates the United States, comorbidity has been identified as one of the key factors that increases risk for serious complications. Chronic disease burden in the US, including hypertension, heart disease, diabetes, chronic lung disease, and arthritis, is 28%, compared to the Organization for Economic Cooperation and Development (OECD) average of 17.5%. Furthermore, life expectancy in the US is 78.6 years, compared to the OECD average of 80.7 years. Significant research demonstrates that the US spends more on healthcare yet has the worst health outcomes of all high-income countries. Reasons for poorer health outcomes in the United States are multi-faceted, though one thing is clear: the US has significantly under-invested in primary care.

The United States spends 5.6-10.2% of its healthcare dollars on primary care, compared to the OECD average of 14%. Significantly, research has shown that higher levels of spending on primary care leads to improved health outcomes and lower healthcare costs. Unfortunately, the US has not quite struck that balance. First, medical students are financially incentivized to pursue medical or surgical specialties, as specialists are paid far more than primary care physicians. According to the Medscape Physician Compensation Report in 2018, primary care physicians earned $237,000 on average, while specialists earned $341,000. The highest paid specialists make double to triple times the salary of primary care physicians. Furthermore, primary care is often viewed as the “easy” field and does not garner as much prestige as other specialty fields.

Because primary care is not incentivized, there is an exponentially increasing primary care physician shortage in the United States. Because of this shortage, primary care visits are reduced to 15 minutes, on average… this includes addressing multiple complex medical conditions like congestive heart failure, uncontrolled hypertension and diabetes, asthma, COPD, depression, anxiety… AND social conditions like unstable housing, food insecurity, unemployment, and intimate partner violence. This is my everyday as a primary care doctor in America.

Then, we wonder why the United States is the hardest hit country of the COVID pandemic so far. Our patients are plagued with comorbidities, thereby allowing COVID to ravage our population… and this is largely due to our huge under-investment in primary care and the social drivers of health.

Primary care specialties include Family Medicine, Internal Medicine, and Pediatrics. Notably, though, 79% of Internal Medicine residents pursue subspecialty fellowships. Family Medicine is the crux of primary care, as it trains physicians to care for patients across the lifespan, which includes pediatrics, adult medicine, geriatrics, obstetrics, and family planning, as well as trains physicians to provide emergency and inpatient medical care. However, many medical schools do not have Family Medicine departments, thereby not exposing medical students to Family Medicine as a viable career path.

This lack of emphasis on Family Medicine unfortunately includes Harvard Medical School. Of the 177 medical students in the March 2020 National Resident Matching Program (NRMP), only 2 Harvard students matched into Family Medicine, which represents 1.13% of the graduating class. As the top ranked medical school in the country, Harvard should work to develop a Family Medicine department—the specialty most needed in the United States.

As the COVID pandemic continues to devastate the United States, we must bear witness to the fact that this is largely due to our gross under-investment in primary care and the social drivers of health. If comorbidities increase risk for COVID complications, then we have surely failed the US population by inadequately providing the primary care needed to prevent and manage these chronic health conditions. The time is now to prioritize primary care in America.

**Feature photo obtained with standard license on Shutterstock.


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Rebekah RollstonRebekah L. Rollston, MD, MPH, is a Family Medicine Physician at Cambridge Health Alliance, Clinical Associate at Tufts University School of Medicine, and Resident Affiliate at the Harvard Medical School Center for Primary Care. She earned her Medical Degree from East Tennessee State University James H. Quillen College of Medicine and her Master of Public Health from The George Washington University Milken Institute School of Public Health. Her professional interests focus on social influencers of health & health disparities, gender-based violence, sexual & reproductive health, self-esteem development, addiction medicine, rural health, homelessness & supportive housing, and immigrant health.

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