mgh primary care doctors :: Article CreatorWhat's Behind The Shortage Of Primary Care Doctors?
Welcome, everyone. I'm Dr. John Whyte. I'm the chief medical officer at WebMD. Have you tried getting a doctor's appointment lately? It can be hard. You might have to wait several weeks to see your primary care physician. And that's because there aren't enough primary care physicians around.
People are not going into it. People are retiring early, concerned about burnout, how much they're compensated, the prestige of the profession. So how do we fix it? So whenever I have a difficult question, I go to my very good friend, Dr. David Nash, the founding dean emeritus, The College of Population Health at Jefferson in Philadelphia. David, thanks for joining me.
DAVID NASH
Hey, John. Thanks so much. I really appreciate it. Great to be together.
JOHN WHYTE
You and I were chatting a few weeks ago, and I said to you, David, why would anyone go into primary care right now? We say it's the backbone of our healthcare system. But then we don't financially reward them. We don't give them the prestige. So why would anyone go into it?
DAVID NASH
Yeah. Well, let's start with some of the research evidence. If you look around the world, here's what's so uncanny and why I have such a hard time with this whole question. In every developed nation that we aspire to be like in terms of improving health status, there are three primary care doctors to every specialist, right?
In America, the ratio is uncannily exactly the opposite, three specialists to every primary care doctor. Primary care doctors are not just the quarterback and the coordinator. As you said, John, they're the backbone, meaning they are the patient educators. They are the folks who keep the specialists on track, who connect the dots for patients, who are the early warning system, who do the follow-ups, who talk with families.
Look, I've been around a long time, and I've been a patient. My family, everybody I know, it is a difficult situation. I don't know a single doctor who says that, oh, accessing healthcare is easy for them and their family, and in part because there aren't enough primary care doctors. But I want to establish the research basis for this conversation, which says primary care doctors lower costs and improve health.
JOHN WHYTE
You referenced at the beginning the role of primary care. But let's admit, there really is an identity crisis right now for PCPs. What are they? Are they the backbone? Are they the jack-of-all-trades which isn't celebrated? Are they the gatekeeper? Some people feel like they're the gatekeeper in their insurance system to actually see the doctor they want. So what's their identity, and how do we elevate it?
DAVID NASH
It's a crazy thing, isn't it? You and I remember when the term gatekeeper first came into our lexicon, right? And it sounded like a pretty good idea that we would control access and so on. And here we are, probably 25 years later, and we're still using that term because it's still applicable.
But I think to answer your great question, there is a big cultural shift at work. We have to reflect on the millennial culture, which is they're not going to do what we did for good reason. So the production function, as you would say in microeconomics, is there's fewer people doing a lot more work in a much more complicated environment.
Also, second change is more technologic, which is care is way more complicated. People are in the hospital way shorter. A third change is our good friend and my colleague Bob Wachter, who invented the term hospitalist.
JOHN WHYTE
We didn't have that when you and I--
DAVID NASH
We didn't have that. Listen, in medical school, there was mythology, which I call it the mythology of the triple threat, right? Office, hospital, research, and teaching, we could do it all. Well, it wasn't true then, and it's not true today.
And so the hospitalist movement was born out of the tactical reality that care was too complicated to leave to old guys and gals who had trained decades ago. And so the birth of the hospitalist movement separated folks who might have then gone into primary care. And my fantastic hospitalist leader daughter is a great example of many-- not the only one, of course, of many young people who said, yeah, I want to be an internist, but in reality, I'm not doing that gatekeeper stuff. I'm staying in the hospital where I'm comfortable. I'd much rather treat septic shock than a scratchy throat.
JOHN WHYTE
And it's always about policy. And you've been a policy wonk for 30-plus years, and you think about these things. So the issue is when we think about policy in healthcare, it's usually directed at hospitals, health systems, maybe the specialties.
And it's typically around issues of payment, let's be honest. If we didn't pay for hospitalists, we wouldn't be having people in there. So how do you use policy to drive some of these changes that you just talked about in terms of the culture, the technology, the platforms?
DAVID NASH
All right, so we got to do a little bit of background because you can't know where you're going until you know where you've been, right? So in America, interns and residents in joint commission and Medicare-approved training programs, where do their salaries come from? Hello, everybody. GME money comes directly from CMS.
