Patient Beware of the New Primary Care Workforce

Once again a most important area of primary care is being ignored. The primary care workforce has moved from the most experienced workforce to the least experienced - without so much as a warning.

The focus for primary care has been elsewhere other than significant changes in the workforce in areas such as consumer focus, convenience, quality, metrics, or lower costs.

But there has not been much about changes in the primary care workforce itself.

No, this is not about the movement from physicians to non-physicians, although this change is a big factor in the changing of primary care experience. All of the primary care workforce is impacted - MD DO NP and PA. Fewer enter and even fewer remain. Because they depart and take their primary care experience with them, the remaining workforce is more and more likely to be inexperienced.

Not even researchers are asking many of the important questions with regard to primary care. 

• How is the primary care workforce changing and what does that mean? 
• What does the practitioner or physician bring to the table?
• Is there a depth, breadth, intensity, and volume of previous experiences that matters to care?
• What if the provider has little experience and you have a complex health care need?

You are within your rights to ask to see a specialist if you have an unusual condition, even if you are in a PPO or  HMO. Insist on it. Your provider has a duty to refer. Some providers have been sued for "falure to refer" and have lost.

What Has Happened in the Past 50 Years?

The primary care workforce built by the 1970s and 1980s class years of physician graduates was rich in experience. The health policy of the time supported 30 year careers in primary care with higher volume, intensity, scope, and engagement. The options for them other than primary care were few. The expectation was a career in primary care and this was the result. Options to specialize were few. There were some who left for emergency room careers, but fewer compared to now. There was no hospitalist or urgent care or retail care. There were fewer administrative options.

The primary care workforce based on the graduates of the 2000s and 2010s will be the opposite. This is not just due to the massive increases in graduates. The nurse practitioner and physician assistant higher turnover/transitional role has also been the case for primary care trained physicians.

Physicians go back and specialize. Primary care physicians depart primary care for hospital, urgent, emergent, and other jobs outside of primary care taking their primary care experience out of the primary care pool.

Appeal to Common Sense

Since there is no research on the importance of primary care experience, perhaps we should appeal to common sense.

Ask yourself what would you like in your physician or practitioner as you approach a health care visit for primary care, mental health, women’s health, urgent care, or retail care?

These are the changes seen

Most years of experience – 10 to 15 on average	Least years at 3 to 6 years
3000 – 4000 experiences or encounters a year	2000 – 2500 experiences or encounters a year
40,000 to 60,000 experiences on average previous to the current visit	8000 to 12000 experiences previous to the current visit
High intensity, broad scope experiences, many patients who were very ill	Low intensity, narrow scope, few patients who were very ill
Supervisory role across career, must deal with the issues, less referral	Less autonomous role, can defer to others, more referral
Engagement level high with each patient encounter as this is your career, it is all that you expect and plan for and prepare for	Less engaged as this job is likely temporary and you will be going to another primary care job or leaving for a specialist job
High levels of continuity and contact with patients and family after a visit to see outcomes	Low levels of continuity and contact due to constant changes in insurance, practices, etc.

In summary, most plans require a primary care physician to see you first. Not all PCPs are the same. Some are internal medicine, Ob/Gyn, Pediatrics or Family Practice. Most family practice physicians who have graduated in the past ten years are board certitifed by the American Board of Family Medicine. 





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Patient Beware of the New Primary Care Workforce