Going to the doctor can be enough of a hassle, from having to make an appointment, to filling out stacks of paperwork, and of course, the universally-dreaded waiting room. But for some, the biggest issue is finding is a hospital to provide the basic care that they need to maintain their health. Nathan shows how, as a result of unequal physician distribution, more people are suffering from preventable diseases as a result of inadequate access to physicians.

In a sleepy Dallas, Texas suburb, a well-dressed man checks his watch nervously as he leaves his house late for his biannual visit to his primary care physician of over 15 years. Just five miles south, in the heart of Dallas, another man takes three red pills for his backache as he leaves his house for work. His wife stops him at the door and reminds him of his appointment with the orthopedic surgeon; it has been over a year since he has seen any doctor and even longer since he has had any insurance, but his wife is worried because his back pain isn’t going away like it usually does. Across the state line, in a New Mexican rural township, a third man unexpectedly collapses on a construction site and is rushed to the closest hospital several miles away. The diagnosis is a stroke and he is found to have untreated high blood pressure and high cholesterol with his last recorded medical visit at a hospital a town over almost five years prior.

Unfortunately, in the current United States health system, scenes like these can be accurate snapshots of healthcare experiences faced by everyday Americans. These anecdotes, in addition to broad research studies, reveal an alarming disparity: while some Americans seem to be getting necessary care, other Americans do not seem to be receiving any care at all. One of the most significant determinants for the type of healthcare access an American individual will receive is their geography.1 Studies have increasingly found that where you live can play a huge role in answering related health care behaviors questions: How often do you visit the doctor? When do you seek healthcare services? Do you effectively maintain long term treatment plans?1

In the second and third scenes, two men are placed in drastically different locations, an inner-city and a rural setting, respectively. However, both men seem to share similar problems, both unable to access healthcare services and seek medical care prior to their acute symptoms. Americans living in the inner city are at some of the highest risks for being uninsured. Over eight in ten of the uninsured are in low- or moderate-income families, which make up most inner-city populations.2 The uninsured are some of the most likely to go without medical care due to cost and least likely to receive preventative care services.2

Similarly, Americans living in rural settings will avoid medical care and express fewer preventative behaviors due to geographical barriers. About 20% of the US population lives in rural areas, but only 9% of the nation’s physicians practice and live in rural communities.3 While the second man lacks the necessary insurance coverage for health services associated with living in the inner-city, the third man is geographically isolated in the rural town from convenient health providers.

In contrast, Americans living in suburbs and affluent metropolitan hubs, represented by the first scene, have the best access to healthcare, as confirmed across studies on multiple measures of geographic access, including physician-to-population ratios and average distance traveled to the nearest physician.4

However, it is not just an issue of where Americans are choosing to live, but also an issue of where America’s physicians are choosing to live. The United States currently does not actively monitor the geographic distribution of its physician workforce, nor does it actively regulate the type and number distribution of physicians. Health care professionals themselves choose where to work and what type of work they want to do. As a result, workforce distribution and, by consequence, patient access, relies on competing market forces like the annual physician income per region.5 In effect, the limited scope of regulation on physician distribution has driven most physicians to subspecialize and live in large metropolitan areas and affluent suburbs where they are paid more, especially for specialized care, and have access to more desirable living comforts.5 And, specialized medicine is more highly paid  than primary care. Specialized physicians will make 1.5 times more money over their lifetime than primary care physicians on average.6 Looking at visualizations of physician distributions, it is clear physicians have refused to live in rural areas and work in inner-city locations, effectively creating “physician deserts” in these areas.7

This trend continues if not worsens in light of recent physician shortage predictions. A recent report published by the AAMC Center for Workforce projects that, by 2025, the United States may face a shortage of between 14,900 and 35,600 primary care physicians.8 Additional reports from medical publications like the Annals of Family Medicine, expect with population growth considered and the sudden addition of insurance holders under the Affordable Healthcare Act, an even greater shortage of 52,000 primary care physicians.9 With these shortages, there is a compounding of an already drastic situation. With few doctors who choose to become primary care physicians and even fewer who decide to live in rural and inner city areas, these shortages will impact already struggling regions. The primary care dilemma is one of interrelated issues based on the current incentives presented to aspiring physicians.