So your tax dollars are paying the salaries of doctors in training. And that money goes to the hospitals with a direct payment and an indirect payment. So there's direct GME and indirect GME, and this is in the billions of dollars. Roughly $18 billion from Medicare goes to support the tens of thousands of house officers.
So one policy would be, hey, let's reallocate the dollars away from specialty training to primary care. This mostly has been tried by a federal agency, HRSA, HRSA, Health Resources Service Administration. Very modest success.
JOHN WHYTE
Why?
DAVID NASH
Well, because hospitals resist it. So let's be real. There's a lot of money, and we want primary care house officers to do the grunt work, but we still want to have our cardiology, pulmonary, GI, various--
JOHN WHYTE
Ortho.
DAVID NASH
--all funded. So let's get real. Some of this is we're resistant to increasing the total number of primary care slots. That's one challenge. The other challenge is how the money is allocated at the local level. When the money hits the door, then there's the internal allocation, John, within the academic training institutions. And I'm not picking on any one in particular, certainly not.
But there's 145 major academic medical centers in America, 140-plus allopathic med schools. They all have their own internal allocation formula for who gets the money. Is isn't the chief of surgery, chief of medicine, chief of OB? How's that going? With very little outcome measure connected to the longterm training.
So nobody really is responsible at the training level, understandably, for the outcome at the societal level. So there's a policy disconnect about primary care. And then and now, we have a downstream impact of this policy, which is unionization. Holy mackerel, right?
You've seen the headlines, 400 primary care doctors at the mass general are going to join a union. And in my own city, Philadelphia, five medical schools, 3,000 house officers are going to join a union. Oh, boy. I mean, we could spend a whole program just on that. To me--
JOHN WHYTE
Good and bad. There's good and bad on that.
DAVID NASH
Right. But it's a downstream effect of what we're talking about here.
JOHN WHYTE
And part of it is partly because people feel they're overworked, they're not getting paid, they're burnt out, they're not treated with respect. So that's where, often, collective bargaining can come in.
DAVID NASH
I want to go back to one other policy, explicit and the implicit culture, right? The implicit culture is, look at those poor, bedraggled general internists doing most of the inpatient teaching because their unit opportunity cost is low. You're not going to see typically pulmonary GI, other specialists, doing the bulk of the general internal medicine bedside teaching. Their time is too valuable.
So the opportunity cost of keeping a person who does procedures, letting her teach, that cost is too high. So we have to recognize that there are economic incentives driving the primary care challenge, too.
JOHN WHYTE
David, everyone talks about disruption. That's the new buzzword, disruptor. So how do things like AI, digital tools, help disrupt? Is it going to be primarily in primary care, in the sense that it's going to be the role of chatbots, it's going to be augmented intelligence? Is that where we're going to see real disruption, and maybe that can elevate primary care as a profession?
DAVID NASH
Great question. I have two ideas, but first, let me tell the story because, you know-- look, I'm following ChatGPT. I've even started to pay for ChatGPT 4.0, which is wicked cool stuff. So ChatGPT 2.0 got an 85 on the boards. I got a 79, and I studied my little tail off. That's all to say, holy mackerel, this is a powerful tool.
Its immediate impact on primary care is evolving, right? Because machine learning as a part of AI is really in repetitive areas, reading EKGs, reading X-rays, reading, biopsy slides, right? So we're going to start to see more applications of AI in terms of especially patient communication, that you'll be able to-- AI will be able to write letters to patients, write letters to consultants. That will unburden primary care doctors.
So I don't see it as a job threat in any way. I see it as a primary care enhancement, to answer your question. It will tackle the overutilization issues. I also think, John, AI will give great feedback to primary care doctors.
Let me give you another scenario that I know two companies working on this. Hey, Dr. Nash, primary care doctor, you want to refer your patient to this cardiologist, we don't think that's a good idea. We want you to send to this cardiologist because she, according to our algorithm, returns patients, is a great communicator, doesn't overutilize, has high patient scores, and we gleaned all that with our AI algorithm. OK, that gives me, the primary care doctor, a little bit more information in the marketplace.
