state, getting as low as 4.6 PCPs per 10,000 people in counties like Sherman. This primary care doctor shortage is not unique to Oregon—it’s happening across the entire U.S. Research consistently shows that primary care is the foundation of an effective health care system. Having good access to primary care physicians not only improves patient outcomes, it lowers mortality rates. But for a variety of reasons—partly because we have a fee-for-service system and partly because we’ve underinvested in primary care at the federal and state levels for decades — primary care doctors in the U.S. are in short supply. The U.S. has fewer primary care physicians as a share of its population than almost any other rich country. One Ailment, Many Causes There are many reasons we lack a sufficient number of primary care doctors in this country. First, medical students are less and less likely to go into family medicine because it doesn’t pay as well as specialties like cardiology, dermatology or neurosurgery. When you have looming medical school debt, an annual salary of $587,360 (for cardiology) is more enticing than a salary of $318,959, which is the average family-medicine salary in the U.S. according to the latest figures from Doximity. (This same Doximity report shows that when compensation is adjusted for cost of living, Portland is the city with the 10th worst compensation for any type of doctor in the U.S.) Second, policy shifts at the national level have kept the number of residencies in family medicine artificially low. Primary care residencies are important to increasing the number of PCPs in the state because research shows that over half of all family medicine residents end up practicing within 100 miles of their residency. In their new book, Abundance, authors Ezra Klein and Derek Thompson point to federal policy failures. “In the early 1980s, a special committee established to review the state of American medicine reported to the U.S. Department of Health and Human Services that the U.S. was on the verge of a massive surplus of doctors,” they write. “Physician groups backed up the finding…. Starting in the 1980s, the government cut its support for medical schools and medical students, and many universities agreed to freeze the number of new studies and stop construction on medical programs.” Between 1980 and 2005, they report, the number of medical school graduates “flatlined.” The policy of “deliberate scarcity,” they write, succeeded. The result was a scarcity of residency slots at medical schools—and the result of that was a shortage of doctors, especially primary care physicians. The Balanced Budget Act of 1997 also did not help, says Eric Wiser, MD, FAAFP, assistant dean of rural undergraduate medical education at OHSU. That law basically capped the number of residencies per institution to the number it was in 1997. And obviously, since population is far bigger now than it was 28 years ago, that number is inadequate virtually everywhere in the nation. So-called “capped naive” hospitals — those that didn’t have any residencies in 1997 — could create a residency program and then, in five years, it would be capped to however many residents it had. Residencies, which are mostly paid for by Medicare, are expensive for hospitals or Fed- “We will never solve the problem of shortages of health care providers in rural areas unless we start educating rural kids in science and show them a pathway in which they can actually succeed.” ROBERT DUEHMIG, DIRECTOR OF RURAL HEALTH, OHSU Robert Duehmig is the director of Rural Health at OHSU. 23
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