Family doctors: An endangered breed

As more medical students shun primary care for higher-paid specialties, experts warn of a severe imbalance that could cripple the nation's health care system.

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By Parija B. Kavilanz, CNNMoney.com senior writer

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Medical student Luis Manriquez said he's been told that primary care doctors are less respected as physicians.
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First-year medical student Katherine Glass wants to become a primary care doctor while a majority of her peers are shunning family medicine in favor of higher-paid sub-specialties.

NEW YORK (CNNMoney.com) -- Luis Manriquez and Katherine Glass share a common -- and increasingly rare -- ambition: They both want to become family doctors.

"As a primary care doctor, you are a gatekeeper of the medical system," said Manriquez, 26, who with Glass is a first-year student at the University of Washington School of Medicine. "Primary care is where you can have the most immediate impact in affecting patients' lives by managing their health."

Still, Manriquez realizes that he's setting himself for considerable challenges.

For one thing, as a family doctor, Manriquez will probably make one-fourth the salary of a specialist while trying to pay down $140,000 on average in medical school debt.

"That's why only the most committed pursue primary care. Kudos to them," said Jonathan Weiner, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

Then there are some intangible challenges.

"Primary care physicians are considered to not do as much as specialists," Manriquez said. "People have told me that generalists are less respected as doctors."

Glass, 29, agreed. "Primary care doctors don't have a lot of status in the medical field," she said. "But I've always focused on the big picture. I want to offer my patients a more holistic picture of health versus what a specialist does."

Glass said she wants to "form a long-standing relationship with her patients and empower them to be healthy."

In the minority: Despite their noble intentions, Manriquez and Glass know that they are exceptions in an otherwise depressing situation for the nation's health care system.

In the past 10 years, 90% of medical school graduates have opted to enter higher-paid sub-specialties like orthopedic surgery, radiology and dermatology. Only 10% have chosen primary care, according to the American Academy of Family Physicians (AAFP).

This trend has fueled a growing shortage of primary care doctors in the United States. "On the eve of (health care) reform, we have a very real primary care crisis," said Dr. Ted Epperly, president of AAFP.

Epperly estimates that the health care system will be 40,000 doctors short of where it needs to be in the primary care arena by 2020 to support the demand for medical care.

"We need 150,000 family doctors in total by then," Epperly said.

However, his more immediate worry is what will happen to this demand-supply imbalance if President Obama's health care reform initiative is successful and 46 million more Americans get medical coverage.

"It will be total chaos," Epperly warned. "We could have a total implosion of the health care system since primary care doctors are the first point of medical contact for most people."

High debt, low pay: Some experts say the doctor shortage boils down to one basic problem -- health care's payment structure.

"A specialist can earn $500,000 or more a year and work 20 hours a week versus a family doctor who earns on average $120,000 a year and works more than 60 hours a week," said Weiner.

Medical students such as Manriquez and Glass, are keenly aware of this payment inequity given that both will incur considerable debt upon graduation.

This payment inequity has resulted in a workforce inequity. "About 70% of all doctors are specialists and only 30% are in primary care," Epperly said.

"The top three reasons that my clients choose specialization over primary care are financial, lifestyle and administrative," said Dr. Michelle Finkel, a former Harvard admissions officer who now is an independent consultant to students on medical school admissions.

Epperly, who is a family doctor, said primary care physicians deal with two to three times more paperwork than specialists, including filing insurance reimbursement from Medicare, Medicaid and private insurers.

"I think those applying to residency training programs are well aware of their financial burdens and some to potential lifestyle issues," Finkel said. "Still fewer may understand so early in their career the administrative challenges primary care doctors face."

Dr. Jason Dees, a family physician based in New Albany, Miss., chose family medicine in school because he wanted to "develop relationships with his patient across multiple generations."

Dees said he had to deal with school debt. But he was able to secure some funding to pay it down through state and local hospital programs -- in exchange for practicing in an underserved area in Mississippi.

"Becoming a family doctor is not an easy choice," Dees said. "The health care system is broken. I see 30 to 35 patients a day, sometimes only 7 minutes per patient.

"But we have a system that pays for volume and procedures used rather than quality of care," he added. "It's a sad comment. I am absolutely terrified that it will only get worse."

Fixes: The Obama administration's health reform proposal contains measures to correct the most obvious challenges. These include reducing medical school debt through more funding for programs such as the National Health Service Corps, revising Medicare reimbursement rates to physicians, and expanding the role of community health centers to deal with doctor shortages.

AAFP's Epperly has some other ideas.

"Information technology is at the heart of any long-term solution," he said. One way to expand the capacity of Medicare care is to encourage doctors to communicate with patients via telephone and e-mail, he said.

Some primary care doctors are already doing this -- although most insurers don't yet reimburse physicians for telephone or digital communication with patients.

Epperly also said the system must reward doctors for quality, not quantity of care. His ideal system of the future would look like this: A doctor sees 4 to 5 patients in the morning and afternoon for 30 minutes each. A doctor would also spend three hours each day commuting remotely with patients.

"But you have to align payment incentives accordingly to make this model work," he said, paying for both in-office and remote consultations.

For his part, Johns Hopkins' Weiner said policy makers have to come up smarter solutions than just creating more doctors. "The idea that we need more doctors is not so simple. Studies have shown that more doctors doesn't mean better quality of care," he said.

"The (health care) system shouldn't disadvantage you if you are trying to do the right thing and better the community," said Manriquez.

Should specialists, nurse practitioners and physician assistants be encouraged to fill in the gap left by shortage of primary care doctors? We want to hear about your experiences. E-mail your story to realstories@cnnmoney.com and you could be part of an upcoming article. For the CNNMoney.com Comment Policy, click here.  To top of page

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