Over the last eight years, Oregon has seen growth in the number of primary care providers, but according to experts, the state will need more than a 40% increase in practitioners to meet growing demand in the next decade.
Betsy Boyd-Flynn is the CEO and executive director of the Oregon Academy of Family Physicians. Jane Akpamgbo is a family physician for Kaiser Permanente and president-elect of OAFP. Eva McCarthy is a core faculty physician for Samaritan Health Services’ Family Medicine Residency Program and current president of the organization. They join us to share more about the challenges physicians are facing in the state and what could be done to change that.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Jenn Chávez: This is Think Out Loud on OPB. I’m Jenn Chávez, in today for Dave Miller. When it comes to your health, before the specialist, before urgent care or the ER, before a hospital stay, you wanna see a primary care provider. These providers are often your first contact with the healthcare system. They consider all aspects of your health, and they stick with you to manage your health over time. But for many reasons, there is a shortage of physicians like these in the U.S., and that includes Oregon. Though the state has seen a growth in the number of primary care doctors in recent years, some experts predict that the state will need 40% more of these physicians over the next 10 years to meet future demand.
Why does this shortage exist and what can be done? For perspective on this, I’m joined today by three guests: Betsy Boyd-Flynn is the executive director and CEO of the Oregon Academy of Family Physicians or OAFP; Jane Akpamgbo is a family physician for Salem Kaiser Permanente, the pioneer physician for the Northwest Permanente Center for Black Health and Wellness and the president-elect of OAFP; and Eva McCarthy is a core faculty physician for Samaritan Health Services’ Family Medicine Residency Program and the current president of OAFP. Betsy, Jane and Eva, thank you for being here. Welcome to Think Out Loud.
Betsy Boyd-Flynn: Thank you, Jenn.
Eva McCarthy: Oh, hi Jenn. Thank you.
Chávez: Hi, everyone. So Betsy, I want to start off with you. I described a little bit of what primary care providers do, but can you, in a basic sense, tell us what is considered primary care and what kind of health professionals fall under this category?
Boyd-Flynn: Sure, that’s a great question. And the answer for Oregon is a little bit unique. So primary care clinicians include physicians – people with MD degrees or DO degrees. They also in Oregon include naturopaths, and physician associates can also be considered primary care clinicians for purposes of, how does Medicaid count who’s giving primary care.
Chávez: What do we know about the number of primary care clinicians nationwide? How far short are we of what’s needed?
Boyd-Flynn: It’s a good question and it’s a hard one to answer with the exact [inaudible]. And that’s in part because we don’t have a national database of primary care clinicians. What we know is we have numbers of who is licensed in a specialty that counts as primary care – pediatrics, internal medicine, family medicine – but we don’t know how much those folks are working necessarily and we don’t know how many clinics might be working in. So some of my members, who have academic appointments or work for health plans, also may work in one or two clinics, one or two days a month. And we don’t know, from looking at the data we have access to, whether those folks are counted as a full clinician or just as a point to the clinician.
So one of the things folks who talk about primary care policy talk about is the desperate need for a comprehensive set of data that tells us who is practicing, who is working and where are they working, and do they have capacity for new patients?
Chávez: Oh, interesting. So there’s not only a problem with the amount of care but also just data to demonstrate how much we actually have.
Boyd-Flynn: Yes. Exactly.
Chávez: Oh, interesting.
Boyd-Flynn: This shows up in problems like people who are trying to find a new doctor. Their insurance company might say here’s our network of available primary care clinicians, but the insurance company doesn’t know at that moment which of those doctors or other care providers are actually accepting new patients. So that’s part of where it becomes frustrating for patients to try to track through the system, find a place to be seen.
Chávez: So what about in Oregon? I mentioned there has been some growth in the number of primary care providers in the state … but not enough, right? What does the shortage look like here in our state?
Boyd-Flynn: In our state, it looks like … the biggest challenges that we have are that we have more folks retiring than are coming in. We have been a net importer of physicians for many years. In family medicine, we are training more physicians now than we have been ever before. Currently, we have 191 residents in training in the state, and back in 2020 it was only 128. So we’re working on it.
But what we know is, in the Portland metro area – and again, I can give you sort of the impact stats rather than the actual counts – wait-time for a new visit with a primary care clinician can be many months. And in some metro areas where clinics have changed hands or different owners have come in, there may be many thousands of patients who are left without a primary care clinician because of contract changes. So we just know it’s bad. It’s difficult to get exact numbers. That help?
