Thursday, December 11, 2008

Where Have All the Doctors Gone? -

One morning during my medical residency many years ago, one of the senior doctors pulled me aside after rounds, as was his routine, to review the status of patients in the intensive care unit. A few had single-organ failure — their lungs weren't doing well, or their hearts weren't beating efficiently. A few struggled with double-organ failure. But the majority of patients were battling multisystem organ failure, and their prognoses were not good.

"People can survive one organ system failing and even two," the senior doctor said to me after we were finished. "But when that third one goes ..."

He leaned forward and looked me in the eye. "Three strikes, and the game is over."

That remark came to mind recently when I thought about the crisis in primary care and President-elect Barack Obama's plans to make health care accessible to all.

Primary care is delivered in a variety of settings by a variety of professionals, including nurses and physicians' assistances, but it is anchored by family-practice doctors, general internists, pediatricians and, for many women, gynecologists. As the nation's front-line doctors, primary care physicians address everything from chronic diseases, like diabetes, heart disease and high blood pressure, to more acute conditions, like pneumonias, intractable flus and potentially cancerous masses and lumps.

While their initial work in diagnosis often sets the trajectory of care for a patient, they also manage long-term conditions, guard the public's health and advocate preventive care measures. For many patients, too, primary care doctors are invaluable guides through the maze of health care options and specialists.

In the last several months there have been reports in medical journals about an impending shortage of primary care physicians. This spring in the health policy journal Health Affairs, researchers at the University of Missouri-Columbia and the federal Department of Health and Human Services published a study that projected a generalist physician shortage of 35,000 to 44,000 by the year 2025. The researchers based their figures on current physician usage patterns and did not take into account increases that might occur because of rising access to health care.

The news got worse in September, when The Journal of the American Medical Association published a study showing that just 2 percent of graduating medical students are choosing to enter general internal medicine. The students surveyed were concerned in part by what they perceived to be a more difficult personal and professional lifestyle, compared with other fields. They felt that the paperwork and charting required of primary care physicians were more onerous, and they were not eager to care for the chronically ill in a health care system that focuses on acute care.

The potentially devastating public health implications of both of these reports rippled out into the medical community. Last month in an official statement, the American Medical Association vowed to support financial incentives for medical students who choose to go into primary care.

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