JOHN WHYTE
So we opened our interview with, why would anyone go into primary care? And you talked about the backbone, all the important things in terms of reducing costs, improving outcomes. So I'm going to end with that again to you, David, but maybe phrase it a different way. What would be your advice to someone who's at the point where they're considering primary care versus one of the specialties? The fourth-year or third-year medical student, what do you tell them, David?
DAVID NASH
Yeah, great question. Here's what I tell students, you got to do what you love. You got to do what you love. It's too hard a job to say, don't do it because you're going to be working hard or your salary is going to be lower. So my first piece of advice is, you got to find what you love to do, but you have to recognize that it's not a lifetime decision forever, that medicine is changing so rapidly, and tools, like you mentioned, AI and others, changes in the reimbursement system.
But I'll end with this, John, which is I tell every student, whatever you do, if you go to primary care, get the extra training to become a leader. Because what I've been about is training leaders, doctors, nurses, pharmacists, but what we need in our whole $4 trillion industry is more leadership from the people on the front lines. And there's research evidence that clearly shows, you want to reduce burnout in primary care doctors, give them a stake in the operations.
Give them leadership training so that they're a part of how the place is organized, how the resources are allocated, and give them training on how to improve. So I'll close with this, doctors have two jobs every day, primary care doctors especially. We have two jobs every day. Job one, the job of doctoring, doing all that hard work on the front lines. And job two, getting the tools and the learning on how to improve job one. That is how you reduce burnout, and you make primary care primary in our system.
JOHN WHYTE
That's why I go to you. That's what I said in the beginning that I always go to you for advice. So Dr. David Nash, thank you for sharing your insights and really helping us rethink about the role of primary care.
DAVID NASH
Thank you, John. It's a pleasure to be together.
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JOHN WHYTE
Welcome, everyone. I'm Dr. John Whyte. I'm the chief medical officer at WebMD. Have you tried getting a doctor's appointment lately? It can be hard. You might have to wait several weeks to see your primary care physician. And that's because there aren't enough primary care physicians around.
People are not going into it. People are retiring early, concerned about burnout, how much they're compensated, the prestige of the profession. So how do we fix it? So whenever I have a difficult question, I go to my very good friend, Dr. David Nash, the founding dean emeritus, The College of Population Health at Jefferson in Philadelphia. David, thanks for joining me.
DAVID NASH
Hey, John. Thanks so much. I really appreciate it. Great to be together.
JOHN WHYTE
You and I were chatting a few weeks ago, and I said to you, David, why would anyone go into primary care right now? We say it's the backbone of our healthcare system. But then we don't financially reward them. We don't give them the prestige. So why would anyone go into it?
DAVID NASH
Yeah. Well, let's start with some of the research evidence. If you look around the world, here's what's so uncanny and why I have such a hard time with this whole question. In every developed nation that we aspire to be like in terms of improving health status, there are three primary care doctors to every specialist, right?
In America, the ratio is uncannily exactly the opposite, three specialists to every primary care doctor. Primary care doctors are not just the quarterback and the coordinator. As you said, John, they're the backbone, meaning they are the patient educators. They are the folks who keep the specialists on track, who connect the dots for patients, who are the early warning system, who do the follow-ups, who talk with families.
Look, I've been around a long time, and I've been a patient. My family, everybody I know, it is a difficult situation. I don't know a single doctor who says that, oh, accessing healthcare is easy for them and their family, and in part because there aren't enough primary care doctors. But I want to establish the research basis for this conversation, which says primary care doctors lower costs and improve health.
JOHN WHYTE
You referenced at the beginning the role of primary care. But let's admit, there really is an identity crisis right now for PCPs. What are they? Are they the backbone? Are they the jack-of-all-trades which isn't celebrated? Are they the gatekeeper? Some people feel like they're the gatekeeper in their insurance system to actually see the doctor they want. So what's their identity, and how do we elevate it?
DAVID NASH
It's a crazy thing, isn't it? You and I remember when the term gatekeeper first came into our lexicon, right? And it sounded like a pretty good idea that we would control access and so on. And here we are, probably 25 years later, and we're still using that term because it's still applicable.
