Doctors Shun Primary Care, Nurse Practitioners and Physicians Assistants Do Too

There is a physician shortage in the United States that is especially acute in primary care, according to the Association of American Medical Colleges. The physician shortage could reach 86,000 doctors by 2036, of which nearly half of the missing doctors could reflect shortages in primary care. One reason is demographics. The average age of physicians is 47 for women and 55 for men. Many of the older practicing physicians are among the Baby Boomer generation, who will be retiring soon and need care for themselves as they grow old. Another reason for the shortage is a 1996 federal law capping the number of graduate medical education training slots that Medicare will fund.

A partial solution is expanding the scope of practice for so-called mid-level providers, nurse practitioners (NPs) and physicians’ assistants (PAs). In recent years many states have granted more practice autonomy for NPs and PAs. Mid-level providers are an area of growth in the medical industry. Between 2016 and 2021 the number of NPs increased by 75%, while the number of PAs rose by 43%. However, only about one-third of NPs want to be primary care providers, while less than one-third of PAs want to work in primary care. Here is what Kaiser Health News had to say:

For many patients, seeing a nurse practitioner has become a routine part of primary care, in which these “NPs” often perform the same tasks that patients have relied on doctors for.

But NPs in specialty care? That’s not routine, at least not yet. Increasingly, though, nurse practitioners and physician assistants are joining cardiology, dermatology, and other specialty practices, broadening their skills and increasing their income.

Over the years I’ve spoken with many doctors, and I have yet to find one who said he or she hated primary care. Indeed, I’ve met numerous physicians who said they felt drawn to primary care because they liked helping people, but often ended up working in a physician specialty. One reason is medical school professors often encourage their students to specialize. Another reason is that primary care pays only about half what many specialties pay. In addition, many doctors say they enjoy the idea of being among the best at something among peers, such as cardiology for example. However, many physicians also admit that the difference in pay and prestige between primary care and a specialty drove them away from primary care. It should come as no surprise that NPs and PAs are experiencing similar feelings about primary care. They too are being drawn to specialty practices where they can earn more money.

They’re succumbing to the same challenges that we have with physicians,” said Atul Grover, executive director of the Research and Action Institute at the Association of American Medical Colleges. The rates NPs can command in a specialty practice “are quite a bit higher” than practice salaries in primary care, he said.

About 88% of nurse practitioners are certified in an area of primary care, according to the American Association of Nurse Practitioners. But it is difficult to track exactly how many work in primary care or in specialty practices. Unlike physicians, they’re generally not required to be endorsed by a national standard-setting body to practice in specialties like oncology or cardiology, for example. The AANP declined to answer questions about its annual workforce survey or the extent to which primary care NPs are moving toward specialties.

The average annual starting salary for nurse practitioners and PAs in specialty care is $172,544, slightly higher than those in primary care ($166,544). Over the next eight years NPs are expected to increase by 45%, while PAs are expected to grow more than one-quarter (27%). They will be needed in all areas of medicine, but a key to maintaining access to care will be enticing some to practice primary care.

A major reason for the physician shortage is the bottleneck in residency training positions. The U.S. also maintains a protectionist system that requires foreign-trained physicians, even those who’ve been practicing in a developed country, to repeat residency before being allowed to practice in the United States. One way to boost primary care physicians would be to expand primary care residency graduate medical training slots. Another way may be to fund scholarships for NPs and PAs who agree to practice primary care for a set number of years.

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