Episode Information

The Doctor Can't See You Now is a collaboration between WNPR - Connecticut Public Radio's Health Reporting Initiative and WBUR – Boston.

One of the fundamentals of medicine in the U.S. is primary care. In The Doctor Can’t See You Now,
reporter Rachel Gotbaum tells a story about the changing roles of the
family practitioner and internal medicine doctors, both historically
and today. It is the story of how the complexity of the modern
healthcare environment, the aging population and new attitudes towards
practicing medicine among doctors, have transformed the pivotal role of
the doctor at the center of a patient's medical journey.

The result, in the short term, is that patients are finding it harder
and harder to get in to see a primary care physician. In the longer
term, many policy makers and practitioners think that a lack of focus
on primary care across the country means that we are losing out on an
important way of improving the nation's health and reducing the
spiraling costs of healthcare.

Today, Where We Live presents the full documentary version of this report. Please add your comments and questions below - tell us what you think of the special report, and tell us your stories about primary care. We'll use them in a future episode of Where We Live.

Text Below:

[Dan Lasser] The primary care doctor is someone who provides first-contact medicine, prevention and counseling…

[Gotbaum] Primary Care doctors are a patient's vital link to the entire health care system. Access to primary care means better health-and it saves money.

[Naomi Leeds] That is the essence of health care: the personal touch.

[Gotbaum] But Primary Care is in trouble. Doctors are growing dissatisfied, and more medical students are choosing to become higher-paid specialists. Patients are being shut out.

[Robert Parsons] There's no need of her being in an emergency room. If she'd had a primary care doctor we wouldn't have had to have been there.

[Gotbaum] I'm Rachel Gotbaum, and this is a special report from Inside Out Documentaries: "The Doctor Can't See You Now." In the next hour we'll explore why both patients and doctors are unhappy with the current system of primary care. And we'll report on new ways to keep patients out of the waiting room. The Problem

[Gotbaum] This a special report from WBUR's Inside Out Documentaries and WNPR: "The Doctor Can't See You Now." I'm Rachel Gotbaum.

[Moris] Thank you for calling Mass. General Physician Referral Service; this is June, may I help you?

[Gotbaum] This is the patient referral hotline for Massachusetts General Hospital. This hotline gets more than 600 calls a week from people looking for a primary care physician. But they won't find one here.

[Moris] Well, right now Mass. General doesn't have any primaries that are currently accepting new patients…[fade under]

[Conn] If you really want to give me heartburn you can say excuse me but I know you work at Mass. General and I would like a primary care physician please.

[Gotbaum] Dr. Alistair Conn runs the emergency department here.

[Conn] Our primary care physicians are tapped out. They're supposed to be managing 2000 patients and they're running 3500. To do their proper job they need to be working eighteen hours a day, and you just can't work people eighteen hours a day.

[Gotbaum] At this big Boston teaching hospital, all the primary care practices are full. It's a common situation in hospitals and private practices throughout the country, even here in Massachusetts, which has the highest number of doctors per capita in the nation.

[Fenney] We're barraged with patients every day, looking for primary care.

[Gotbaum] Marianne Fenney manages her husband's practice on Cape Cod.

[Fenney] The patients start calling they start walking in the door. You know, "I have asthma," "I'm old, I have to have my medications," "I need my x-rays," "I haven't had my mammograms and I have no doctor." They're frantic. You know, we have soft hearts in here; we try to accommodate anybody with a good story.

[Gotbaum] When Susan Reverby needed a new doctor, she thought she had a good story.

[Reverby] Yeah, I asked people who had really good doctors that they would put a word in for me and it was almost like writing a personal ad: "Hi, interesting woman who'll talk to you, gives good history…" "Gives good history," that would be a really good thing to say! [laughs]

[Gotbaum] Reverby's economic status didn't help her either.

[Reverby] I always thought, you know, a middle class woman, I have contacts. It's a little bit like getting a good contractor. And then the rude awakening: everybody I called in the Boston area was full. I was really in trouble; I didn't have a doc.

[Goldstein] As a matter of fact, I can't find a physician for myself, and I'm a faculty member here.

