Amber Meiwes is happy to tell you what's wrong with primary care in America: It's hard to get any, and when you do, it's a health risk.
During a long struggle with recurring stomach pain, Meiwes got used to waiting three weeks to get in to see a doctor—and then being hustled back out in mere minutes. "They had way more patients than they really can see," says Meiwes, 29, of Piedmont, Okla. "They would say, Take an antacid and go home." When she fell ill on weekends, her only options were an after-hours clinic or the emergency room. It took three years of office visits and ER visits before she got a diagnosis: inactive gallbladder. "I got to the point where I wouldn't even go to the doctor anymore."
It's not supposed to work that way. A primary-care doctor is supposed to be the go-to doc for almost every ailment from ingrown toenails to suspicious breast lumps—the trusted guide to the system who knows the patient, her medical history, her family. Any time the patient must navigate the bumpy and often frightening path through specialty care, it's these internists and family and general practice doctors who make sure that nothing critical falls through the cracks. Indeed, study after study has shown that patients fare better in areas of the country not overpopulated by medical specialists and where primary-care physicians handle the bulk of care. Yet increasingly, the system is fraying. Consider:
• Twenty-nine percent of people with Medicare said they had trouble finding a doctor who would take that insurance in 2007, up from 24 percent the year before. That's 11.6 million people.
• Two thirds of Americans say they have a hard time getting medical care on nights, weekends, and holidays, according to 2007 survey by the Commonwealth Fund.
• Just 30 percent of Americans say they can get in to see their doctor on the same day—putting the United States second to last among industrialized countries, ahead of Canada, according to the Commonwealth Fund survey.
• In California, almost half of emergency department patients surveyed in 2006 by the California HealthCare Foundation said they thought their problem could have been handled by a primary-care physician. Two thirds of those people said they couldn't get an appointment with their doctor.
• In Texas, 24 counties now have no primary-care doctors at all.
• In Alaska, not one of the 749 private-practice physicians was taking new Medicare patients for primary care in November 2007.
The shortages don't reflect a lack of doctors; the number of physicians per capita rose 77 percent between 1970 and 2000. But given the choice, most new doctors simply reject primary care. A specialist performing a procedure—a colonoscopy, say—is commonly paid three times as much for 30 minutes as a primary-care physician who spends that time talking with patients about how to manage their heart failure or diabetes. An internist or a family-practice physician might start off making $100,000 to $150,000 a year, but specialists make about twice as much on average, says David Dale, a Seattle internist who is president of the American College of Physicians. And a typical medical student graduates with $130,000 in debt.
As a result, the number of grads choosing residencies in family practice, internal medicine, and pediatrics fell 7 percent from 1995 to 2006, according to congressional testimony from the Government Accountability Office in February. And while half of residents in internal medicine chose to go into primary care in 1998, now just 20 percent do. In the past few years, many have instead chosen to join the growing ranks of "hospitalists," a new genre of internist who manages the care of patients while they are in the hospital. Hospitalists may make $200,000 a year to start, with fewer hours than a private practitioner and none of the start-up costs or managerial headaches.
Those who remain find themselves struggling to make money even though they can't meet demand. "The waiting list to get a physical with me is 14 months," says Kate Atkinson, a family-practice physician in Amherst, Mass., who does home visits, answers patients' E-mails within a few hours, and prides herself on being the kind of doctor she'd like to go to. Atkinson sees 25 to 30 patients a day, yet she's barely staying afloat, largely because of the cost of staff she needs to keep up with insurance paperwork and Massachusetts's combination of low insurance reimbursements and a high cost of living. "It's very frustrating," she says. Her salary is supposed to be $110,000. But one month last year, she wasn't able to pay herself at all.