Reflections on Why Pediatrics Does Not Have a Primary Care Physician Shortage at Present
Article Outline
- Common Philosophy
- Medical Problems
- Pay Scales
- Close Ties with Other Child-Focused Physicians
- Treated with Respect
- References
- Copyright
It has been well documented that the United States has a primary care physician shortage for adult patients.1, 2, 3 In some cities, adult primary care practices are closed to new patients,4 and baby boomers wonder if there will be enough primary care physicians to care for them as they age.5 For children, on the other hand, there appear to be enough general pediatricians available, but there are inadequate numbers of pediatric subspecialists.6, 7, 8 Approximately 60% to 80% of internal medicine residents pursue fellowship training, and 20% to 40% choose to practice primary care9; in pediatrics, the opposite is true; that is, 60% to 70% of pediatric residents choose primary care and 30% to 40% pursue subspecialty fellowships.10
Why is there such a big difference between the two fields? I propose several reasons to explain why pediatrics is not experiencing the same primary care crisis as internal medicine: (1) most pediatricians (generalists and subspecialists) share a common philosophy concerning child health care; (2) generally, the medical problems of children are not the result of poor life choices; (3) pay scales for general pediatricians and pediatric subspecialists are not as disparate as they are in internal medicine; (4) child-focused physicians in other disciplines besides pediatrics (eg, pediatric surgery, pediatric radiology, etc), are often closer to pediatric colleagues than they are to colleagues in their own fields who treat adults; and (5) usually, pediatric subspecialists treat general pediatricians as respected peers. Although there are exceptions to these statements, I suspect that these five factors are common scenarios in our field.
Common Philosophy
Most pediatricians feel strongly that all children have a right to medical care regardless of parental ability to pay for services. Most pediatricians, regardless of area of expertise, are advocates for children. And, most pediatricians follow the adage that decisions that involve children’s health care should be based on what is right for children, not on what is right or convenient for the physician.11 This shared philosophy forms a bond among many pediatricians.
Medical Problems
With few exceptions, the medical problems of children are much different from the medical problems of adults. For example, in adult cardiology, myocardial infarction and hypertension are common diagnoses; in children, the most common cardiac problems are congenital. No one ever blames the child for causing his heart disease by making poor life choices or chides the general pediatrician for not convincing his young patient to lead a healthier life style. I doubt that internists “blame” their patients for their health problems, but they may become weary of advising us adults to change our lifestyles to be healthier. In conditions that appear similar in children and adults, as in type I diabetes mellitus, the disease in children does not have the end-organ complications seen in adults who have lived with the disease much longer. This may make it easier to care for children with diabetes than adults. There are probably many other examples.
Pay Scales
Pediatrics is one of the lowest compensated fields of medicine. And, unlike internal medicine subspecialists, most pediatric subspecialists are employed by children’s hospitals and/or academic medical centers. Salaries are based on academic rank as well as subspecialty. With few exceptions, individuals in the same part of the country, at the same academic rank, at the same salary percentile but in different pediatric nonprocedural subspecialties, have salaries that are within $50 000 to $60 000 of one another.12 This includes academic general pediatricians, whose salaries are not much different from pediatric subspecialists who do not do procedures. One could argue that it is because salaries are low that we have a shortage of subspecialists. In other words, 3 more years of training past a general pediatrics residency does not result in much higher pay for many pediatric fields, and therefore most pediatricians choose not to pursue subspecialties. However, physicians who care for children in other fields also make less money than their colleagues who care for adults (eg, anesthesiology, psychiatry).13 Perhaps the pay scale issue is more a reflection of society’s values than anything else.
Close Ties with Other Child-Focused Physicians
Most general pediatricians have a cadre of specialists to whom they refer. These colleagues include pediatric subspecialists and nonpediatric subspecialists, such as child psychiatry and pediatric surgery. Just as pediatric subspecialists are in short supply, so are the other child-focused physicians. A recent survey by the American Academy of Pediatrics indicates that child psychiatry is the top field that general pediatricians have difficulty accessing, followed by developmental/behavioral pediatrics.7 Both child psychiatrists and behavioral pediatricians are too few in number to meet the needs of children and youth. Perhaps because there are so few subspecialists for children available, everyone who cares for children knows everyone else who cares for children. Close ties among us are very common.
