A Commentary authored by Gary Freed, M.D., P.H.M., professor of pediatrics and communicable diseases at the University of Michigan Medical School suggests that adults may have a tougher time finding a doctor than children as America faces a shortage of primary care doctors. In the commentary, which appears in the May 13 issue of The Journal of the American Medical Association, Dr. Freed argues that reports on physician shortages, mostly by public bodies and policy makers, have lacked details about the specialties of primary care in which shortages will occur.

The omission could lead to the misdirection of training funds, over-saturation of physicians in areas where numbers are healthy, and lack of improvement in areas where likely shortages could pose a threat to public health.

Physician shortage reports stem from statistics showing that fewer internal medicine residents are choosing to pursue primary care and fewer medical students are choosing family medicine residencies.

Among medical students, fewer than 22% planned careers in internal medicine and fewer than two percent intended to practice general internal medicine, according to a 2008 report. Researchers have theorized this is because primary care specialties offer lower salaries
than other specialties.

These declines have not been true in the number of pediatric residents choosing primary care pediatrics. As a result, researchers believe that
discussion of shortages regarding primary care should focus on adult care rather than pediatrics.

Among pediatric residents completing training, 40% planned to pursue a career in primary care, according to 2008 data, with similar findings among senior residents scheduled to complete training in 2009.

In pediatrics, a doubling or substantial increase of the proportion of doctors entering primary care could result in a possible oversupply of primary care pediatricians, likely at the expense of needed pediatric sub-specialists.

While the number of children in the U.S. has remained stable, the number of pediatricians has increased substantially. This has resulted
in an increase in the number of primary care pediatricians from 32 to 78 per 100,000 children between 1975 and 2005. The number of pediatric
sub-specialists also increased during this period.

These changes have not so far resulted in a surplus of pediatricians and the general effect of the increase has been positive, researchers say.

Freed warns, "Increasing the number of primary care pediatricians in the pipeline could create more physicians than jobs, resulting in the opposite effect of any intended legislation or other policy solution aimed at primary care," Freed says.

Some reports have in fact shown that pediatric primary medicine physicians are not in short supply. But these have gotten lost among the
vast number of reports indicating an overall shortage.

Studies should focus more deeply on workforce issues and not overall numbers, Freed argues. For example, while there currently seems to be an
adequate number of pediatricians, there is a problem of geographic distribution and many areas in the United States are underserved.

Freed feels that rather than increasing quantity of physicians, more attention should be paid to quality of care. Financial support is needed to improve training in the quality of care that all primary care physicians provide.

A more serious issue in pediatrics is that residency programs at free standing children's hospitals receive limited support from Medicare
compared to training programs based in adult hospitals. This support is tenuous and relies on an annual appropriation separate from the federal
funding of internal medicine and family medicine residency training.

Primary care reimbursement is at the top of the list of issues in pediatrics that warrant revision and policy changes, particularly among physicians who care for large numbers of poor children.

Medicaid covers the vast majority of poor children and its rates are established on a state-by-state basis, not by national policy decisions.

Policy makers can't assume they've fixed the problem of reimbursement, if their policies don't trickle down to the state level, Freed says.

"Oversimplifying the nuances of the primary care workforce may result in policies and priorities at odds with needs," says Freed. "For pediatrics, it appears that a close to appropriate proportion of trainees continues to enter the primary care arena. However, the supply of physicians in all fields should be monitored closely."

Reference: JAMA, May 13, 2009 - Vol. 301, No. 18.

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