NPR logo
Bucking The Trend: Primary Care Doc Practices Solo
  • Download
  • Transcript
Bucking The Trend: Primary Care Doc Practices Solo




And I'm Robert Siegel.

The U.S. is facing a potentially catastrophic shortage of primary care doctors and other health professionals. Now, the nation is about to expand health care coverage to tens of millions more Americans, so many more people are going to be seeking medical care, a situation that threatens to stress the system even further.

Today and for the rest of this week, we're going to explore a primary care system overwhelmed.

To see how the shortage is playing out and some of the solutions being proposed, we sent NPR's Julie Rovner to Maine. It's one of the states that's leading the effort to solve this problem, and she's with us in the studio.

Hi, Julie.


SIEGEL: From the economics textbooks, we know that shortages are caused either by too little supply or too much demand. Which is it with primary care?

ROVNER: Well, unfortunately, it's a bit of both. Let's start with the demand side. That would be the patients. First, we have an aging baby-boom population. By the year 2030, we'll have more than 70 million seniors - one of every five Americans will be over the age of 65. And as anyone who's ever been in a doctor's waiting room knows a little too well, older people use more medical care. They have more medical problems.

Then we have the good news/bad news of the new health care law, which will give an estimated 32 million more people insurance who didn't have it before. And a lot of them will be looking for primary care doctors. So it's kind of a double whammy.

SIEGEL: That's the demand side. On the supply side, the question is where are the doctors?

ROVNER: Well, doctors who are in training are going into every field except primary care, according to a report earlier this month in The New England Journal of Medicine. Less than a fifth of all the students graduating from medical schools this year are likely to end up practicing primary care. They're all becoming specialists.

SIEGEL: For the money?

ROVNER: Well, it's partly the money. Primary care doctors, which include family practitioners, internists and pediatricians, earned a median salary of about $191,000 last year. That's according to one major survey. That's about half of what a dermatologist earned and barely over 40 percent of what a cardiologist made. Now, if you graduate from medical school with student loans in the neighborhood of $200,000 or so, you can see why more and more of those students are opting to become specialists.

But it's also a lifestyle choice. Primary care doctors work long hours, including nights and weekends, and it's much more emotionally demanding work than something like radiology, where you're basically looking at pictures all the time.

SIEGEL: So what's the solution? How are we going to get enough primary care givers for everyone who needs them?

ROVNER: Well, it's definitely not going to be easy, and like everything else in health care, there's no single answer. But there do seem to be some ideas out there - both to help people who are practicing now become more efficient and get better paid and to help train more people.

SIEGEL: Okay. Let's then hear, Julie Rovner, part one of your series. It's a profile of a member of a vanishing breed: a doctor in solo practice.

(Soundbite of phone ringing)

Ms. AMY ASALI (Office Manager): Dr. Crute (unintelligible) office. Can you hold for a moment?

ROVNER: Cathy Crute wants to get one thing straight from the get-go: She is not a dinosaur.

Dr. CATHY CRUTE (Family Practice Physician): No, no. I mean, I think patients love a small practice. My receptionists can recognize a lot of patients' voices over the phone. They know who they're talking to every time. They don't have to go through a whole chain of command.

ROVNER: And the patients in the waiting room at her Portland office second that notion. Laurie Warhol has been seeing Crute for nearly a decade.

Ms. LAURIE WARHOL: I just think it's better service to come to the same person all the time and have one person overlooking you.

ROVNER: And it's not just Crute herself, says patient Mike Greenleaf. It's the entire atmosphere.

(Soundbite of phone ringing)

Mr. MIKE GREENLEAF: The staff's great, and they know you on an individual basis. And it just makes you feel that much better.

ROVNER: Crute actually came to her solo practice late in her career. She was one of the first doctors to become a certified family practitioner. She worked in a small group for 10 years - and later, a larger one.

Dr. CRUTE: And realized very quickly that that was not where I wanted to be.

ROVNER: The emphasis was on moving patients in and out as fast as possible, and she didn't feel like she had enough control. Crute said she had some friends who were solo practitioners.