But I think to answer your great question, there is a big cultural shift at work. We have to reflect on the millennial culture, which is they're not going to do what we did for good reason. So the production function, as you would say in microeconomics, is there's fewer people doing a lot more work in a much more complicated environment.
Also, second change is more technologic, which is care is way more complicated. People are in the hospital way shorter. A third change is our good friend and my colleague Bob Wachter, who invented the term hospitalist.
JOHN WHYTE
We didn't have that when you and I--
DAVID NASH
We didn't have that. Listen, in medical school, there was mythology, which I call it the mythology of the triple threat, right? Office, hospital, research, and teaching, we could do it all. Well, it wasn't true then, and it's not true today.
And so the hospitalist movement was born out of the tactical reality that care was too complicated to leave to old guys and gals who had trained decades ago. And so the birth of the hospitalist movement separated folks who might have then gone into primary care. And my fantastic hospitalist leader daughter is a great example of many-- not the only one, of course, of many young people who said, yeah, I want to be an internist, but in reality, I'm not doing that gatekeeper stuff. I'm staying in the hospital where I'm comfortable. I'd much rather treat septic shock than a scratchy throat.
JOHN WHYTE
And it's always about policy. And you've been a policy wonk for 30-plus years, and you think about these things. So the issue is when we think about policy in healthcare, it's usually directed at hospitals, health systems, maybe the specialties.
And it's typically around issues of payment, let's be honest. If we didn't pay for hospitalists, we wouldn't be having people in there. So how do you use policy to drive some of these changes that you just talked about in terms of the culture, the technology, the platforms?
DAVID NASH
All right, so we got to do a little bit of background because you can't know where you're going until you know where you've been, right? So in America, interns and residents in joint commission and Medicare-approved training programs, where do their salaries come from? Hello, everybody. GME money comes directly from CMS.
So your tax dollars are paying the salaries of doctors in training. And that money goes to the hospitals with a direct payment and an indirect payment. So there's direct GME and indirect GME, and this is in the billions of dollars. Roughly $18 billion from Medicare goes to support the tens of thousands of house officers.
So one policy would be, hey, let's reallocate the dollars away from specialty training to primary care. This mostly has been tried by a federal agency, HRSA, HRSA, Health Resources Service Administration. Very modest success.
JOHN WHYTE
Why?
DAVID NASH
Well, because hospitals resist it. So let's be real. There's a lot of money, and we want primary care house officers to do the grunt work, but we still want to have our cardiology, pulmonary, GI, various--
JOHN WHYTE
Ortho.
DAVID NASH
--all funded. So let's get real. Some of this is we're resistant to increasing the total number of primary care slots. That's one challenge. The other challenge is how the money is allocated at the local level. When the money hits the door, then there's the internal allocation, John, within the academic training institutions. And I'm not picking on any one in particular, certainly not.
But there's 145 major academic medical centers in America, 140-plus allopathic med schools. They all have their own internal allocation formula for who gets the money. Is isn't the chief of surgery, chief of medicine, chief of OB? How's that going? With very little outcome measure connected to the longterm training.
So nobody really is responsible at the training level, understandably, for the outcome at the societal level. So there's a policy disconnect about primary care. And then and now, we have a downstream impact of this policy, which is unionization. Holy mackerel, right?
You've seen the headlines, 400 primary care doctors at the mass general are going to join a union. And in my own city, Philadelphia, five medical schools, 3,000 house officers are going to join a union. Oh, boy. I mean, we could spend a whole program just on that. To me--
JOHN WHYTE
Good and bad. There's good and bad on that.
DAVID NASH
Right. But it's a downstream effect of what we're talking about here.
JOHN WHYTE
And part of it is partly because people feel they're overworked, they're not getting paid, they're burnt out, they're not treated with respect. So that's where, often, collective bargaining can come in.
DAVID NASH
I want to go back to one other policy, explicit and the implicit culture, right? The implicit culture is, look at those poor, bedraggled general internists doing most of the inpatient teaching because their unit opportunity cost is low. You're not going to see typically pulmonary GI, other specialists, doing the bulk of the general internal medicine bedside teaching. Their time is too valuable.
So the opportunity cost of keeping a person who does procedures, letting her teach, that cost is too high. So we have to recognize that there are economic incentives driving the primary care challenge, too.
