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States Faces Shortages of Primary Care Doctors

January 6, 2009 at 6:35 PM EDT
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While universal healthcare legislation in Massachusetts means more people today are insured, the new demand for primary care doctors outstrips the supply. Educational loans, low wages and fights with insurance companies are turning growing numbers of students away from the field. Betty Ann Bowser reports.
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JIM LEHRER: Next, the second of our stories on health care problems facing President-elect Obama and the next Congress. Tonight, health correspondent Betty Ann Bowser reports from Massachusetts on the shortage of primary care doctors. Our Health Unit is a partnership with the Robert Wood Johnson Foundation.

DOCTOR: Would you recommend interventional radiology as the way to go?

BETTY ANN BOWSER, NewsHour Correspondent: It’s the annual career day for third-year medical students at Boston University.

DOCTOR: There are lots of procedures that are done, though, in radiology that are done in interventional radiology.

BETTY ANN BOWSER: They are engaged in a kind of academic speed date, moving from table to table every few minutes to hear doctors describe their specialties.

DR. THOMAS HINES, Boston University Medical Center: The most essential skill for a good family doctor is knowing what you know, knowing what you don’t know, and being able to distinguish the difference between those two things.

BETTY ANN BOWSER: The students listen respectfully to the primary care physician, but the truth is very few of them will ever go into the field.

A recent survey published in the Journal of the American Medical Association found that only 2 percent of medical students plan to go into primary care. And since 1997, the number of medical school graduates going into the field has dropped 50 percent.

One reason is salaries. Family medicine doctors frequently are on the bottom of the pay scale, making an average of $185,000 a year. Specialists, like radiologists and cardiologists with two to seven more years of training, make two times that much.

Also, because of the sophisticated interventions and procedures specialists offer, they are paid more by insurance companies than primary care physicians.

Dr. Bruce Auerbach is president of the Massachusetts Medical Society.

DR. BRUCE AUERBACH, President, Massachusetts Medical Society: A primary care physician spending 30 minutes with a patient, talking to them about their health care needs, would get paid about a third of what a gastroenterologist would get paid for spending 30 minutes to do an endoscopic procedure.

And the young people certainly know that. And they’re hearing that in their training. And they’re seeing what happens. They understand the reimbursement system, very specifically values, those that are intervening with procedures rather than those that are sitting in an office and talking to someone about healthier lifestyle, weight reduction, exercise, taking care of their diabetes, and getting the right testing, and the like.

Medical school loans are huge

BETTY ANN BOWSER: Now, with the economy in disarray, more of these students have an even more compelling reason to stay away from primary care.

Almost all of them will graduate from medical school with college loans that could take decades to pay off. Christine Higham and Ashleigh Halderman are typical of medical students at B.U.

CHRISTINE HIGHAM, Medical Student: Every year, I take between $65,000 to $75,000. It's going to be over $200,000 before you count interest. If I take the full time to pay, I could pay $500,000.

BETTY ANN BOWSER: Wow.

CHRISTINE HIGHAM: Yes, it's a fair chunk of change.

ASHLEIGH HALDERMAN, Medical Student: It doesn't seem possible for me to go into primary care, which is sad, but I want to have a family. I want to be able to provide for my family. I want to be able to pay off my loans quickly. I don't want to have them for 30 years.

BETTY ANN BOWSER: But there are other reasons medical students are steering away from the field. Because primary care doctors are generalists who deal with a wide range of medical issues, they have to justify more types of treatment decisions with insurance companies.

Brian O'Gara recently shadowed a primary care physician, and he did not like what he saw.

BRIAN O'GARA, Medical Student: I just saw how difficult his life could be at times. I could see sort of the stress of having to see so many patients every day, not having enough time to see them. They're so overwhelmed currently, undercompensated, and I feel like a lot of people who are primary care physicians are not very happy with their job.

Primary care doctors overworked

BETTY ANN BOWSER: In 2006, Massachusetts became the first state to pass universal health care, requiring every resident to have health insurance. Under the mandate, those who can afford to buy coverage but chose not to pay a tax penalty.

For those who can't afford insurance, the government provides subsidies, and employers are also required to contribute.

The result is nearly 95 percent of residents now have health insurance; 440,000 people previously uninsured are covered.

But the downside has been that there aren't enough primary care doctors to go around. Here in Hampshire County in western Massachusetts, at least 20 primary care physicians have closed their practice or retired in the past two years.

DR. KATE ATKINSON: I'm beginning to feel like I'm going to be extinct, that primary care doctors are going to be like dodo birds.

BETTY ANN BOWSER: Dr. Kate Atkinson is one of those who's still practicing. Her day usually begins at dawn. Her bustling family care practice in Amherst has 3,000 patients. She is so busy that she hasn't accepted new patients in five years, except for a few weeks in 2007.

DR. KATE ATKINSON: Overall, it's getting bad. Just a couple of weeks ago, I was in church, and I ran into a patient of mine who had gotten married. And her husband said, "And now I get to be your patient." So that's just, what, marrying into the practice.

It is very difficult. And my staff tell me that people literally are crying and begging and pleading. It's sad.

BETTY ANN BOWSER: Dr. Atkinson's patients have to book their routine physicals a year in advance, and some, like Jennifer Haugsjaahabink, don't live close by.

JENNIFER HAUGSJAAHABINK: So even though I'm meeting people that are now referring primary care physicians, their waiting lists are really long. And so I'd rather just drive the 55 minutes here, once a year, and maybe three times if I get sick.

Strong patient-doctor relationships

BETTY ANN BOWSER: The 46-year-old Dr. Atkinson often works seven days a week and spends a lot of time on the phone dealing with insurance issues.

DR. KATE ATKINSON: I spend more time doing paperwork and less time talking to patients. And every time there's a problem, the solution is to generate another form or another hurdle that the doctors need to go through.

If you come to me and you have stomach pains, what medicine I can put you on depends upon your insurance company. I wasn't trained to say, "What's your insurance company before making a treatment decision?" And now I have to.

Now, this is just what I received in one week.

BETTY ANN BOWSER: Dr. Atkinson says some insurance reimbursements don't cover what it really costs her to see a patient. Still, even with all of her frustrations, she says she's sticking with it.

DR. KATE ATKINSON: I'm the first place you go when you need something. If I have a child who's having trouble academically at school, the parents call me. If I have somebody who has a chest pain, they call me. They come to me first. They come to Dr. Kate. They've known me for years. I've known them. They have this home.

And if I don't have the answer, I help them find the answer. Sometimes it feels like there's not a lot of respect for primary care. Thank goodness the patients appreciate us, and they do, and that's what keeps you going.

Improving primary care

BETTY ANN BOWSER: Industrialized countries with strong primary care networks -- the Netherlands, Germany, Switzerland -- have some of the world's best medical outcomes: longer life expectancy and lower infant mortality rates.

The Massachusetts Medical Society's Dr. Auerbach says that's why it's important for the U.S. to improve its system of primary care.

DR. BRUCE AUERBACH: We know that, when patients have their chronic disease managed regularly because they have a relationship with and contact with a primary care physician, that those individuals will have the best outcomes.

They will have the least likelihood of complications of their diseases, and they will have the best outcomes. And so anything that detracts from our ability to provide a robust primary care network ultimately will have a negative impact on the quality of care that the population can get.

BETTY ANN BOWSER: Medical schools, like the one at Boston University, try to encourage their students to go into primary care. Massachusetts and other states are even offering financial incentives to attract young doctors, but low salaries and today's economic conditions make those incentives a hard sell.

JIM LEHRER: In her next report, Betty Ann looks at health insurance for small businesses.