Chávez: Yeah. But some of those statistics you give about the impact are really helpful to put this into context.
Jane, I want to turn to you now. I know you began your medical training in Nigeria, then trained as a family medicine practitioner in Chicago, and have now worked in Canada and multiple states in the Pacific Northwest. First of all, why did you choose family medicine? What’s important about this type of health care to you?
Jane Akpamgbo: Thank you for that question, Jenn. So the reason that I chose family medicine … actually, there are so many reasons why I chose family medicine. First of all, when I did my internship, I wasn’t quite sure what direction to go. I decided, after medical school, to do a one-year internship at the Eko Hospital in Lagos, Nigeria. And that internship opportunity allowed us to do an internship where you could actually rotate through [what] they call the departments within medicine. And by that, I’m referring to things like surgery, medicine, OBGYN and pediatrics. So I did a rotation through all of those departments.
At the end of the day, I felt like I needed to be in a specialty that could actually do a little bit of everything. I was curious to know how I could impact on the patient and the family at large much better. So I decided to go into family medicine because I wanted to be able to take care of the baby, all the way to the grandma, to the grandpa.
Primary care, basically family medicine, is personal. It is a very proactive specialty, which centers on preventative care. It allows you an opportunity to build a relationship with your patient over time. So there is prolonged continuity of care. Primary care also allows you an opportunity to be able to address chronic diseases, which that patient may have. And even within primary care, you also are taking care of patients acutely. And this is why you find that most of our primary care physicians can staff the urgent care, they can staff the emergency room. The primary care physician, when there’s a pandemic, they are the first group of doctors who are reached out to, to go help out with that pandemic. And that’s just because of the broad spectrum of the training that will receive us as primary care specialists.
So that, in a nutshell, is the reason that I went into primary care.
Chávez: And I know you’ve been practicing in North America now for decades, and I imagine being a family physician has changed over that time. Could you tell us about what some of the biggest or most common challenges are that you come up against in your day to day work in family medicine?
Akpamgbo: Yes. So when I look back to when I was practicing in Idaho in the early 2000s, the whole system was different. We were still using paper charts at the time. We didn’t have anything called an electronic health record – the EHR – and if a patient needed something, the patient physically came into the office. Most times the patients would physically walk into the office to make an appointment with their healthcare provider. Some, who had access to phones, would make contact by calling in to make an appointment. So when you saw your patient, you were able to just look through the paper chart, you had the lab results filed in there, whatever results from specialists were in there, and we did just a little SOAP [subjective, objective, assessment, and plan] note. So you could, within 10-15 minutes, deliver effective care to the patient.
Nowadays, the setup is different. We do have the electronic health records. And I think that part of the reason that electronic health records became something that transformed medicine was because of this quest to be able to access the patient’s records from wherever you are. So clinicians all over America are hoping to see the data … if you were practicing in Oregon and a patient came from Washington, you could actually access that patient’s medical records and be able to deliver care, get the information that you need for the records and deliver care. So the electronic health records has been beneficial in some ways, but like with everything else, there are always pros and cons.
The challenges that we’re faced with right now in primary care especially, as well as in other specialties that use the EHR system, is that you may not have as much personal care with your patients. Most times you have a computer in the exam room, and you have to be on that computer, kind of getting information. And then also, you have a lot of information that is constantly streaming into the EHR on a daily basis. So while the provider is delivering hands-on medical care, you, at the same time, have an influx of information into what we call the in-basket. In most cases, you don’t really have any designated time to really address that in-basket. So you find, especially, the primary care physicians have to make time. It could be in between patient care, it could be at lunch time, it could be at their own spare family time to be able to get to that information in a timely manner. So these are some of the challenges that we’re faced with.
We’re also faced with challenges that have to do with administrative duties that really could be removed from the plate of a primary care physician, things like prior authorizations that now exists. Whereby a patient, for example … I mean, I’ve had so many cases, but just more recently I had a patient who came to see me because she’s diabetic; she has Type II diabetes. And she was diagnosed with heart failure for the very first time. I had referred her to see the cardiologist – and this was like a follow-up appointment from seeing the cardiologist. And she came to me because the medication – in this particular case, Jardiance, which the cardiologist had recommended for her to get, a medication that is beneficial for reducing cardiovascular risk – she didn’t have access to it because the cardiologist had written for the medication. But the patient wasn’t able to access it because it needed a prior authorization. So now that medicine had been written for a week prior, but up until when she was able to gain access to see me, she had not started the medication.