JOHN WHYTE
David, everyone talks about disruption. That's the new buzzword, disruptor. So how do things like AI, digital tools, help disrupt? Is it going to be primarily in primary care, in the sense that it's going to be the role of chatbots, it's going to be augmented intelligence? Is that where we're going to see real disruption, and maybe that can elevate primary care as a profession?
DAVID NASH
Great question. I have two ideas, but first, let me tell the story because, you know-- look, I'm following ChatGPT. I've even started to pay for ChatGPT 4.0, which is wicked cool stuff. So ChatGPT 2.0 got an 85 on the boards. I got a 79, and I studied my little tail off. That's all to say, holy mackerel, this is a powerful tool.
Its immediate impact on primary care is evolving, right? Because machine learning as a part of AI is really in repetitive areas, reading EKGs, reading X-rays, reading, biopsy slides, right? So we're going to start to see more applications of AI in terms of especially patient communication, that you'll be able to-- AI will be able to write letters to patients, write letters to consultants. That will unburden primary care doctors.
So I don't see it as a job threat in any way. I see it as a primary care enhancement, to answer your question. It will tackle the overutilization issues. I also think, John, AI will give great feedback to primary care doctors.
Let me give you another scenario that I know two companies working on this. Hey, Dr. Nash, primary care doctor, you want to refer your patient to this cardiologist, we don't think that's a good idea. We want you to send to this cardiologist because she, according to our algorithm, returns patients, is a great communicator, doesn't overutilize, has high patient scores, and we gleaned all that with our AI algorithm. OK, that gives me, the primary care doctor, a little bit more information in the marketplace.
JOHN WHYTE
So we opened our interview with, why would anyone go into primary care? And you talked about the backbone, all the important things in terms of reducing costs, improving outcomes. So I'm going to end with that again to you, David, but maybe phrase it a different way. What would be your advice to someone who's at the point where they're considering primary care versus one of the specialties? The fourth-year or third-year medical student, what do you tell them, David?
DAVID NASH
Yeah, great question. Here's what I tell students, you got to do what you love. You got to do what you love. It's too hard a job to say, don't do it because you're going to be working hard or your salary is going to be lower. So my first piece of advice is, you got to find what you love to do, but you have to recognize that it's not a lifetime decision forever, that medicine is changing so rapidly, and tools, like you mentioned, AI and others, changes in the reimbursement system.
But I'll end with this, John, which is I tell every student, whatever you do, if you go to primary care, get the extra training to become a leader. Because what I've been about is training leaders, doctors, nurses, pharmacists, but what we need in our whole $4 trillion industry is more leadership from the people on the front lines. And there's research evidence that clearly shows, you want to reduce burnout in primary care doctors, give them a stake in the operations.
Give them leadership training so that they're a part of how the place is organized, how the resources are allocated, and give them training on how to improve. So I'll close with this, doctors have two jobs every day, primary care doctors especially. We have two jobs every day. Job one, the job of doctoring, doing all that hard work on the front lines. And job two, getting the tools and the learning on how to improve job one. That is how you reduce burnout, and you make primary care primary in our system.
JOHN WHYTE
That's why I go to you. That's what I said in the beginning that I always go to you for advice. So Dr. David Nash, thank you for sharing your insights and really helping us rethink about the role of primary care.
DAVID NASH
Thank you, John. It's a pleasure to be together.
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400 Mass General Brigham Physicians Cleared For Union Vote
The National Labor Relations Board has sided with primary care physicians at Mass General Brigham's Massachusetts General and Brigham and Women's hospitals by allowing the proposed 400-member bargaining unit to proceed to union election, The Boston Globe reported.
The NLRB ruled April 18 that the primary care physicians belong in a single proposed bargaining unit, creating a path for a union election.
In 2024, physicians filed a petition with the NLRB, seeking an election to decide whether to join Doctors Council, an affiliate of the Service Employees International Union. After the filing, Mass General Brigham argued that 18 of the 29 work sites were ineligible from joining the bargaining unit, as they were acute-care hospitals.
The NLRB found instead that most of the 18 locations were not part of acute-care hospitals and were therefore eligible to join the proposed bargaining unit, and that some facilities adjoining Mass General Brigham's acute-care hospitals were eligible under "extraordinary circumstances," according to the Globe.