Dr. CRUTE: I was like, well, yeah, I guess I can do it, too.

ROVNER: That was 10 years ago. Since then, she's built a tight, efficient little team around her. So efficient, in fact, that Crute only works three and a half days a week. She gets in at 8:15 and says she rarely leaves the office after 5:30.

Ms. ASALI: David(ph), we do have samples if you want to stop by and pick up some. You'll just how to do two of the 10 milligrams because we only have fives and tens in samples.

ROVNER: It's easy for the staff to know the patients, says office manager Amy Asali. Most of them have been with the practice for years. She literally inherited her job.

Ms. ASALI: My mother actually was her office manager when she was in the group practice. She retired, so I hopped into a position.

ROVNER: Crute credits Asali with keeping the practice financially viable. Crute says Asali is always on the lookout for various hospital or state or insurance incentives to boost cash flow.

But Asali, who's also answering the phones on this, the receptionist's day off, concedes her job is a challenge. Keeping a small practice afloat takes some doing these days.

Ms. ASALI: Definitely a juggling act without having the overhead of, you know, a larger practice helping us. You know, it's a game week to week, making sure we've got enough patients on the schedule.

ROVNER: But Crute says as long as the bills get paid, she's okay. She says she's definitely not in this for the money.

You're not driving the latest BMW?

Dr. CRUTE: No.

(Soundbite of laughter)

Dr. CRUTE: No, I'm driving a 10-year-old car.

(Soundbite of laughter)

ROVNER: Although she wishes she and her staff could spend less time on insurance company bureaucracy.

Dr. CRUTE: We have a part-time person just doing referrals, and that's a huge piece. And we also spend a lot on - a tremendous amount of time on the phone with prior authorizations for medications.

ROVNER: That's medical speak for getting permission to prescribe a specific drug. But what really keeps Crute up at night is what will happen to her practice and her patients when she retires. She's 63.

Dr. CRUTE: I'm planning to work in probably another three years.

ROVNER: So she's spending some of her time trying to recruit her replacement. Among her targets: the family practice residents currently in training at the nearby Maine Medical Center. She's got all their photos hanging on the bulletin board in her office, but she knows that finding one to take on a solo practice won't be easy.

Dr. CRUTE: It's probably going to have to be someone that doesn't have a huge debt.

ROVNER: Which doesn't leave a very large pool of young doctors finishing their medical training. And she's competing for those residents with local hospitals and huge doctor groups like Martin's Point, located across town. Some on her staff derisively call it Wal-Mart. But Wal-Mart or not, those groups can offer something she can't: some certainty that they can begin to pay back their medical school loans.

Dr. CRUTE: That's probably the biggest roadblock to having a small practice because I can't guarantee somebody a salary coming out of residency.

ROVNER: So for her patients and for Cathy Crute, the clock is ticking.

SIEGEL: And Julie Rovner is here in the studio with us today, and, Julie, you went to Maine because that state is leading efforts to solve this problem of the primary care shortage. What are they doing?

ROVNER: Well, one of the things they're doing is pioneering something called the medical home, and it's a way to bring together heath professionals as a team - doctors, nurses, other types of health professionals - to really take some of these big groups - in fact, Martin's Point, one of the groups we heard about in that piece...

SIEGEL: Just heard about them.

ROVNER: ...that's right - is one of the places that's doing this. And it's really an effort to make some of these big groups act more like the very small groups that we just heard about, make it really seem more like a place where everybody knows all the patients. So that was one of the things that I really wanted to see by going to Maine.

SIEGEL: Hence, the homey name.

ROVNER: Indeed.

SIEGEL: And this is what you will be reporting on tomorrow?

ROVNER: Yes, I will.

SIEGEL: Okay. And it also was summertime when you went to Maine. That was another reason for choosing it, perhaps?

ROVNER: It didn't hurt.

(Soundbite of laughter)

SIEGEL: Okay. NPR's Julie Rovner.




