November 05, 2008

USA desperately in need for more family doctors

The US desperately needs to increase its numbers of family doctors to improve patients' care and reduce their costs, particularly for those most vulnerable in society. Incentives must be given for medical students to specialise in general, primary care rather than the narrow specialties which earn them more money but do not meet the needs of the public. The call for action is made by four doctors from the American Academy of Family Physicians in a Comment published early Online and in an upcoming edition of The Lancet.

Drs Perry A Pugno, Rick Kellerman, Amy L McGaha, and Norman B Kahn Jr say: "The US health-care system needs reform. On that point, we have national consensus. Information from WHO and the Commonwealth Fund shows the poor state of health-care access and patients' outcomes in the USA compared with other nations. These findings are despite US citizens paying the world's highest costs for health-care services; costs that are currently borne by government, employers, and—most importantly—patients themselves. US citizens are more concerned about their health-care system than any other issue, apart from the state of the economy and the effect of the war in Iraq."

They add: "Of all developed nations, the USA is the only one without universal access to comprehensive, continuous, and preventive services in a primary-care-based system. Moreover, our system is riddled with unconscionable disparities—geographical, socioeconomic, ethnic, and racial—in health care and health status, which could all be mitigated by consistent access to a medical home. A medical home is a health-care setting that facilitates partnerships between individual patients and their physicians. So, what we really need in this country is universal access to primary care."

Factors that adversely affect the choice of primary care careers for medical students include a payment system that favours procedures over cognitive services, increasing students' debt, decreasing federal support for both medical school and residency education in primary care, and specialty-focused admissions policies and processes for students.

The authors say that definitive steps must now be taken to support and promote careers in primary care to meet the health-care needs of the USA. Those steps need action in three domains. First, increase the attractiveness of careers in primary-care medicine, including appropriate payment for primary-care services and more control over one's lifestyle. Second, prioritisation of medical students' interests in primary-care careers that practise the generalist approach to health care, by contrast with practising only a narrow scope of care. Third, support for training programmes for primary-care physicians. Furthermore, they advocate payment reform, looking at the fee-for-service system which favours treatment volume rather than its treatment quality; and extension of after-hours on-call services for patients which reduces the use of emergency departments and costs.

The four doctors conclude: "The changes we need cannot be brought about by a single discipline of medicine. They require the concerted efforts of physicians, community leaders, businesses, policy makers, state and federal governments, and others. To fix our dysfunctional health-care system is in the best interests of the USA. We know what needs to be done—we simply require the political will to do it. Primary care, epitomised by family medicine, is the linchpin of success in all these endeavours."

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