Still, research shows that populations with a higher primary care to specialization ratio are generally healthier and have better overall health outcomes.10 Access to primary care allows people to seek treatment before more severe problems occur.10 Primary care availability encourages preventative health care behaviors, leading to fewer emergency department visits and hospital admissions.10 Higher distributions of primary care physicians in an area are associated with lower mortality rates, even after the effects of poverty rates, education, and lifestyle factors are considered.10 In addition, having a primary care physician is associated with increased trust and treatment compliance in patients.10 Primary care accessibility enhances the entire performance of the health care system from efficacy to satisfaction.

What this means for healthcare reform, now, is a new look on the value of the primary care physician in the fight against health disparities. Primary care physicians play a key role in preventative health care behaviors and have proven to be effective in improving both overall health outcomes and geographic health equality. What kinds of steps are needed to incentivize and legitimize the primary care profession once more? Questions like these will lead healthcare conversations on the primary care dilemma, if the sheer data does not.

References

  1. Arcury, T. A., Gesler, W. M., Preisser, J. S., Sherman, J., Spencer, J., & Perin, J. (2005). The Effects of Geography and Spatial Behavior on Health Care Utilization among the Residents of a Rural Region. Health Services Research, 40(1), 135-156. doi:10.1111/j.1475-6773.2005.00346.x
  2. 29, 2. S. (2016, October 04). Key Facts about the Uninsured Population. Retrieved April 09, 2017, from http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population
  3. Rosenblatt, R. A. (2000). Physicians and rural America. Western Journal of Medicine, 173(5), 348-351. doi:10.1136/ewjm.173.5.348
  4. Rosenthal, M. B., Zaslavsky, A., & Newhouse, J. P. (2005). The Geographic Distribution of Physicians Revisited. Health Services Research,40(6p1), 1931-1952. doi:10.1111/j.1475-6773.2005.00440.x
  5. Why Are There So Few Doctors in Rural America? [OLGA KHAZAN]. (2014, August 28). Retrieved April 9, 2017, from https://www.theatlantic.com/health/archive/2014/08/why-wont-doctors-move-to-rural-america/379291/
  6. Phillips RL Jr, et al.; Robert Graham Center. Specialty and geographic distribution of the physician workforce: what influences medical student and resident choices? March 2009, from http://www.graham-center.org/online/graham/home/publications/monographs books/2009/rgcmo-specialty-geographic.html
  7. Murthy, S. (2016, May 26). Visualizing America’s health care deserts – Sohan Murthy – Medium. Retrieved April 09, 2017, from https://medium.com/@sohanmurthy/visualizing-americas-health-care-deserts-675f4502c4e1
  8. The Complexities of Physician Supply and Demand: Projections from 2014 to 2025 (Rep.). (2016). Retrieved April 9, 2017, from IHS Inc. website: https://www.aamc.org/download/458082/data/2016
    Report prepared for Association of American Medical Colleges
  9. Petterson, S. M., Liaw, W. R., Phillips, R. L., Rabin, D. L., Meyers, D. S., & Bazemore, A. W. (2012). Projecting US Primary Care Physician Workforce Needs: 2010-2025. The Annals of Family Medicine, 10(6), 503-509. doi:10.1370/afm.1431
  1. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly. 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x.

Posted by Nathan Magalit

Nathan Magalit is a California-native pursuing a major in Public Health Studies. In his Sophomore year, now, he is a member of the HMR Domestic Health Team, a weekly volunteer at the Baltimore Rescue mission, and a JHH Emergency Department aide. His work focuses primarily on the systematic issues that have contributed to the United State's healthcare inequalities. He is an aspiring medical doctor and healthcare reformer and believes the medical journal is one of the most important sites for changing medical thought.

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