Primary Care Practitioners Feeling Squeezed

April 25, 2015
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Possible solutions may include more technology, physician extenders and seeing children less often.

The Physicians Foundation’s recent survey of practice, patterns and perspectives found 44 percent of U.S. doctors plan to cut patient access, a move that both reflects and potentially exacerbates trends troubling pediatric medicine. Eighty percent say they can handle no more patients or already have too many.

The growing number of patients with behavioral or chronic and complex conditions and a shortage of pediatric subspecialists are already shifting work onto primary care pediatricians. The additional millions insured under the Affordable Care Act and the emphasis on creating a patient-centered medical home are sources of consternation for some, but the lead authors of the 2013 American Academy of Pediatrics Pediatrician Workforce Policy see them as improvement opportunities.

“A lot of physicians feel overloaded with their practice, and that varies by where they practice,” says Mary E. Rimsza, MD, chair of the AAP Committee on Pediatric Workforce. In rural areas and underserved neighborhoods, she says, “We find primary care pediatricians work longer hours and take care of more complex cases compared to areas where patients have access to subspecialists.”

While nearly half of all doctors in the Physicians Foundation survey give the ACA a grade of D or F, Dr. Rimsza says the act has been positive for pediatrics. “Certainly, it’s better for pediatricians that more kids are insured and Medicaid has been expanded,” she said. More secure sources of funding encourage pediatricians to open and keep practices.

Dr. Rimsza and William T. Basco, MD, MS, director of the Division of General Pediatrics at the Medical University of South Carolina, are lead co-authors of theAAP’s Workforce Policy. To deal with growing caseloads affecting primary care doctors, they endorse more use of technology, but to different degrees.

“Increasing the use of telemedicine may help,” Dr. Rimsza says. “It may not be financially feasible to set up a pediatric cardiology practice in a small town, but using telemedicine can make it possible for a pediatric cardiologist to assist the primary care pediatrician to provide care in the child’s medical home.”

Another option is to expand services provided in the medical home by a nurse practitioner or physician assistant. Either could see a healthy 6-year-old with a cough but no fever. The pediatrician would see the 6-year-old with cerebral palsy, a cough and fever, Dr. Bacso says. “That’s a model we’re slowly evolving to now.”

But Dr. Basco also sees medical homes as the place to make serious changes. “I’m not sure the AAP would endorse this,” he says. “But do I really need to see every child every year?”

Instead, a practice could send an email asking the technology-literate parent of a 6-year-old to fill out online behavioral, physical and cognitive development screens, Dr. Basco suggests. The practice reviews them and if the child passes, it emails the parent saying so, scheduling a vaccine visit or eye or hearing screening if needed, and saying, “We’ll do this again next year.”

“That’s almost heresy,” Dr. Basco admits. “But I think for a huge proportion of 6-year-olds, that may be all that’s needed.”


  1. Basco WT, Rimsza ME; Committee on Pediatric Workforce; American Academy of Pediatrics. Pediatrician workforce policy statement. Pediatrics. 2013 Aug, 132(2):390-7.
  2. The Physicians Foundation. 2014 Survey of America’s Physicians: Practice Patterns and Perspectives. 2014 Sep.