Family Physician Ranks Here Face Shortage

Physicians here say the practice of family medicine is ailing badly as medical students select other specialties rather than become primary-care doctors.

The number of medical residents choosing to become family physicians has been plunging since the late 1990s, and even if that trend levels

In the early 1990s, an increasing number of students entered family practice and other primary-care fields as, health-care experts predicted those physicians would be the gatekeepers of a highly managed health-cue system, health-care professionals say.

As managed care's popularity with the public waned and physicians grew frustrated with their gatekeeper role, more and more students chose to enter subspecialty fields, after receiving additional training.

"The great experiment in making family docs the gatekeepers is going down the tubes," says Dr. Gary Newkirk, program director at Family Medicine Spokane. "It's leveling off at the bottom, and we're in the tank, period."

Family Medicine Spokane is a family-practice residency program that's supported by the University of Washington, Sacred Heart Medical Center, and Deaconess Medical Center. It also offers a post-graduate fellowship in obstetrical training and a rural-training track program and it currently has 26 residents.

In 2005, 1,200 fewer U.S. medical students decided to enter family practice than in 1997, representing a nearly 50 percent drop, according to the Washington, D.C.-based National Resident Matching Program.

The University of Washington School of Medicine's Department of Family Medicine, which U.S. News & World Report has ranked as the top primary-care program in the country since 1993, recently funded a study of the Washington, Wyoming Alaska, Montana, Idaho and doctors in those (WWAMI) regional work force and doctors in those states. Those five states have teamed up with the UW School of Medicine to provide access to publicly supported medical education to their residents. The study found a significant drop in the number of UW medical students - 10 percent from 35 percent a decade ago-who selected family medicine as a career choice.

Family Medicine Spokane's program coordinator, Deanna McRae, says that when she joined the program in 1992, it had 2,200 applicants for seven spots. In the past two years, it has had 200 applicants a year. The program, along with other residency programs across the U.S., has shifted from selecting students through a highly competitive process to recruiting residents from a dwindling base of applicants, she says.

About 141 family-care physicians currently are practicing in Spokane County, up from about 122 in 1995, says Jan Monaco, executive director of the Spokane County Medical Society. She says there's a 3-to-1 ratio of specialists to family physicians here, and expects that trend to continue.

"It's like the canary in the cage," in terms of the warning the trend toward fewer students choosing to enter family practice is sending to the community, Monaco says. "If the numbers of people going into family medicine go down, it's very disconcerting, because those are the folks that primarily take care of us."

Family medicine was born in the 1960s and instituted in the 1970s as a way to recognize the demands of coordinated primary care for the general patient population, Newkirk says. The idea "took off like wildfire," but in the 1980s primary-care doctors became the front-line physicians in the managed-care network, and "then came the paper chase," he says.

"The generalist is getting killed with referrals that have nothing to do with touching a person's life," he says. "Primary-care physicians spend twice as much time on paperwork as they do with their patients, and residents don't choose the profession to push paper."

Declining reimbursement rates and skyrocketing malpractice insurance premiums also are causing fewer medical students to choose family medicine concerns, he says.

The federal government continues to cut reimbursement rates by around 5 percent a year for family physicians, he says. Those cuts have a big impact when 30 percent of the average family-care practice's patients have Medicaid insurance, he says. In small towns that percentage is even higher, and family physicians can't tell people to go somewhere else when they're the only doctor in town, he says.

In addition, family physicians who do obstetrical work are having a difficult time meeting the cost of rising malpractice premiums, so fewer doctors are performing OB procedures, he says. In Washington state, a doctor who performs nonCesarean deliveries typically pays $18,000 a year for insurance, while a doctor who performs Cesareans pays upward of $20,000.

To pay those premiums, a physician has to deliver about 30 babies just to break even, in addition to managing the rest of their general practice. By contrast, specialty OB physicians in Spokane probably deliver 50 to 100 babies a year on average, Newkirk says.

"Especially in small towns, OB is a huge lightning rod in malpractice," he asserts. "Residents see that and are running scared."

McRae says tort issues in the state also make recruiting primary-care physicians harder. For every family doctor, there are 10 openings nationwide, and it's becoming harder to attract family doctors to Spokane, especially when "border states offer better deals, and Post Falls is only a short drive away," she says.

