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Wednesday, March 29, 2006 - Page updated at 12:00 AM


Guest columnist

The collapse of primary care

Special to The Times

Health care in the United States is like a house riddled with termites. On the outside, everything looks fine: Gleaming hospital towers punctuate the skyline; MRI machines produce stunning images; and surgeons use robots to work miracles. But underneath the surface, the foundation is starting to sag: Tens of millions of people have no health insurance, emergency rooms are overwhelmed by patients who don't have regular physicians, and the cost of medical care is rising into the stratosphere.

One of the reasons for the rot at the core is the impending collapse of primary care, the family doctors and other health-care professionals who are the foundation of the health-care system. Just as your house cannot stand without its supporting beams, neither can the health-care system function without doctors and other clinicians who are experts in primary care. They work to prevent illness before it occurs; manage people with complex chronic diseases; care for pregnant women and their babies; and attend to the mental-health and substance-abuse problems that produce so much illness and social disruption.

Why is the primary-health-care system unraveling? The main reason is that new physicians are not choosing to pursue careers as family physicians and general internists, the two physician groups that provide primary care for adults. The number of medical students entering family medicine residencies — the graduate training programs that take medical students and turn them into licensed physicians — has declined 52 percent in seven years.

The reasons for this seismic shift in medical student career choice are not hard to find: Reimbursement rates for primary care have declined, student-loan debts have skyrocketed, and the complexity of caring for an aging population has become more and more challenging.

The situation has been made worse by the federal government's decision to drastically cut funding for training family physicians (a program called Title VII) at the same time the need for these physicians has increased.

One of the first signs of this crisis is in the nation's community health centers, community-sponsored clinics that receive governmental assistance to provide care for the poor and uninsured. There are dozens of these clinics here in Washington state. Without them, thousands of people living here would be unable to get basic medical care.

Our research team at the University of Washington — working with the National Association of Community Health Centers — recently surveyed all of the nation's nearly 1,000 community health centers. We found that many centers can't find enough family physicians to take care of their patients. The percentage of unfilled positions for family physicians is in the double digits, and recruitment is quite difficult, especially in rural areas.

Other disciplines such as obstetrics, psychiatry and dentistry also have high rates of unfilled positions, but the largest aggregate need is for family physicians. The situation can only get worse, as those currently working in community health centers retire and fewer and fewer new graduates are available to replace them. The full study is in the March 1 issue of the Journal of the American Medical Association:

The shortage of primary-care physicians in community health centers is an early sign of the structural weakness at the core of America's health-care system, and will ultimately affect everyone. Research has shown that regions with more primary-care physicians have better health outcomes at lower cost. An adequate supply of primary-care physicians is vital to our society's health and well-being.

The supply, however, is dwindling nationwide. Even at the University of Washington School of Medicine, whose five-state regional medical education program has been recognized for more than a dozen years as the nation's best for training primary-care physicians, fewer medical students are choosing primary-care careers.

What can we do to change this situation? The solution is ultimately political, since it requires making sure that our enormous public investment in medical care goes where it will do the most good.

First, we can make sure that our political representatives know that government investment in family medicine and primary care makes sense, at both the state and federal levels. Specifically, Title VII funding needs to be restored.

Secondly, we need to make sure that Medicare and Medicaid provide fair and adequate reimbursement for primary care; the private insurance companies will follow.

And third, we have to support social policies that make sure that the foundations of our health-care system are solid, and that all of our country's residents are guaranteed access to basic health care.

Dr. Roger A. Rosenblatt is a professor and vice chairman of the Department of Family Medicine at the University of Washington School of Medicine. He is the founder of the UW's Rural Health Research Center and lead author of "Shortages of Medical Personnel at Community Health Centers" (JAMA, March 1, 2006).

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