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Originally published | Page modified August 14, 2009 at 11:24 AM

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Primary care in need of first aid

Many family doctors and others on the front lines of medical care, who typically earn far less than their specialist counterparts, hope any health-care-reform package will include tools for easing a dire shortage of primary-care doctors.

Seattle Times staff reporter

As a medical-school graduate doing her residency at several Tacoma hospitals, Stacie Sutton Beck is rotating through pediatrics, internal medicine, orthopedics and other departments for the training she needs to become a family doctor.

Each week she looks forward to Wednesdays, when she gets to hold her own clinics. It's then that Beck serves as a primary-care doctor for all kinds of patients — from a baby needing a regular checkup to an older man with stomach pains and a woman who needs contraceptives.

"That's the fun part," Beck said. "There's a full spectrum of primary care and it's really fun to have that autonomy."

During the clinics, Beck usually sees about three to four patients. But once she finishes her residency, she, like other family doctors, could be seeing more than 20 patients a day. And with the potential of a health-care overhaul to swell the ranks of new patients, patient loads could become far higher still — even as the nation's health-care system already struggles under a dire shortage of primary-care physicians.

Many going into primary care support efforts to make health care accessible to people who now lack insurance. But they are hoping that any change to the nation's health-care system will help not just patients, but also primary-care doctors, who are on the front lines of providing care but typically earn far less than other doctors.

Experts say that in a well-functioning health-care system, about half of all doctors would be internists, family doctors or pediatricians, who together would comprise the category of primary-care physicians. But in the United States, only about 30 percent fall into that category (about 35 percent in Washington), and the rate of medical students going into it is far lower still — less than 10 percent nationwide.

"There's so few primary-care physicians available, and even fewer in the pipeline, that once you open the floodgates" it could take a decade for the supply of doctors to meet the national demand, said Roger Rosenblatt, professor of family medicine and public health at the University of Washington School of Medicine.

Many point to Massachusetts as an example. When that state mandated health coverage in 2006, a wave of new patients immediately overwhelmed the system. One study showed that even now, it takes slightly more than two months for a new patient to see a family doctor.

For Washington state, a health-care proposal before the U.S. House — America's Affordable Choices Act — could mean up to half a million new patients over the next decade, according to a study by Families USA, a nonprofit advocacy organization.

For many medical students in primary care who have hefty student loans, the prospect of long hours, hassle of dealing with insurance companies, and earning power that's far less than their specialist counterparts trump the desire to go into primary care.

Others find little support at medical schools more geared toward producing specialists and say they often hear well-meaning comments from mentors that they are too smart to go into family medicine and should pursue a specialty instead.

Choosing primary care

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Idealism is what drives many who choose primary care despite the obstacles.

They want to care for patients in underserved communities, focus on preventive medicine and catch problems early enough to spare patients costly and traumatic procedures. Many want to work at community health centers.

"I wanted to find a program that would allow me to take care of people in vulnerable populations — the working poor, those that don't speak English," said Meg Mullin, a first-year resident at Harborview Medical Center. "The sacrifices in the pay, they don't count as much for me."

While primary-care physicians can earn $120,000 to $150,000 a year, a diagnostic radiologist or orthopedic surgeon typically earns triple that amount.

Doctors blame that gap largely on the current system of reimbursement. Many doctors are paid according to how many patients they see or on the procedures and tests they do. Rarely are they paid for the amount of time they spend with patients — and for primary-care doctors, getting to know patients is essential in helping them stay healthy and manage chronic diseases.

"Medical records can't give you all the details that come from knowing the patient and having worked with them for a period of time, knowing their husbands, grandchildren, their children and how their community influences their health," said Mark Johnson, a family doctor at Swedish Family Medicine, First Hill campus.

Before Johnson decided to become a family doctor, he weighed his options. He valued the long-term relationships he would build with patients and the ability to provide health care in a more holistic way. But he also knew he could earn more money if he specialized in something.

Then one day, during his rounds as a medical student, he met a woman with advanced cervical cancer who had never been given a Pap smear. That struck him as wrong — and helped him decide what to do.

"Someone could have prevented that cancer," he said. "It would be more rewarding for me to be that person at the front end of things rather than the back end."

Potential solutions

Many in or considering primary care are hoping health reform will address their concerns.

One proposal being discussed in the House measure would authorize grants to community health centers to set up training programs for primary-care residents. Typically, those grants now go to hospitals. Another provision would provide training grants for primary-care residents.

At the UW, which produces more primary-care physicians than the average medical school — 12 to 13 percent of last year's graduating med students, compared to 8 percent nationally — one program already focuses on training students from rural areas who are more likely to practice primary care in outlying areas.

At a primary-care summit that ended this week in Washington, D.C., experts looked at other potential fixes, including more options for forgiving student loans of those in primary care.

Rosenblatt said undecided students will more likely lean toward primary care if fixing the inequities seems a possibility.

"The medical students are so sensitive to this, that they change their preferences in a flash," he said. "So if the United States actually decides to do something about health care, and started to support primary care, you'd see an instant transformation of future doctors."

Copyright © The Seattle Times Company

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