Whatever Happened to the Family Doctor?

Kathleen Macken, MD, works down the hall from Rumsey, where for the past seventeen years she has directed the United Family Medicine Residency Program, training recent medical school graduates from such local schools as the University of Minnesota, Iowa, University of Minnesota–Duluth, and Mayo and those from much farther away—Harvard, Dartmouth, Brown, Tufts, Tulane, and Notre Dame, among many others. Residents spend three years in this bustling urban clinic, treating 13,000 patients from places as divergent as Somalia and Summit Avenue with everything from strep throat to suicidal thoughts. Macken, who has earned national recognition as one of the top family medicine educators in the country, says the knowledge base needed to deal with such a broad spectrum of health needs over the course of a long life is one of the main attractions of family medicine.

“There is really a magic to it,” she says. “That opening of the human spirit that comes with attending the birth of a child, visiting a patient in the hospital, seeing someone with a depression stabilize, or live through a state of grief, or celebrate their children’s accomplishments. It’s very gratifying being involved in so many stories of life.”

So why aren’t more young doctors choosing to follow her into family medicine?

“Well,’’ she says, turning her attention to a pager that has gone off twice since she started talking. “It’s also like being on a hamster wheel.”

Though primary care physicians are now the most sought-after doctors in health care, regularly leading the “wish lists” of medical employers, the high demand hasn’t helped boost the supply. Some explanation for that may be found in an annual survey of primary care physicians conducted by the recruiting firm Merritt, Hawkins & Associates, which recently asked those doctors where they felt they stood in the medical hierarchy, compared to diagnostic and surgical specialists. Nearly 54 percent chose the answer “second class citizen.” Though 40 percent said they believe primary care will play a “vital” role in the future of health care, 14 percent said they believe primary care will “eventually disappear.” If given the chance to do it all over again, only 40 percent said they would go into primary care.

Perhaps, predictably, much of this job dissatisfaction centers on money. Nationwide, the average base salary for a physician in family medicine is $161,000, while the average base salary for specialties such as radiology, cardiology, and orthopedic surgery, can be two or three times that amount. Tallying up the long office hours, the hospital rounds, and a full spectrum of patient needs, the income physicians make on an hourly basis can be especially disheartening.

Blame for the problem is often attributed to a reimbursement structure that rewards higher rates for the sorts of procedures and tests performed by surgeons and other specialists in acute care and less for the cognitive and harder-to-quantify healing that takes place in primary care settings. While some medical historians suggest that the system was put in place in the advent of Medicaid in 1965, others say it started several centuries earlier, sometime around 1216 A.D. That was when Rome issued a papal edict banning priests from drawing blood—and leaving surgery to the barbers.

"Since then, we’ve always paid the barbers, and we've never paid the priests," jokes Macaran Baird, MD, professor and head of the department of family medicine and community health at the University of Minnesota Medical School. “We have a long history of paying more for procedures than for [the less invasive] forms of health care—the healing, the listening, the laying on of hands."

In real terms, says Rumsey, it translates this way: “Say you’re a GI [gastroenterologist], and you do a half-hour colonoscopy on a patient, and you get paid maybe $500 to $1,000. Here, we can do an hour-long visit with a schizophrenic patient who’s suicidal and you get about $185. I don’t have anything against GI docs, but that’s just how the system works.”

While senior physicians may be secure enough in their careers, or close enough to retirement, to be inured to such inequities, medical students with loans to pay off may not have such a luxury. Consider, for instance, that proposed cuts to Medicare will reduce payments to physicians by 10 percent starting this month and by as much as 40 percent over the next nine years. During that time, the American Medical Association predicts the costs of running a practice will increase by about 20 percent. [Note: At presstime, physician groups were lobbying Congress to turn back the proposed cuts.]

“The overall rate of reimbursement is going down and it’s just getting to a critical point now,” explains Peter Dehnel, chief of staff at Children’s Hospitals and Clinics of Minnesota and medical director of the Children’s Physician Network. “You have these young, energetic, highly skilled and smart people coming out of medical schools, but they’re reading the same headlines and asking, ‘Do I want to go into a situation where there’s not a good future?’ ” After all, half of the graduates of public medical institutions leave with over $119,000 in debt, while medical school students at the University of Minnesota, the second-most-expensive public medical school in the country, now face an average total loan bill of more than $140,000.

“So here you are, you’re twenty-four or twenty-five, you have all of that debt just for that education, plus living costs, plus whatever you owe on your undergraduate education. And now you’re saying, ‘What kind of doctor should I be?’ ” says Daniel Foley, vice president of medical affairs of United Hospital in St. Paul. Little wonder a recent survey of med school grads found that 32 percent say that debt level had influenced their choice of a specialty.

Another influence has been a shift in the culture of medicine. Many current family medicine physicians came of age in the 1960s and 1970s, when creating access to quality health care was part of the political movement of the times. “I went into medical school believing health care was a right, a human right, and that’s why I chose family medicine,” says Macken. Though she finds that many of her residents are moved by the same ideals, they may not owe their career choice to a compatible cultural movement.