Whatever Happened to the Family Doctor?

“Another trend, I believe, is that we have a culture now that encourages increasingly focused intellectual pursuits,” says the U of M’s Baird. “Being a generalist [as family physicians have to be] is almost countercultural.” Against the high debt load and the high bar of simply getting into medical school, many may feel the pressure to get the highest yield from their investment.

“There’s an incredible amount of pressure to specialize,” agrees Lisa Holland, a third-year resident at United Family Practice Health Center, who grew up outside of St. Cloud and graduated from the U and medical school at Dartmouth. Almost the entire state of New Hampshire is designated as a partial shortage area for primary care physicians, but, she says, “when I would tell [professors and faculty members] that I planned to go into family medicine, the attitude was, ‘Why would you want to do that?’ ”

Regard for family medicine has always been higher in Minnesota, where primary care has been essential to the rise of the HMO and an emphasis at the U of M. In the thirty-five years between 1971 and 2006, the U has trained more than 1,150 family physicians, more than any primary care training program outside of the U.S. military’s. While an estimated 17 percent of U graduates go into family medicine—more than twice the current average of 8 percent of all medical school graduates—that percentage is about half of what it was as recently as a decade ago, when almost a third of all U of M med students went into family medicine.

“It’s still the most popular specialty,” says Baird. “But not nearly at the numbers we need to see.’’ The American Academy of Medical Colleges has recommended a 30 percent increase in first-year medical student enrollment by 2012, in part to meet the growing need in primary care. Though there are now 31.2 family physicians for every 100,000 Americans, the American Academy of Family Physicians says we need 41.6 doctors for every 100,000 patients.

But even if those goals were met and Minnesota trained more family physicians, there’s no guarantee they’d stay. “We’re not just competing [for good doctors] locally anymore,” says Foley. The medical marketplace is national now, even global. (Last year, twenty-eight of the seventy-eight first-year residents in family medicine programs in Minnesota were trained at foreign medical schools.) And while Minnesota still ranks among the best states in many indicators of quality health care, when it comes to recruiting and keeping family doctors there are other factors that may hurt more than the long winters. For instance, The Health Research Group of Public Citizen, a national nonprofit public interest group, recently ranked Minnesota in the top ten of all states when it comes to providing health care to Medicaid patients, giving the state high marks for the wide scope of services offered and generous eligibility provisions. But one criteria that hurt Minnesota’s standing was our nineteenth-place ranking for reimbursement, and the fact that we pay primary care Medicaid providers significantly less than what their Medicare counterparts receive. At the same time, Medicare reimbursements, which are based on a regional cost of living equation, pay substantially less in Minnesota than they do in other parts of the country. “If you’re a young doc, you can see that Medicare pays me half as much in Minnesota as it does in Florida and Texas and California,” says Foley. “You start looking at other things, other places.”

Factor in other capital costs—such as the current push for electronic medical records—and it’s easier to understand why formerly independent family practice groups have been merging lately with larger health care systems. For instance, in the northern suburbs, Columbia Park Medical Group merged this fall with Fairview Health Services, while Allina and Crossroads Medical Centers, in the southwest metro, were in discussions about a merger at presstime. Allina Hospitals and Clinics recently closed its merger with St. Paul–based Aspen Medical Group. In 2005, Aspen’s eight clinics reported revenues of nearly $81 million and expenses of $83 million.

Foley says these recent consolidations remind us that health care “is also a business, and unless you can run it efficiently and make the numbers work, you’re out of business.”

Given the dismal forecast, the question emerges—do we really need family docs? After all, you can get your blood pressure checked at Target, your strep throat cultured at Cub Foods, and all the symptoms and side effect warnings a hypochondriac could ever dream of on the Internet.

In spite of all these choices—or maybe because of them—a great majority of patients would prefer to seek initial care from a primary care physician rather than a specialist. A review of studies from Johns Hopkins University found that adults with primary care physicians had 33 percent lower costs for their care and were 19 percent less likely to die from their conditions than those who saw a specialist. An increased supply of primary care physicians in a population is also associated with lower rates of death, Medicare expenditures, and hospitalizations. Not only that, family physicians play a critical role in lifestyle changes that can prevent the onset of preventable conditions such as heart disease and type 2 diabetes. Considering that more than 300 baby boomers turn sixty every hour in this country, the potential savings of this kind of preventive care could really add up.