Vanishing Breed: What Happened to the Family Doctor?

For 26 years, Dr. Joseph Lalka has been a family doctor, treating 3,000 patients in his cramped office in Chatham, N.Y., a small town nestled in the rural northern part of the state.

But Lalka recently told his patients he is taking down his shingle and closing his practice. He says he no longer can afford to maintain a family practice.

Now his patients fear a future without the man who has cared for some of them for a quarter of a century. And they say they are angry at a system that has forced their doctor to leave because of escalating operating costs and declining reimbursements.

“Here is a doctor who is not retiring because he wants to,” says Constance Mondel, 81, who Lalka has treated for many years. “He is leaving because the system is not working. It’s a real shame.”

Her husband, Joseph Mondel, 78, said that his first reaction to the news was fear and then anger.

“Who is going to take care of me in my aging life?” he asked. “What the hell do I do now?”

Lalka’s story illustrates an American family care system in trouble.

Costs are steadily rising while reimbursements from government programs like Medicare continue to slide. Five years ago, Lalka paid $8,000 for malpractice insurance. Today he pays $18,900 — still relatively low compared to many doctors and specialists, but a big expense when matched against shrinking Medicare reimbursements that most recently declined anotherer 9.9 percent.

Lalka, 54, says that with an income of only $60,000 last year, and little opportunity to expand his practice, he no longer is able to make ends meet.

“I am giving up my practice, the love of my life,” he said recently as he stared out of his office window. The office closed on Oct. 11. Now Lalka will work for a company that assigns doctors to temporary work.

Lalka’s patients are anxiously looking for someone to replace him, but it will not be easy to find successors for him and other doctors like him who are being forced to close their family practices.

Family doctors provide comprehensive medical services to individuals and families regardless of sex, age or type of medical complaint. Family physicians are primary care providers, as are internists and pediatricians.

But fewer medical school graduates want to become family physicians, because there is more money to be made in specialized medicine. Last year only 8 percent of U.S. medical school graduates chose to become family physicians, half the number that made the same choice in the early 1990’s, according to the American Academy of Family Physicians (AAFP). The number of medical school graduates going into internal medicine, another important area of primary care, is also declining, according to Dr. Richard Wender, president of the American Cancer Society.

The AAFP, which represents 95,000 family physicians, reports that many family physicians, like many of their baby boomer patients, are nearing retirement age. This will further thin the ranks of family physicians at a time when aging patients will need more medical attention.

“We are facing a crisis in the shortage of family physicians,” former AAFP president, Dr. Rick Kellerman said in a telephone interview “It’s an absolute shortage.”

Kellerman said specialists make three to four times the income of family physicians, and the specialties attract the bulk of medical school graduates. The appeal is that practicing specialized medicine will enhance a graduate’s lifestyle and make it easier to pay off college loans, which generally total at least $100,000.

Family doctors are in an untenable position because shrinking Medicare payments often cover only 60 percent of the cost of treating a patient. Medicare also allows no adjustment for inflation, and operating expenses increase 3 percent to 5 percent annually, said Dr. Terry McGeeney, the president of TransforMed, an organization established to address the quandary faced by family doctors.

McGeeney said physicians are not compensated for the staff and time required to file claims to Medicare and private insurers. He said that unless Medicare reimbursement increases and family doctors receive better compensation, the question of a way out of this situation becomes academic.

In many suburbs throughout the country, specialists team up to provide group practices to serve patients. But a medical team of private physicians is not practical everywhere — particularly in low-income urban areas and in low-population rural areas that typically rely on Medicare and Medicaid disbursements.

The shortage of primary care physicians has had far-reaching consequences for the nation.

Nearly one in five Americans – 56 million people – have inadequate or no access to primary care physicians because of the shortage of such doctors, reports a study conducted jointly by the National Association of Community Health Centers and the AAFP. Most of the patients have health insurance, but they are underinsured, according to the report. An additional 47 million Americans have no health insurance whatsoever and crowd hospital emergency rooms when they need urgent care.

The American Medical Association agrees with Kellerman that there are shortages and foresees a grim situation for seniors getting access to health care in the future because of anticipated 40 percent cuts in Medicare over the next eight years.

Aging baby boomers will need more care adding to the burden of an already overstretched primary care system with shrinking Medicare reimbursements. This population has a high incidence of chronic conditions such as heart disease, diabetes and asthma. The U.S. health care system does not deal well with this newly emerging challenge, according to the Institute of Medicine, a non-profit organization specifically created to advise the government on health matters.

The shortage of family physicians has been acutely felt even in Massachusetts, a state that the U.S. Census lists as having one of the nation's highest median household incomes. A month after the introduction of a universal health care plan in Massachusetts in April 2006, the state discovered it did not have nearly enough family care doctors to fully implement the program, according to Dr. Kevin Grumbach, chairman and professor of family medicine at the University of California. The Massachusetts Medical Society said that it was struggling to cope with a “severe shortage” of family physicians.

Grumbach said Massachusetts has recognized that the state needs to begin investing more money in primary care to make its health plan work. “They learned that doctors aren’t going into primary care anymore,” he said.

Experts agree that a primary care doctor should be the cornerstone of our health system.

A greater ratio of primary care doctors to the population makes for lower death rates, according to a four-year study of 99.9 percent of the nation’s counties done by Johns Hopkins University, funded by the U.S. government.

There are currently 31.2 family doctors per 100,000 of population in the U.S. However, according to the AAFP, the ratio should be 41.6.

Family care physicians are in the front line in the battle against cancer and the vital early detection of the disease, according to American Cancer Society president, Dr. Richard Wender, a family care physician. “They are just as important as those people who treat cancer themselves.”

Much heart disease and type two diabetes could be prevented by family physicians who recommend lifestyle changes and proper diet and exercise prior to the onset of the diseases, according to articles in the prestigious New England Journal of Medicine.

“Unfortunately, our health system rewards the surgeon who amputates the infected foot of a diabetic much more than the primary care doctor who discovers the preliminary symptoms of the disease and recommends ways to prevent it,” said Grumbach.

The United States spends more money on health care than any other nation and gets fewer results, according to studies done by the World Health Organization and the independent Commonwealth Fund.

“By no stretch of the imagination do we have as good results as many other advanced nations,” said professor Stephen Spann of Baylor College of Medicine. “We are not anywhere close.”

Spann’s criticism of our health care system is shared by big companies like IBM which is spearheading a campaign to reform America’s healthcare system and promote a new primary-care model.

The company spends more than $2 billion a year on health care for its 355,766 employees and is not happy with the results. “When you have a system of family care like ours where the foundation is entirely broken and there is no supply line to repair it you’re in a crisis,” said Dr. Paul Grundy, the company’s director of Health Care Technology and Strategic Initiatives.

The company’s employees in Denmark are happier with their family physicians than IBM’s workers in the United States, said Grundy. Danish employees have easier access to their doctors and are given more time during visits. European nations give high priority to primary care in their health systems.

The emphasis on the primary care physician in many countries stands in sharp contrast to the situation in this country where Lalka in Chatham, N.Y. and many other doctors throughout the country are being forced out of practice.

The growing shortage of family care physicians is an urgent national problem with a profound impact on individuals such as 38-year-old Florence Sullivan, one of Lalka’s patients who desperately needs a doctor.

“The other local doctors are so overwhelmed they don’t want to take new patients,” she said. “This has been horrible. I feel like I’ve been left out in the cold. I have medical conditions that can’t wait.”