One morning during my medical residency many years ago, one of the senior doctors pulled me aside after rounds, as was his routine, to review the status of patients in the intensive care unit. A few had single-organ failure - their lungs weren't doing well, or their hearts weren't beating efficiently. A few struggled with double-organ failure. But the majority of patients were battling multisystem organ failure, and their prognoses were not good.

"People can survive one organ system failing and even two," the senior doctor said to me after we were finished. "But when that third one goes ..."

He leaned forward and looked me in the eye. "Three strikes, and the game is over."

That remark came to mind recently when I thought about the crisis in primary care and President-elect Barack Obama's plans to make health care accessible to all.

Primary care is delivered in a variety of settings by a variety of professionals, including nurses and physicians' assistances, but it is anchored by family-practice doctors, general internists, pediatricians and, for many women, gynecologists. As the nation's front-line doctors, primary care physicians address everything from chronic diseases, like diabetes, heart disease and high blood pressure, to more acute conditions, like pneumonias, intractable flus and potentially cancerous masses and lumps.

While their initial work in diagnosis often sets the trajectory of care for a patient, they also manage long-term conditions, guard the public's health and advocate preventive care measures. For many patients, too, primary care doctors are invaluable guides through the maze of health care options and specialists.

Physician shortage

In the last several months there have been reports in medical journals about an impending shortage of primary care physicians. This spring in the health policy journal Health Affairs, researchers at the University of Missouri-Columbia and the federal Department of Health and Human Services published a study that projected a generalist physician shortage of 35,000 to 44,000 by the year 2025. The researchers based their figures on current physician usage patterns and did not take into account increases that might occur because of rising access to health care.

The news got worse in September, when The Journal of the American Medical Association published a study showing that just 2 percent of graduating medical students are choosing to enter general internal medicine. The students surveyed were concerned in part by what they perceived to be a more difficult personal and professional lifestyle, compared with other fields. They felt that the paperwork and charting required of primary care physicians were more onerous, and they were not eager to care for the chronically ill in a health care system that focuses on acute care.

The potentially devastating public health implications of both of these reports rippled out into the medical community. Last month in an official statement, the American Medical Association vowed to support financial incentives for medical students who choose to go into primary care.

What are the consequences of these projected shortages for patients? According to the Health Affairs report, there are about 75 generalist physicians for every 100,000 individuals. By 2025, when the population will have grown by 18 percent and the number of individuals over age 65 by 73 percent, either primary care doctors will be seeing many more patients than they do now, or several million people will be without a primary care doctor, no matter how accessible health care might be for the rest.

Strike one.

Crisis already here

But a recent survey indicates that the primary care crisis may not be looming on the horizon; it may already be at our back door.

The Physicians' Foundation, a nonprofit organization that supports physicians' work with patients, last month published the results of a survey on current medical practice conditions in the United States. Some 12,000 doctors responded, the vast majority of whom were primary care physicians.

Nearly half of them said they planned in the next three years to reduce the number of patients they see or to stop practicing altogether. While these doctors rated patient relationships as the most satisfying aspect of practice, over three-quarters felt they were at "full capacity" or "overextended and overworked."

Only one-third felt they had the time to fully communicate with and to treat all patients, and 60 percent felt that paperwork demands resulted in less time spent with patients.

The primary care crisis raises questions not just about future access but about current morale.

"There was a tremendous amount of disenchantment, frustration, all bordering around one thing," Tim Norbeck, the executive director of the Physicians' Foundation, said of the survey. "Doctors feel they can't spend enough time with their patients because of the paperwork and red tape hassles."

Mr. Norbeck added: "Physicians went into medicine to spend more time with their patients, and that time has just been eroding. There's serious reason to believe that there won't be enough doctors to cover people sooner than we thought."

Strike two.

A wake-up call

I won't envy Mr. Obama as he steps into the White House in January. Any attempt to make health care more accessible will be doomed to failure without an adequate number of primary care physicians and a strong primary care system. The situation in Massachusetts should be a wake-up call. Since a landmark law was enacted in 2006 requiring health insurance for nearly all residents, the state has struggled to provide primary care to the estimated 440,000 newly insured.

Mr. Obama and his team may find ways to give more Americans access to the waiting room, but what if there's no doctor on the other side of the door? The crisis in primary care must be addressed before any real change can occur; otherwise, the flood of new patients may instead turn out to be a final strike for our ailing health care system.

And at that point for all of us, doctors and patients, the game would be over.

 

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