[Gotbaum] Even doctors can't find a doctor. Marc Goldstein is an adolescent medicine specialist at Massachusetts General Hospital.

[Goldstein] I suppose I could ask a favor of someone to add me on as a new patient. But they're loaded too, with patients.

[Mosely] We have an acute shortage of primary care physicians currently in America.

[Gotbaum] That's Kurt Mosely, a vice president at Merritt, Hawkins, the largest physician recruiting firm in the U.S. Mosely says the demand for primary care doctors has increased 100 percent in the last two years and now primary care physicians are the number-one recruited position nationwide.

[Mosely] A majority of our clients are hospitals and they've told us time and time again: we are short of primary care physicians. It'll only get worse over time due to patient demand, lack of candidates going into primary care medicine, and also, physicians' increased frustration with primary care.

[Gotbaum] Across the U.S, according to a study by the American Academy of Family Physicians, twenty percent of patients do not have sufficient access to a primary care provider. And half of those patients have health insurance. The Academy also predicts that within the decade, the country will need forty percent more primary care physicians to meet the growing demand.

[tv sound, music]"Dr. Welby, Dr. Marcus Welby." "I'll be right there…" [sound fades under]

[Gotbaum] Americans have long cherished the notion of having one doctor who would take care of them and their families, often over a lifetime. That image of America's family doctor was embodied in the popular 1970's TV show, "Marcus Welby, M.D."

[tv sound] "…You can't expect a miracle from me, can you?" "From you, Doctor, I can!" [music ends]

[Gotbaum] Today, primary care physicians are a patient's vital connection to the entire health care system. Allan Goroll, a professor of medicine at Harvard Medical School, says these doctors are responsible for coordinating their patients' care, and for managing all of their medical conditions.

[Goroll] We need a plan laid out by somebody who can take the whole patient into account and design an intelligent approach to the diagnosis and management. In essence, we need a quarterback; we need somebody who is going to size up the situation, call the play and help carry it out.

[Gotbaum] Studies show that better access to primary care is linked to better health. Patients who see primary care doctors have lower death rates from heart disease, diabetes, stroke, most treatable cancers, and lower infant mortality. Dr. Barbara Starfield is a professor of health policy at Johns Hopkins University.

[Starfield] We've done many, many, many studies in the U.S., and the states that have a higher primary care physician-to-population ratio have better health levels of virtually all kind.

[Gotbaum] Starfield's studies show that, compared to most industrialized nations, the U.S. ranks highest in health care spending, yet it has higher rates of death from preventable diseases. Thomas Bodenheimer, professor of family medicine at the University of California at San Francisco, says that's because U.S. health care is oriented toward high-cost, high-tech medical interventions.

[Bodenheimer] Essentially, what's valued in health care in the United States is rescuing people from health care problems that if they'd had really good preventive and primary care they might not have had those problems.

[Gotbaum] It's early in the morning and Doctor Kate Treadway is checking in on her patients in the hospital before she sees her office patients in the afternoon. [hospital sound, door knock] " Hi" "Oh, hi" "How're you doing?..." [fade under]

[Gotbaum] Treadway is a primary care doctor at Massachusetts General Hospital. She has been practicing for thirty years. Most of her patients have been with her for a long time, many for at least two decades. That includes seventy-four year-old Donald Fulton. He's in the hospital today because he has complications from diabetes and an abnormal heart rhythm. [hospital sound, Treadway] "How are you doing with food? Are you eating pretty well?"

[Fulton] "Uh, yes as a matter of fact…" [fade under]

[Gotbaum] Fulton says Treadway has helped him stay healthy over the years, and she often spots problems before they arise.

[Fulton] I'm particularly impressed with her competence. For example, I give her credit for diagnosing my need for a quadruple bypass. She's not a cardiologist but she certainly had it right.

[Gotbaum] Treadway's patients know they are lucky. They feel secure because their doctor's advice is based on her knowledge of who they are as people, not just on what their lab tests reveal. Treadway says she loves her job.

[Treadway] To me it really is embodiment of what it means to be a physician. I'm not saying that my specialty colleagues are not doing meaningful work but what is meaningful to me is having this extraordinary relationship with a patient over time, with their family, helping them though illness, and actually helping patients die.

