Last January the American College of Physicians issued an alarming report called "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care." But anyone who's spent an afternoon dialing for a doctor willing to take him or her on as a patient would say that the collapse has already occurred.

Primary care doctors, the general practitioners, pediatricians and internists who prevent, detect and treat illness, are the health care system's gatekeepers. It is virtually impossible to see a specialist or to have a doctor visit covered by insurance without passing through the gate. When no one is at the gate, care is delayed, sometimes with serious results, or it is provided inefficiently and expensively in emergency rooms.

On Sunday, the Monitor's Margot Sanger-Katz reported that only one of Concord's nine primary care practices is accepting new patients. Most have been closed to new patients for months or years. The problem is national, critical and worsening. It is not one that the medical profession should or can solve on its own. It is a matter of public policy that will require political action. In a society that expects quick and painless cures, it will also require a cultural change.

American medical schools are enrolling fewer than half as many future doctors in primary-care residency programs as they did just seven years ago. Last year, graduates of foreign medical schools filled half the slots in family medicine. The system would have collapsed without them, but America's gain is their nation's loss.

A study of physician recruitment offers by a national health care search firm goes a long way to explaining the primary care shortage. Family practice doctors were offered an average of $145,000 per year, cardiologists $342,000, radiologists $351,000 and orthopedic surgeons $370,000. Doctors several hundred thousand dollars in debt for their education act rationally when they choose to specialize.

Medical school students who choose general practice like talking to people, but the pressure to see enough patients to pay the bills or meet a quota leaves them little time to do so. Treating or diagnosing an illness can often be done relatively quickly. Teaching patients how to cope with chronic illness or persuading them to make a lifestyle change cannot.

The financial and societal pressure for quick solutions has become so strong that some medical schools no longer teach doctors how to talk to people. They are turning out many doctors who are good at treating disease but not so good at alleviating the suffering that accompanies it or causes it.

A few things should be done now.

Lawmakers should expand -with proper oversight - the functions that nurse practitioners, physician assistants, dental technicians and other paraprofessionals are allowed to perform. In the short run, they will be the answer to alleviating the shortage.

The cost of a medical education should be partially subsidized for general practitioners who agree to stay in that field for a decade or more. Medicare reimbursement rates, which can be one-third less than the cost of providing a service, must not be cut, as the Bush administration plans to do next year.

The disparity in payment rates for general practitioners and specialists must be narrowed. Specialists will have to make less so generalists can make more. Since no doctors are about to reduce their own incomes, lawmakers at the state and federal level should restructure reimbursement rates under Medicare and Medicaid to recognize that preventing a disease and its complications is at least as important as treating it.

Years of work and hundreds of millions of dollars have made Concord a regional health care center, one that is of little value to people who can't get through its gates.

------ End of article

Monitor editorial