Where have you gone, Marcus Welby?

Family doctors are a dying breed that is not being revived by medical students. This is the healthcare crisis the candidates should be talking about.

By Robert Burton

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July 8, 2008 | A friend of mine died not long ago from colon cancer. She was a fit, health-conscious middle-aged woman who phoned her family doctor, complaining of rectal bleeding. Her doctor was too busy to see her for several weeks; his medical assistant, also booked for several days, reassured her that most rectal bleeding is from hemorrhoids. "Wait a few weeks and see if it doesn't go away," he told her. The bleeding did stop, temporarily, then returned a few months later. When she finally saw her doctor, her colon tumor was inoperable. Whether her outcome would have been different with an earlier diagnosis can't be known with certainty. But what can be said is this is not the way medicine should be practiced.

Although not often this dramatic, everyone has his or her own tale of long waiting times, inability to find a new family doctor, or general frustration getting prompt and adequate care. Just as the U.S. financial gurus failed to acknowledge the seriousness of our present credit crisis, today's politicians are avoiding what promises to be a similar catastrophe in healthcare -- the availability of primary care physicians.

The current healthcare debate about accessibility and affordability reminds me of a committee of well-intended E.R. doctors furiously debating the optimal cost, shape and efficiency of various tourniquets, while a casualty victim slowly bleeds to death. Better and more widespread and affordable health insurance won't be of value if you can't find a primary care provider willing and happy to treat you.

Make no mistake: Primary care is the backbone of a good medical system. No matter how great our latest medical technologies, most of our illnesses are best screened or handled by the family practitioner. You don't need a gastroenterologist to treat an ulcer or irritable bowel. You don't need a pulmonologist to treat most cases of asthma and emphysema. And you don't need an orthopedist for most aches and pain.

What we need, and most of us want, is the Norman Rockwell version of a concerned, empathetic family doctor we can trust to sniff out the rare or serious illness, manage the ordinary, while also being a medical cleric who knows his patients. What we need is a family friend to whom we can turn for reassurance, comfort and, yes, even bad news.

But primary care physicians -- those trained in family medicine and general internal medicine -- are an endangered species. It's only a bit of hyperbole to say that, if the trend continues, the family doctor will become a fond memory, a nostalgic reminder that the medical system once had a more human face and sense of community.

For a moment, put aside the very real contributions we doctors have made to the destruction of our profession. Arrogance, hubris, condescension, greed, complacency, cronyism; you name it, we've done it. But it serves no useful purpose to feel a sense of righteous vindication that the American medical establishment has been brought to its knees. Instead, we should be focusing on attracting the next generation's best and brightest.

Currently, roughly 200,000 family practitioners and general internists practice in the U.S. One-third are over 55 and are likely to retire within five to 10 years. Meanwhile, an alarmingly low percentage of students are choosing to become primary care physicians.

Take a look at the changing choices among the approximately 16,000 students who graduate from U.S. medical schools each year. In 1998, of the 2,930 graduates entering internal medicine residencies (specializing in the diagnosis and treatment of most common illnesses), 54 percent planned on entering primary care practice. By 2005, 2,668 opted for general internal medicine residencies, with only 20 percent of them planning on entering primary care practice. That means that at present, less than 600 graduating seniors per year plan on entering general internal medicine practice.

Primary care residencies, where residents learn to manage common illnesses and perform minor surgical and obstetrical procedures, show the same ominous trend. Between 1997 and 2005, the number of U.S. graduates entering primary care residencies dropped by 50 percent. We can now expect the combined family practice and general medicine residencies to deliver 1,000 to 2,000 U.S.-trained replacements annually. No matter how you slice the figures, five to 10 years down the road, today's difficulty finding a primary care physician will seem like a minor inconvenience.

To underscore the general lack of recognition of the declining appeal of a primary care practice, consider that in 1976, a Department of Health and Human Services Advisory Committee predicted a surplus of 145,000 primary care physicians by the year 2000. And yet, in 2004, revised estimates suggested that by 2020 there will be a shortage of 90,000 to 200,000 physicians.

This shortsightedness and inept public policy planning continues in our present crop of presidential candidates. Barack Obama's answer to increasing the number of med students choosing primary care has been strictly economic -- decreasing educational debt, better reimbursement, and better medical infrastructure. John McCain isn't any better. Neither has addressed the more basic problem of why fewer bright students are opting for primary care practices.

What is needed is an understanding of the diverse, complex and often conflicting motivations prompting students into medicine in general, as well as determining which specialties to pursue. Limiting discussions to the cost effectiveness of medical care is to nearly miss the entire point of the nature of primary care.

Next page: Should we be recruiting doctors from disadvantaged areas to ameliorate our shortages?