[Gotbaum] Currently about one-third of all doctors working in the U.S. practice some form of primary care. But there was a time when most of the nation's doctors were general practitioners. At the turn of the 20th century, these were family doctors who worked in their community, handling patients' day-to-day medical needs, including surgery. By the end of World War Two, the country had recognized the value of medical specialists, and the government would begin to pay for advanced medical training so that veteran doctors could pursue a specialty.

[Mullan] By the early 1960s, more than half of physicians were now practicing as specialists; by the 1970s, two-thirds.

[Gotbaum] Dr. Fitzhugh Mullan is author of "Big Doctoring in America: Profiles in Primary Care."

[Mullan] And during that time the GP really became discredited from the Norman Rockwell portrait of the grandfatherly or avuncular GP of the early century. He was not seen as keeping up with the times.

[Gotbaum] As more medical students chose to specialize, the U.S. began to experience a shortage of general practitioners. Dr. Dan Lasser is chairman of the department of family medicine at the University of Massachusetts medical school. He says the country not only needed more general practitioners, it needed a new kind of general practitioner.

[Lasser] Family practice was recognized as a medical specialty in the early 70s, and there were twenty or thirty state-sponsored medical schools that were established, and most of them had the training of primary care doctors written into their mission.

[Gotbaum] Lasser says this new breed of physician would receive more extensive training and have a pivotal position in the modern health care system.

[Lasser] The primary care doctor is somebody who provides first contact medicine, prevention, and counseling, not just biological issues but psychological issues, and who doesn't turn you away if there's nothing wrong.

[Gotbaum] By the 1990s, many Americans belonged to managed care plans, such as HMOs. Managed care was conceived as a response to increasing health care costs, and primary care doctors played the central role in controlling those costs. They became the so-called "gatekeepers," determining a patient's access to tests, procedures and specialists.

[Goroll] "Gatekeeping" has the assumption that you're going to keep people out, and that is an unethical approach to medical care.

[Gotbaum] Dr. Alan Goroll is a professor of medicine at Harvard Medical School. He says that, under managed care, the gatekeepers' mandate was to save money for the insurer paying the bill.

[Goroll] They transferred the risk to the doctors with the direct message that if you save money, you can keep the dollars. And that's a deal with the devil; it's an absolute deal with the devil.

[Gotbaum] The widespread perception that doctors might be withholding care to increase profits for insurance companies and themselves, led to a backlash against managed care. In 1996, Congress held hearings about questionable practices under this system.

[Peeno] I am here primarily today to make a public confession. In the spring of 1987, as a physician, I denied a man a necessary operation that would have saved his life, and thus caused his death.

[Gotbaum] Linda Peeno was a primary care physician who worked for a large HMO.

[Peeno] No person and no group has held me accountable for this because, in fact, what I did was I saved the company a half a million dollars for this.

[Gotbaum] Now, over a decade after Peeno's testimony, some primary care doctors feel their profession has not regained its status. Furthermore, the current payment system has left primary care salaries below those of most physicians. This may explain the lack of interest in the field among young doctors. In 2007 at Massachusetts General Hospital, of the fifty medical residents who could have gone into primary care, only one did.

[Leeds] They see how how hard it is. They see the uncompensated care, they see the frazzled, frustrated physicians in our practice and they don't want to end up like that.

[Gotbaum] Thirty-seven year-old Naomi Leeds is a primary care doctor at M.G.H.

[Leeds] I'm pretty pessimistic, to be honest with you. I work with a lot of the residents here in the primary care program dedicated for residents who want to pursue this, and more and more I'm seeing even those dedicated primary care residents not pursuing primary care as a discipline.

[Gotbaum] After a short break, we will report on how the movement toward universal health insurance is putting pressure on an already-ailing system of primary care. We'll hear why it's no longer a fulfilling profession for so many doctors, and how their dissatisfaction has contributed to a steep decline in the number of medical students choosing to practice primary care.

[Leeds] We need to show them that there is value in what we do as primary care physicians, that we're not just gatekeepers, we're not just secretaries that refer everywhere, that we're doctors who take care of patients over generations.