The Doctor Drought

I am a primary care internist. All the health care reforms before Congress are counting on me and other doctors to be ready and willing to accept the millions of new patients with shiny new insurance cards. But this concept is a dream, or worse, a nightmare. In reality, my species of doctor will soon be extinct, replaced by nurse practitioners.
The growing doctor shortage in the U.S. is in the way of any real health care reform. Sen. Charles E. Schumer's, D-N.Y., proposed amendment to the Senate health bill--to provide $2 billion in funds over 10 years to create 2,000 new residency training slots geared toward primary care medicine and general surgery--is a tiny band-aid at best.
Consider that the American Academy of Family Physicians predicts a shortage of 40,000 primary care doctors (family practice, internal medicine, pediatrics and OB/GYN) by 2020. Consider that the number of medical students choosing primary care as a profession has already dropped by 51.8% since 1997, and that currently only 2% of medical school graduates choose primary care as a career.
It is understandable why my field of practice is so unpopular. Medical students tell me every day that mounting loans are too steep without a lucrative procedure they can master.
Creating additional training slots will not change any of that, unless accompanied by full loan repayments and guaranteed positions upon graduation, a plan that would cost taxpayers many more billions of dollars.
The national shortage of primary care doctors leads to a shortage of health care that cannot be compensated for with insurance of any kind. According to the federal Health and Human Services Department, as of March 2009 there were 6,080 primary care Health Professional Shortage Areas in the U.S. with 65 million people living in them. In comparison, the National Health Service Corps (a group of primary care physicians who work in HPSAs in return for two-year, $100,000 federal scholarships or $50,000 in loan repayment) has only 3,500 providers caring for 4 million people.

True, the 2009 American Recovery and Reinvestment Act invested $300 million in the National Health Service Corps, which is expected to double field strength by next year to about 7,000 providers. But this is another tiny band-aid, especially in states like Nevada, New Mexico, Montana, Utah and Alaska, which are almost entirely underserved.
With health insurance expansion on the horizon but no realistic plan to promote the creation of more primary care doctors, our place will be quickly taken by nurse practitioners--nurses with additional graduate training who are able to work semi-independently of physicians.
Unfortunately, there is no consistent way to integrate the physicians we do have with the expanding group of nurse practitioners, since the provider/patient relationship is largely a one-on-one event. If I sign a chart for a service provided by a nurse practitioner, I am authorizing something that I didn't supervise. If instead the nurse practitioner works unsupervised, then the patient is receiving a service from a practitioner who, while likely competent, doesn't have my level of training.
The most recent Health Resources and Services Administration Sample Survey report from 2004 shows 141,209 Nurse Practitioners in the U.S., an increase of more than 27% over 2000 data. The actual number of nurse practitioners is now greater than 150,000.
This number is huge and growing, especially since there are only 300,000 physicians in the U.S.
It is clear that if we end up with an expensive health insurance expansion that tries to pay for itself by cutting hundreds of billions from Medicare and extending Medicaid while asking the states to pay for it, physician and hospital reimbursements will be cut drastically as a result. The only way doctors and hospitals will be able to stay in business will be by seeing more and more patients while providing fewer services. Nurse practitioners are cheaper (their average salary is $88,000, compared with nearly $150,000 for a primary care physician) and will be used to make up the difference. Doctors and hospitals will hire them to "farm" their patient populations.
Quality of care will diminish along with the availability of our latest technologies, which only specialists are trained to administer. I believe nurse practitioners are useful, but I also believe my four years of medical school and three years of residency count for something. If primary care doctors become extinct, so will the kind of care our patients are used to receiving.
Marc Siegel, M.D., is an associate professor of medicine and medical director of Doctor Radio at NYU Langone Medical Center. He is a Fox News medical contributor.