So for a diabetic who also has kidney issues, has heart failure, and needs this medication – not only for the Type II diabetes, but also to help reduce cardiovascular risk, can also improve her kidney function – there was a delay in her getting that care. And this prior authorization obviously has a lot of paperwork involved. So we have to figure out with a particular insurance company: what website do we go to, how do we get this prioritization process going? So that, in effect, can definitely affect healthcare delivery and can actually be life threatening in some cases.
Chávez: Yeah. So it sounds like there is just a big increase in the amount of things that you are needing to spend your time on that aren’t direct care for your patients.
Eva, I want to turn to you now. First of all, Jane just told us about some of the challenges that she faces as a clinician. Do the challenges she described feel familiar to you? If so, how so?
McCarthy: Yeah, they definitely do. So prior to my position as a faculty physician for a family medicine residency program, I practiced as a community primary care provider in a couple of different smaller communities in Oregon. And what Jane describes is very much reminiscent of the things that I would spend an exorbitant amount of time on. Generationally, I am a product of the digital age of the practice of medicine. So when I was in medical school on rotations and then in residency, I also exclusively used an electronic health record.
What’s interesting now, and where I see this play out in my daily life as a faculty physician, is I’m training the next generation of family medicine physicians. They are residents who are in a three-year program to gain their board certification in family medicine. And they are learning how to navigate some of these administrative burdens, and teaching them what to do when we get a notice in our in-basket that a patient’s medication has been denied. It’s trickier for residents because they are obligated to spend time on their various rotations, which are required by the program. And that will lead to some fragmentation because they are trying to check their in-basket and manage these prior authorizations, or these refill requests, or just general patient inquiries, when they might be also doing a rotation on the inpatient pediatric ward, or on labor and delivery while they’re managing a laboring patient.
So it can just add to some of the daunting nature of medicine in the training setting, and then they see all of this responsibility and understand that this is the environment that they will be graduating and subsequently practicing in. A lot of residents now are feeling like when they graduate, they don’t want to be a full-time clinician, meaning a 1.0 FTE [full-time equivalent]; they are seeking out contracts that give a little more flexibility that might allow them to work a 0.8 FTE, because they know that there is going to be that extra administrative burden that will be factored into their day. And they’re doing it almost prophylactically, so that they don’t feel burnt out immediately upon hitting the market as a brand new graduate.
Chávez: I want to stick with you because I’m just curious – thinking about attracting more young professionals to the field of primary care and family medicine, what types of conversations are you having with your students about what you would like to see change to make this field more more amenable to them, more appealing to them as people just starting out in their careers?
McCarthy: Yeah, that’s a great question. The conversations that I have with prospective students and trainees kind of fall into two buckets. The first bucket is just the general joy of primary care and how family medicine is such an important specialty to our communities and to our patients. And how we are the only specialty really that improves health outcomes for communities … and that’s been proven through research and data collection. We can just see that primary care really serves as a foundation for our medical and healthcare system. So I feel really proud and inspired by that. I really try to double down on the joys of medicine and how interesting of a field family medicine is – as Jane described, our broad scope of practice, how we can really use our skills to help a wide range of folks in many different settings. I think that that’s incredibly unique to our practice. But I also have conversations about the fact that it is a hard field to operate in, and we have to adapt, and we have to commit ourselves to lifelong learning and being curious, so that we can ride the wave of change that is just the constant nature of health care.
Then the second bucket, that I put my advice in the conversations that I have with trainees in, is just about the healthcare team. Back in the day, before the concept of a primary care medical home or even the EHR, the electronic health care record, came about, medicine was really a physician going into a clinic and seeing their doctor, getting advice or getting a treatment, and the care was very one-on-one and personalized. But now, primary care as a field has really evolved into a team-based practice. And I think in order to deliver high quality health care in a primary care setting that benefits both the patients and the providers, and prevents the providers from getting burnt out, you really need a team-based approach.
