Ten thousand Americans turn 65 every day, according to the Association of American Medical Colleges. Not only is our population getting older, but it’s also growing at such a rate that by 2025 we will need an additional 52,000 family doctors.

This strain on primary care is compounded by The Affordable Care Act, which expands health insurance coverage to an additional 38 million people. According to the Kaiser Foundation (April 2011), while 56 percent of patient visits in America are primary care, a mere 37 percent of physicians practice primary care medicine, and only 8 percent of the nation’s medical school graduates go into family medicine. The result is a shortage of primary care doctors.

According to American Medical News, there is an anticipated deficiency of at least 125,000 physicians by 2025, but 22 states and 17 medical specialty societies are already reporting shortages. In 2002, U.S. medical schools graduated 5,746 students who selected family medicine as a career; five years later, that number fell to 4,210.

Another significant part of the challenge is that public and private reimbursement systems (Medicare, Medicaid, government and private insurance plans) undervalue primary care services in comparison to procedures done by specialists.  Most medical students want to pursue careers other than being a primary care physician or an internal medicine physician. One reason is that the pay is lower than many specialties. According to Medscape Physician Compensation Report for 2012, in 2012, radiologists and orthopaedic surgeons “topped the list at $315,000, followed by cardiologists ($314,000), anesthesiologists ($309,000), and urologists ($309,000)… The bottom-earning specialties in 2012's survey were pediatrics, family medicine, and internal medicine.”

In Lynchburg, a number of solutions that reflect a national trend are meeting the needs of a growing patient base that demands the care of primary care and internal medicine physicians. One is to hire physician assistants (PA) and nurse practitioners (NP), both positions costing less than an MD. While family physicians receive 21,700 hours of education and clinical training during their years of medical education, nurse practitioners and physicians assistants complete an average of 5,350 hours of education and clinical training during five to seven years (this, according to the American Academy of Family Physicians). However, Dr. Archibald Lord of Medical Associates of Central Virginia says that these mid-levels assist with urgent care, diabetes education, and some wellness exam services.  Dr. Lord notes that the patients at his facility have come to realize that the scope of medicine is changing and their attitude towards PAs and NPs should, as well. He says he has found that PAs and NPs are capable but have to know their limitations, and the local doctor should be available to assist them. “We make sure that we are fully accessible to them,” he says.

The American Academy of Physician Assistants states that PAs can conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, write prescriptions and make rounds in nursing homes and hospitals.  The U.S. Bureau of Labor Statistics projects that PA will be the second fastest growing health occupation between 2008 and 2018. Additionally, the number of nurse practitioners will nearly double by 2025, according to an analysis published in the July 2012 Medical Care, the official journal of the medical care section of the American Public Health Association.

Paul Foster, a , who attended Eastern Virginia Medical School (EVMS) in Norfolk and has a critical care paramedic certification, works at Central Virginia Family Physicians in its immediate care centers.  He says that at EVMS, over half of the PA curriculum was taught by the same doctors that instructed medical students. The main difference was in the number of rotations – PAs and NPs had about half that of those studying to be doctors. Still, while he was working in an emergency room, he was allowed to do a lot of the same things as the attending physicians.

As far as patient attitude, he says he has patients who prefer being seen by him. “They tend to listen to you and do better with their treatment if you explain it to them,” he notes, “and we are very capable of doing this.” He says it used to be that patients would request only a doctor, but it’s rarer now. They are beginning to realize that being seen sooner by a qualified person is better. Foster notes he has seen “a vast amount of different types of patients,” from heart attacks and pulmonary embolisms to sore throats and colds. He recalls a recent incident of a patient who was having difficulty breathing, and as he finally arrived at the front door of the center, coded. He has diagnosed heart attacks and has been trained to “rule out the worst case scenarios and go from there.” He feels that the role of the PA is becoming more important as the shortage of primary care physicians is exacerbated.

“PAs and NPs are really capable of filling a majority of these roles, but you have to prove that you are capable and able to see all the types of patients that come into the office. Once you have proven this to the physicians, there is a huge respect from the physician to any mid-level,” he explains. The physicians he works with review mid-levels’ charts 100 percent of the time. “There is no way that any provider, whether PA or physician, could see all the patients that are coming into any office now. One of the ways that we help primary care providers is that we are able to see less severe patients and free up physicians for the more detailed help,” he says.

Dr. Lord chose to become an internal medicine physician simply because he wanted to treat the whole patient and give them a continuity of care. At the time he graduated from George Washington University School of Medicine and Health Sciences in 2001, he was not aware of a primary care shortage, but he is now. However, since his practice employs both nurse practitioners and physician assistants, the pinch hasn’t been as severe.

Another solution to streamlining patient care is through electronic medical records. Dr. Mark Kleiner of Central Virginia Family Physicians points out that while the investment may be steep in man hours up front, eventually having electronic records on all the patients will save considerable time.  He says that in a perfect world, physician practices would have two or three scribes – people who input electronic records – but that that goes against the bottom line. And while he also points out that doctors are hard-wired to take care of everybody and anybody, he acknowledges, “We can’t see 100 percent of them.”

Dr. Kleiner is involved in exploring another option, Medical Home, which is a concept that provides comprehensive primary care with the goal of reducing emergency room visits, hospital stays, and repeat clinic visits. He says that integrated into this model is accountability, but for some patients this is difficult. They won’t follow doctor’s orders, won’t take their medicine, and won’t change their lifestyle. “There are so many variables and unknowns in medicine, but the general themes of accountable care are good to aspire to,” he explains.

The dream of accountable care may be that more money goes to primary care physicians and less goes to hospitals. Local insurance companies are exploring this option.

Dr. Kleiner could have gone into any specialty he wanted. He knows that the “prestige isn’t there” for primary care physicians and internists, but he also knows that those who go into primary care are driven by the desire to take care of their community. “We bring an overall breadth of knowledge to send patients in the right direction, but having a solid knowledge base is underappreciated,” he states.

The Association of American Medical Colleges sees the scary writing on the wall. “The United States cannot afford to wait until the physician shortage takes full effect because by then, it will be too late,” it states.

While there are some loan pay-back programs and other draws to the primary care and internal medicine physicians, Lynchburg is not considered a shortage area, says Dr. Kleiner, even though he thinks it is. Meanwhile, a December 2008 report on the physician work force by the Health Resources and Services Administration found that the U.S. would need 976,000 physicians by 2020, but only 926,600 would be available to provide care.