Today, generalist physicians are a third of the U.S. physician workforce and are responsible for more than half of all patient visits at doctors' offices.

"Concern about the supply of generalists is not new," said Colwill, who also is a member of the National Academy of Sciences Institute of Medicine. "It has been with us since the 1960s and was gradually improving. However, during the past decade, the number of generalist graduates has fallen by 22 percent and declines continue as medical school graduates enter other specialties. At the same time, the U.S. population is increasing by about one percent each year, and the baby boomer generation will significantly increase the number of Americans older than 65 by 2025.

In the study, which was published in a recent edition of Health Affairs, Colwill and co-researchers, James Cultice from the U.S. Health Resources and Services Administration and Robin Kruse from the University of Missouri, used data from the National Ambulatory Medical Care Survey to estimate the future demand for generalist care. The Census Bureau predicts that the number of adults will increase 21 percent by 2025, and the number of Americans older than 65 will rise by 73 percent.

Typically, older adults seek care from generalists nearly three times each year, double the rate of adults younger than 65. Because of this, Colwill and his researchers expect the number of doctor visits to increase by 29 percent by 2025. At the same time, they project that the supply of general internists and family physicians will increase less than 5 percent.

"As patient numbers rise, these practitioners will be doing more 'urgent care' and will have less time for preventive services, coordinating care with other specialists, and getting to the depth of their patients' problems," Colwill said. "This will increase the load on other, already overloaded specialists and lead to even more referrals and increased costs of care. We need to change the incentives by making primary care practice more manageable and income comparable with that in other specialties."

Colwill strongly endorsed development of new models of primary care called "medical homes" where teams of physicians, nurse practitioners, physician assistants and others provide comprehensive primary care services that also focus on management of patients with chronic illnesses. These models promote more access through expanded hours and use of telephone, e-mail and electronic medical records. If appropriately reimbursed, these models should increase quality, reduce overall costs and improve both patient and physician satisfaction.

"At the same time, numbers of graduates must be increased," Colwill said. "Students' interest in generalist careers can be enhanced if medical schools renew their commitment to the education of generalists as they have done earlier. Further, incentives such as forgiveness of loans for primary care practice would tip the scales for many medical students and residents as they select a specialty and type of practice."

The Association of American Medical Colleges recommends that medical schools increase their enrollment by 30 percent, but have not indicated specific specialty areas for the increase. Colwill said this enrollment increase could result in more specialists, but little increase in primary care physicians if the incentive for becoming generalists is not examined soon.

Source: University of Missouri-Columbia