A ruling in favor of Mass General Brigham would have limited the proposed bargaining unit to about 100 physicians, Gabrielle Hanley, a lead organizer with the Doctors Council, told the newspaper.
The NLRB has set a date for an election to be conducted by mail. Ballots will be mailed to eligible employees May 6, and all ballots will be counted at the NLRB regional office in Boston on May 30.
"MGB tried to delay, divide, and discourage us — but we stayed united," Kristen Gunning, MD, a physician at MGH Bulfinch Medical Group, said in a union news release. "This ruling confirms what we've known all along: primary care physicians must have a collective voice to fight for our patients and our profession."
Mass General Brigham is reviewing the decision, a spokesperson said in a statement shared with Becker's. The statement also emphasized the importance of the work of primary care physicians.
"Primary care physicians are critical to the health of our patients and community," the statement said. "We know that PCPs across the commonwealth are facing unprecedented volume and stress as a result of a confluence of factors that are not unique to our organization. We share the common goal of offering world-class, comprehensive care for our patients and believe we can achieve this best by working together in direct partnership, rather than through representatives in a process that can lead to conflict and potentially risk the continuity of patient care."
Mass General Brigham may appeal the NLRB ruling.
Labor Board Ruling Sides With Union Against Mass General Brigham
The National Labor Relations Board (NLRB) has ruled in favor of Mass General Brigham (MGB) primary care physicians who are seeking to unionize.
Primary care physicians at MGB began organizing efforts for a union last year with the Doctors Council, the country's oldest and largest union of attending physicians. MGB filed with the NLRB seeking to block the unionization effort by arguing that many of the 400 doctors trying to unionize did not belong in the same bargaining unit.
The April 18 NLRB ruling rejected MGB's claim, clearing the way for the primary care physicians to hold a union election in May.
MGB declined a HealthLeaders' request for an interview about the NLRB ruling, but the health system provided a prepared statement.
"Primary care physicians are critical to the health of our patients and community," the prepared statement says. "We know that PCPs across the Commonwealth are facing unprecedented volume and stress as a result of a confluence of factors that are not unique to our organization. We share the common goal of offering world-class, comprehensive care for our patients and believe we can achieve this best by working together in direct partnership, rather than through representatives in a process that can lead to conflict and potentially risk the continuity of patient care."
The prepared statement says MGB is reviewing the NLRB ruling.
Zoe Tseng, MD, a primary care physician at Brigham and Women's Primary Care Associates of Longwood and a union organizer, told HealthLeaders that her colleagues were confident the NLRB would rule in their favor.
"We expected this outcome," Tseng said. "We were confident that the bargaining unit that we had established was the proper one—it included all primary care physicians."
Tseng called MGB's bargaining unit objection a delay tactic.
Doctors' motivations for forming a union
MGB's primary care physicians are seeking to unionize for several reasons, including the lack of a voice in decision making and onerous working conditions, according to Tseng.
"We have had a very limited voice in the decisions over the years, and it has gotten worse," Tseng said. "We want to be able to represent the patients and the clinical staff that we work with. We want to advocate for resources and the services we need to do adequate primary care for our patients."
"We have understaffing—there are not enough staff to help us with administrative tasks, whether that be paperwork, getting patients the prescriptions they need authorized, or answering phone calls," Tseng said. "That burden is falling on primary care physicians as we try to see patients."
MGB has not invested in primary care, instead concentrating on more lucrative specialty care, according to Tseng.
"They have had the opportunity to lead in investing in primary care as a world-class institution, but they have chosen not to," Tseng said. "Instead, they have built up their specialty care."
Primary care is an essential service for a high-functioning health system, Tseng explained.
"You get into a crisis when you do not build a foundation for primary care," Tseng said.
Forming a union will give the primary care physicians more sway at MGB, according to Tseng.
"The reason for the union is so we can hold them accountable for all of the things that we need and they have promised," Tseng said. "As we have seen over the years, promises have often been empty."
Photo: Primary care physicians affiliated with Mass General Hospital and Brigham and Women's Hospital (BWH) hold an informational picket line outside BWH in December.
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