So it’s how to leverage our position as physicians or future physicians to be a part of that team, to help our team members and demonstrate leadership skills in order to deliver more comprehensive care to our patients. By comprehensive care, I mean involving other important folks in the clinic, like clinical pharmacists, or our mental health and behavioral health specialists who we can then do warm hand-offs, to come in and help our patient who might be having a mental health crisis. Or involve our community health workers if our patients are having difficulty getting into the visits because they don’t have transportation. How can those community health workers assist our patients with travel vouchers or Ride Line? Our patients are able to address their health by building up some of the resources they have just for their well being, like if patients are having trouble paying bills, can we connect them with community services to strengthen their overall wellbeing? [That] will then make them more able to engage in health care and address some of the other major issues, like diabetes or high blood pressure.
So I think the message is that primary care can be very rewarding. In order for it to be successful and in order for the new generation of doctors to feel supported, they need to be able to exist within a healthcare team that can really provide for all of the comprehensive needs that our patients have.
Chávez: Thank you, Eva. And yeah, we’ve heard a lot about what could be done to improve this field for incoming physicians, incoming clinicians from your perspective, Eva, as a physician.
Betsy, I wonder from your vantage point at OAFP, what do you think the state can be doing – whether it’s through policy, or legislative action, or investment – to address this shortage and make this field more appealing?
Boyd-Flynn: Excellent question. At the OAFP, one of the initiatives we have pursued in the last few years is to build a network, an organization specifically dedicated to supporting the family medicine training sites, the residencies. We were lucky enough to secure some state funding for that work in 2023. We’re hoping to have that funding renewed in 2025. So that’s one thing that we think is really important.
Another piece is really taking a look at the layers of what both Dr. Akpamgbo and Dr. McCarthy described: what we tend to call administrative complexity. Oregon has done such tremendous nation-leading work to transform our healthcare system around the concept of a patient-centered medical home. And in successive waves of transformation, in successive Medicaid contracts the clinics must engage in, in successive and different contracts with the other commercial carriers that a practice might work with, we have gotten to a point where I’m hearing from some clinics that they are reporting on 70 different quality metrics. So they have to gather data out of their claims records for 70 different ways that insurance companies are asking them to look how they’re delivering care, to prove that they’re doing it right.
At a conference last week, Representative Rob Nosse and Senator Cedric Hayden were on a panel talking about what might be ahead in 2025 and beyond. They definitely voiced some interest, I think, in taking a look at where the community can go to the legislature and say, OK, here’s where we are now. These are things that could be stripped away to make it less complicated. So that would be point two, right? So let’s take care of the workforce and invest in that over the long-term. Let’s look at administrative complexity.
Then the final thing is to look carefully at how we pay for primary care. A lot of the work that we are expecting primary care clinics to do requires that comprehensive team that Dr. McCarthy was speaking about. But you cannot bill most insurance companies for the services of that community help – if your patient needs that connection to the ride, the rideshare. You have to find those dollars as a clinic. You have to sort of figure out how to pay for those kinds of services by taking little bits of money here and there, and it’s not generally sustainable. What I’m hearing from more and more of our members is that where there might have been grant programs, or implementation dollars, or technical assistance available to implement some of these things in prior years, those resources are drying up. And there, too, the team is at risk of falling apart.
So we think it’s really quite urgent that the state take a look, amongst its other priorities … And we understand that the Health Authority has articulated its strategic plan, and the five pillars of that strategic plan, all driving towards the achievement of health equity by 2030. While their focus is really closely on health related social needs and on behavioral health access, we really feel like it’s critically important to also attend to the crisis in primary care. And some of that might look like improving payment levels for primary care services. That might be complicated. We’re not talking specifically about making sure Dr. McCarthy or Dr. Akpamgbo make more money. We’re talking about making sure that more funds are getting to the clinic, to pay for things like community health workers or clinical pharmacists to help manage medications for patients with lots and lots of drugs …
Chávez: Betsy, I’m sorry we are [out of time]. All right. Thank you so, so much for laying that all out for us. And Betsy, Jane and Eva, thank you for joining us today to discuss this important topic.
All: Thank you so much for having us.
Chávez: Betsy Boyd-Flynn is the executive director of the Oregon Academy of Family Physicians or OAFP. Jane Akpamgbo is a family physician for Salem Kaiser Permanente and the president-elect of OAFP. And Eva McCarthy is a core faculty physician for Samaritan Health Services’ Family Medicine Residency Program and the current president of OAFP.
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