Treated with Respect
We cannot underestimate the value of being treated with respect. In my limited experience of being on the faculty of three different medical schools in the United States in three different parts of the country, I rarely heard academic subspecialists “put down” general pediatricians on the faculty or in the community. In general, physicians who care for children respect other physicians who care for children. There are exceptions to this statement, of course. For example, in one site, a pediatric emergency medicine physician grumbled about doctors who sent in children who were not “sick enough” to need a pediatric emergency room. But she grumbled about specialists as well as generalists. In general, I have observed mutual respect. Perhaps this is a reflection of the type of person who chooses to care for children. Or, perhaps, I have only had jobs in places with nice people.
Certain polls report that pediatricians have the highest scores on job satisfaction among physicians.14 Perhaps we are more satisfied than our colleagues because of the issues described previously. Or, maybe working with kids truly is more fun, as we tell aspiring pediatricians. Nationally, about 10% to 12% of graduating medical students choose pediatric residencies, a fairly constant figure for 10 to 15 years.6 There has been a decrease in the percentage of graduates entering family medicine or internal medicine in the same time frame.6, 15 For example, from 1998 to 2006, the percentage of graduating medical students choosing family medicine residencies decreased by half (16% to 8%) and decreased by one-fifth for internal medicine residencies (24% to 20%).6 At present, there are large numbers of young pediatricians pursuing fellowship training. In 2008 and 2009, respectively, 39% and 32% of pediatric residents intended to pursue subspecialty fellowships when they completed residency.6, 10 These numbers are a little higher than noted in years past and may be an effort to correct the low percentages of previous years. Regardless, we should be vigilant that we do not go down the trail that internal medicine has gone, as we work to increase our deficiencies in the subspecialties. It takes all of us to care for children, generalists and subspecialists alike. And, just as adult patients have the right to have adequate numbers of primary care providers, children have the right to have adequate and appropriate subspecialists caring for them when they need them.
References
- . Primary care: current problems and proposed solutions. Health Affairs. 2010;29:799–805
- . Health reform, primary care, and graduate medical education. N Engl J Med. 2010;363:584–590
- . Addressing the primary care physician shortage in an evolving medical workforce. Int Arch Med. 2009;2:14
- Gurley G. Primary care docs in short supply. Available at: http://www.commonwealthmagazine.org/.
- Greenwich Hospital, Greenwich CT. Baby boomers turn 65, creating a doctor shortage to care for this new geri-boom population. Available at: http://www.newswise.com/articles/baby-boomers-turn-65-creating-a-doctor-shortage-to-care-for-this-new-geri-boom-population. Accessed Sep 20, 2010.
- American Board of Pediatrics. Report to the Association of Medical School Pediatric Department Chairs. Santa Fe, NM; March 10, 2008.
- . Primary care pediatricians’ satisfaction with subspecialty care, perceived supply, and barriers to care. J Pediatr. 2010;156:1011–1015
- . Pediatric workforce projections and unintended consequences. J Pediatr. 2004;145:1–2
- . Career plans for trainees in internal medicine residency programs. Acad Med. 2005;80:507–512
- American Board of Pediatrics. Report to the Association of Medical School Pediatric Department Chairs. Savannah, GA; March 8, 2009.
- . Health equity and children’s rights. Pediatrics. 2010;125:838–849
- Association of Administrators in Academic Pediatrics. Medical School Pediatric Faculty Compensation and Productivity Survey, 2009-2010. Oklahoma City, OK; University of Oklahoma, Department of Pediatrics, 2010.
- Association of American Medical Colleges. Report on Medical School Faculty Salaries, 2008-2009. Washington, DC; AAMC, 2010.
- 2010 Physician Workforce Study. Massachusetts Medical Society. Available at: www.massmed.org/workforce.
- . Easing the shortage in adult primary care: is it all about money?. N Engl J Med. 2009;360:2696–2699
PII: S0022-3476(10)01147-9
doi:10.1016/j.jpeds.2010.12.035
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