Is there a doctor deficit in the house?

Health care reform has been launched, but a medical care “iceberg” is directly in its path. The massive changes contained in the reform bill approved by Congress in March will add 32 million Americans to the insurance rolls. That responsibility contributes to the burden of primary care by doctors already overworked, underpaid and suffering under the growing responsibility of care. It raises questions about recruiting doctors, and their choices between internal medicine and specialty care.

Those factors will affect the medical care we all receive. A few weeks ago, Dr. Charles Plamp, former medical director of The Vancouver Clinic and my primary care physician, and I began a conversation about the future of medical care in America. First among trends is the shortage of family doctors. It starts with schooling. The University of Washington School of Medicine reported only 216 began first-year studies in September out of 4,266 who applied.

That’s part of the reason UW Medicine, the American Medical Association and others warn of shortages in internal medicine, family care and pediatrics. It’s also why the United States has been importing doctors from other countries, starting with India, which may be the world’s largest exporter of doctors. India’s export of medics to the U.S. alone was at 25,000 in 2006.

Presenters last fall at a Washington, D.C., conference of Health Resources and Services Administration pointed out more than 24,000 physicians will reach retirement age in 2017. The supply of physicians, especially primary care physicians, is growing, but not fast enough. About 26,000 enter practice each year. If 20,000 to 60,000 more doctors retire because the stock market is up, “we will be in trouble,” said Edward Salsberg, director of the American Association of Medical College’s Center for Workforce Studies. Predicted shortages of doctors by 2020-’25 run as high as 120,000.

Pay has become a factor

Another major factor is the salary gap between family physicians and medical specialists. The salary range for a family doctor is $110,000 to $204,000, and between $300,000 and $500,000 for a specialist. The higher salary is appealing to doctors who complete their residency and start a practice, because most begin with a college debt of $200,000 or more.

Increasing paperwork on the doctor adds to the physician shortage. “When I come to work each day, I have a stack of papers about an inch and a half high,” said Plamp, who is trained in nephrology (the treatment of kidneys). Paperwork includes authorizing prescriptions for various health insurers, which have different rules about what medicine is purchased, and how much. For many doctors, the work load is 80 hours a week, he added. The paper load is less for specialists than for family doctors.

Hospitalists — doctors who work for the hospitals and medical groups and manage care for people who are hospitalized — are a new trend that further shrinks the number of physicians available for primary care. It has a certain appeal in terms of secure employment with a retirement plan, and more predictability on night calls.

Pressure is building to make up for the doctor shortage through extended work by nurse practitioners and physician assistants, mainly in primary care. The topic is controversial, with the American Medical Association questioning whether nurse practitioners are “adequately trained to provide appropriate care.”

Even with health reform, which Plamp supports, there may not be enough insurance. He also volunteers at a free clinic, and routinely sees working poor who come with their families for care due to their lack of access to health insurance.

What of the future under health reform? “We can only hope that as health care reform rolls out, there are sufficient provisions and incentives to increase the number of primary care physicians and internists,” said Plamp. The significant shortage of physicians that exists now must not become critical, he added.

The health of America is at the crossroads of care.

Tom Koenninger is editor emeritus of The Columbian. His column of personal opinion appears on Wednesdays. Reach him at koenninger@comcast.net.