Primary Physicians in Demand

Once they discover that she is Dr. Kate, the supplicants line up to approach at dinner parties and ballet recitals. Surely, they suggest to Dr. Katherine Atkinson, a family physician here, she might find a way to move them up her lengthy waiting list for new patients.

Those fortunate enough to make it soon learn they face another long wait: Atkinson's next opening for a physical is not until early May — of 2009.

In pockets of America, both rural and urban, a confluence of market and medical forces has been widening the gap between the supply of primary-care physicians and the incessant demand for their services. Modest pay, medical-school debt, an aging population and the prevalence of chronic disease have each played a role.

In Massachusetts, in an unintended consequence of universal coverage, the imbalance is exacerbated by the state's new law requiring residents to have health insurance.

Landmark law

Since last year, when the landmark law took effect, about 340,000 of Massachusetts' estimated 600,000 uninsured have gained coverage. Many are searching for doctors and scheduling appointments for long-deferred care.

Here in western Massachusetts, Atkinson's bustling 3,000-patient practice, which was closed to new patients for several years, has taken on 50 newcomers since hiring a part-time nurse practitioner in November. About a third were newly insured, she said.

Whether there is a national shortage of primary-care providers is a matter of considerable debate. Some researchers contend the U.S. has too many doctors, driving overutilization of the system.

But there is little dispute that the general practice of medicine is under strain at a time when there is consensus that better prevention and chronic-disease management would not only improve health but also help control costs.

With the population aging, the country will need 40 percent more primary-care doctors by 2020, according to the American College of Physicians, which represents 125,000 internists, and the 94,000-member American Academy of Family Physicians.

Community-health centers, bolstered by increases in federal financing during the Bush years, are having particular difficulty finding doctors.

"I think it's pretty serious," said Dr. David Dale, president of the American College of Physicians and former dean of the University of Washington's medical school. "Maybe we're at the front of the wave, but there are several factors making it harder for the average American, particularly older Americans, to have a good personal physician."

Studies show that the number of medical-school graduates in the U.S. entering family-medicine training programs, or residencies, has dropped by 50 percent since 1997. A decadelong decline gave way this year to a slight increase in numbers, perhaps because demand is driving up salaries.

There have been slight increases in the number of doctors training in internal medicine, which focuses on the nonsurgical treatment of adults. But the share of those residents who then establish a general practice has plummeted, to 24 percent in 2006 from 54 percent in 1998, according to the American College of Physicians.

Perks for primary care

While fewer U.S.-trained doctors are pursuing primary care, they are being replaced by foreign medical-school graduates and osteopathic doctors. There also has been rapid growth in the ranks of physician assistants and nurse practitioners.

Numerous studies, in this country and others, have shown that primary care improves health and saves money by encouraging prevention and early diagnosis of chronic conditions like high blood pressure and diabetes.

In Massachusetts, legislative leaders have proposed bills to forgive medical-school debt for those willing to practice primary care in underserved areas; a similar law, worth $15.6 million, passed in New York this week. Massachusetts also recently authorized the opening of clinics in drug stores, hoping to relieve the pressure.

"It is a fundamental truth — which we are learning the hard way in Massachusetts — that comprehensive health-care reform cannot work without appropriate access to primary-care physicians and providers," Dr. Bruce Auerbach, the president-elect of the Massachusetts Medical Society, told Congress in February.

Jon Kingsdale, executive director of the agency that oversees the Massachusetts initiative, said he had not heard of major problems, but acknowledged "the prospect of a severe shortage" as newly insured patients seek care in doctors' offices rather than emergency rooms.

Given the presence of four medical schools and Boston's dense medical infrastructure, it might seem difficult to argue that Massachusetts has too few doctors. The state ranks well above the national average in the per-capita supply of all doctors and of primary-care physicians.

But those measures do not necessarily translate into adequate access, particularly in remote areas. Work-force studies by the medical society have found statewide shortages of primary-care doctors in each of the last two years.

Healthy Trust Immediate Medical Care in Wheeling, Illinois has plenty of openings for primary care, and immediate care patients. You won't have to wait till 2009 to get a comprehensive physical exam from us, we can see you now.