Colleen Mooney, a recruiter for Rockwood Clinic PS, of Spokane, sees things the same way. She says it's becoming harder to find primary-care physicians who are willing to do OB work, especially when malpractice costs are considered in the context of the average family practitioner's starting salary of $125,000 in Washington state. A cardiology fellow's starting salary, by comparison, is $275,000 to $350,000, although a fellowship in some subspecialty fields, such as cardiology, involves additional training beyond residency.

Lower salaries also play a part in Students' decisions not to go into family medicine, not because of greed typically, but because they need to pay off sizable school loans, Newkirk says. New doctors in residencies usually owe $150,000 to $250,000 for their training, and higher sub-specialty incomes allow them to pay those loans off faster. In addition, primary care now tends to attract older students who have chosen medicine as a second or third career have started families already, and have more financial obligations.

"We went from seeing Doogie Howsers to gray-haired people like me," he says. "If you have kids and you're in medical school wondering how to pay off tuition and how you're going to survive, you look at primary care and ask, 'Why would I want to do that?' "

Quality of life

Quality-of-life issues, including the on-call aspect of a primarycare physician's work, also factor into an older medical student's decision on what specialty to enter, Newkirk says. Resident doctors see the beepers, the hospital rounds older doctors they make in addition to their practice loads, and their 60-hour workweeks, and doctors know they can get paid twice as much by becoming a subspecialist, he says.

"Our residents want to be the full-time, do-it-all family doc, and they know they'll be at the bottom of the salary food chain," he says. "If they bring up salary, it's because they're scared about being able to pay premiums and school loans."

As the number of U.S. medical students choosing family medicine decreases, Newkirk says practices and hospital residency programs are turning to international students to meet the demand. In the past five years, half of the applicants Spokane Family Medicine has accepted have been trained in Europe and India.

The University of Washington, one of the premier medical schools in the country, covers such a large geographical area that Spokane-area people who would choose to come back here for their residencies often end up attending offshore schools and practicing elsewhere because they can't get admitted at the highly selective UW, he says.

"I love the international students we get. It's just odd to me that we're having to become an importer of physicians," he says. "We're taking the brightest doctors from the poorest countries in the world that need their services (and are using them) to populate primary-care practices in the Pacific Northwest."

A shortage of family-care physicians affects not only practices that are trying to recruit them, but more importantly, the general patient population that relies on them to coordinate their care, he says. Especially dependent on them are elderly people who see a variety of specialists and can't keep track of everything all those doctors want them to remember, he says.

"Family medicine is critically dependent on subspecialists, and if they can make a better living than me, OK," he says. "But what's going to happen when family care isn't available and there's no way to coordinate care?"

Newkirk says the lack of primary-care physicians is especially felt in the region's small towns and rural areas, where pregnant mothers end up having to travel to Spokane to see an OB doctor and people who are involved in accidents have to be transported here for care.

"If I'm fishing in Wyoming and twist my ankle or have an accident while skiing in Colville, I'd like to see someone that knows what they're doing rather than have to be airlifted to Spokane," he says.

"Or if you have abdominal pain, and it could be the burrito you ate or an aneurysm in your belly, rather than sit in the ER for two hours it'd be nice to pick up your phone and go in to see a doc that knows you."

Family physicians and family medicine associations are attempting to reverse the trend away from family care with a variety of programs aimed at increasing medical students' interest in the field, McRae says.

For instance, the Bellevue, Wash.-based Washington Academy of Family Physicians, which is the state chapter of the American Academy of Family Physicians, has started a mentorship program for residents and new physicians interested in family medicine.

McRae says family-care practices also are getting out into the community more with flu clinics and health clinics and are visiting high schools to talk to students about primary care.

They're also visiting medical schools to be more involved in the admissions process to give students earlier contact with practicing primary-care physicians, which is important because professors tend to come from specialty fields and either directly or indirectly sway students toward careers in subspecialties, she says.

Newkirk recently visited the UW Medical School's extension campus in Pullman to teach students there how to suture wounds.

He's also planning a trip to Phoenix soon to recruit students at a medical school there, he says.

McRea says she would like to see the UW open a branch campus of its medical school in Spokane, and adds the area has plenty of economic and educational resources here to do so.

Newkirk says, "Fortunately, we're in an area where residents want to live, but salaries are down and we're in the middle of a tort crisis, and I worry that we're going to have an even harder time filling the community with good physicians in the future."