The Doctor Will See You Now — or Will He?

"As a medical student in Philadelphia," recalls Dr. Samuel Berger, "I had a big decision to make. After I would graduate and before my residency, should I choose to be a primary-care physician or concentrate on a specialty, like cardiology or surgery, where my income would be considerably better?"

The young man from Buffalo had grown up in a home where his father, a family doctor, cared for countless patients with myriad medical problems. "And he loved what he did, the range of medical issues he handled," explains Berger, whose father is now retired after 47 years of practice. "But he understands that medicine is quite different today than it was in his day."

Dr. Ira Sharp, an internist and family practitioner in Elkins Park, is among many physicians concerned about the looming crisis in primary care.

"The reality today is that many medical students see physicians leaving a general practice, and going into a specialty or even an alternative medical field," he explained. "Diminishing fees and complex controls and regulations have sharply reduced their incomes and affected their lifestyle.

"I always knew I wanted to be a doctor — caring for patients' needs, whatever they might be," he added.

Sharp, who shares his practice with three other physicians, can often spend up to 50 minutes with one patient. His day may require seeing patients at Albert Einstein Medical Center and Abington Memorial Hospital, returning phone calls, talking with insurance companies, consulting with other physicians, completing paperwork and other administrative tasks, none of which are reimbursed by insurers.

"We have to manage our practice very closely to cover overhead such as office expenses, insurance, etc," he said.

Shortage of Certain Physicians
Last year, a study released by the American Academy of Family Physicians (AAFP) called for a significant increase in the number of family physicians to meet the escalating health-care needs of the American people. The Family Physician Workforce Reform study asserted that the nation is experiencing a dire shortage of family physicians specifically, and that unless the U.S. health-care system changes soon, the shortage will become even more acute within the next 10 years as the population continues to age.

The report concluded that to meet the nation's anticipated need for primary care in the year 2020, approximately 3,725 family physicians would need to be produced annually by the Accreditation Council for Graduate Medical Education-accredited family-medicine residencies, and 714 annually by American Osteopathic Association-accredited family-medicine residencies.

Overall, the new AAFP workforce policy calls for an approximate 39 percent increase in the number of family physicians to meet the health-care needs of the American population. This study is congruent with the recent American Association of Medical Colleges report, which calls for a 30 percent increase in the production of U.S. physicians.

The number of internal-medicine physicians practicing as generalists is decreasing. Interestingly, a new trend focuses on an increasing proportion of nonphysician providers, such as physicians, assistants and nurse practitioners limiting their practice to subspecialty areas.

In 1996, the Institute of Medicine concluded that "in the United States, family physicians, general internists and general pediatricians play an unequivocally vital role as primary-care physicians. These family physicians provide a majority of the office-based visits people make to physicians in the U.S."

In 1993, Jessica Otto from Ocala, Fla., enrolled at the Philadelphia College of Osteopathic Medicine, interested in internal medicine in part because "my mentor was definitely our family practitioner, whom I knew and admired from childhood."

When Otto started her training, she had been accepted as a National Health Corps Scholar, a government-sponsored program for young physicians interested in primary care. The purpose of the program is to increase primary-care physicians in underserved communities, both urban and rural.

After completing her residency in internal medicine in Newark, Del., she went to Salville, Va., where she practiced internal medicine for three years (during which time she married Maitin Rhode in Philadelphia). In 2005, she returned to Philadelphia and joined the practice of ZKC Internal Medicine, where she sees patients at two offices, as well as at Pennsylvania Hospital.

"I am very grateful for the government program that allowed me to become a physician and avoid incurring a tremendous debt," she said.

According to a report in the American Family Physician, a peer-reviewed journal of the AAFP, "In 2003, the number of U.S. graduates entering family medicine dropped to 1,234 — barely one half of 1997 numbers. Most graduating medical doctors opted for more specialized fields or for programs in internal medicine or pediatrics that provide the opportunity to subspecialize."

Perry Pugno, M.D., MPH, CPE, director of the AAFP's medical education division, said that "because family physicians are trained to care for patients of all ages and conditions and in all environments, they are best equipped to meet the wide range of health-care needs in our country.

"Until the health-care system places a greater value on family medicine and other primary-care specialties, millions of Americans will struggle to obtain high-quality, affordable care."

While it is generally recognized that income, when adjusted for inflation, has dropped for physicians as a group, it is even more so for primary-care physicians.

The expectations and demands placed on them has increased, yet reimbursement substantially rewards procedures and specialty practices.

It is recognized that primary-care physicians are usually the critical center of caring for patients. The one person who knows the patient best can coordinate the care provided by specialists.

Many physicians are looking for ways to be more efficient in their practices. Electronic records, nurse and physician practitioners, the Internet, a Web site and even e-mail consults contribute to the efficacy of their work.

Policy Options
While the United States leads the world in many areas — militarily, economically and in health-care spending ($1.7 trillion per year) — the nation finds itself behind nearly all of its industrialized peers with regard to health outcomes. Indeed, reports point to a looming primary-care workforce crisis, compounded by increased diversion of medical-school graduates into subspecialties. Many policy options for reorienting the health-care system have been on the table for more than a decade, and include the following:

· Reimbursement that facilitates and rewards continuous and coordinated care;

· Reimbursement that reflects the special challenges of primary care fostering patient-focused continuity and maximizing quality and safety;

· and reimbursement that promotes team practice, and offers patients the expertise and training of each member rather than having them compete to fill the same roles.

The New York Chapter of the American College of Physicians suggests:

· forgive some of the debt of student loans for medical graduates who become primary-care physicians;

· give financial grants to doctors in primary-care practices so they can improve office technology and hire trained staff to educate patients with chronic conditions; and

· appeal to medical schools to make primary care a more prestigious option for med students.

For more information, call the Philadelphia County Medical Society at 215-563-5363.


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