If medical coverage extends to all, will there be enough primary care doctors?

The national health care debate has policymakers and medical authorities worried about what comes next: If today's uninsured millions could get regular care, would there be enough doctors to serve them?

Some experts say that by 2025, the nation could be short by as many as 44,000 adult general care physicians — which includes the traditional family doctors who handle everything from annual checkups to helping manage chronic conditions.

But recent studies show that fewer than 20 percent of U.S. medical students are choosing primary care specialties, which currently account for 35 percent of all practicing physicians.

That statistic was cited in a letter about health care legislation sent to national leaders by the Council on Graduate Medical Education, which advises Congress and the U.S. Department of Health and Human Services on issues related to the physician work force.

"If something does happen where an additional 30 to 40 million people have access to some form of insurance, we do not have the primary care work force to be able to respond to that need," said Dr. Russell Robertson, the council's chairman and a professor of family medicine at Northwestern University. "This is a serious, serious concern."

Even before President Barack Obama made reform his top priority, the Association of American Medical Colleges and the medical education council had called for increasing enrollment at the nation's medical schools to meet the needs of a growing and aging population.

But simply sending more people to medical school won't fix this complex problem. That's abundantly evident in Florida, where three medical schools have been created in recent years and officials still are worried there won't be enough primary care physicians.

Family care pros, cons

In medical school, Dr. Amir Shirmohammad enjoyed everything from surgery to family medicine. The Tampa native faced hard choices in picking a specialty for his residency, the three to seven years of post-medical-school training needed to practice independently.

After a decade at Tulane University, where he earned undergraduate and medical degrees, as well as a master's of public health in epidemiology, Shirmohammad's debt was in the six figures.

In 2008, the typical starting family physician made $150,000, considerably less than doctors can earn in other specialties. The typical neurosurgeon, in contrast, saw a starting salary of $605,000. Both figures come from the most recent survey report by the Medical Group Management Association.

"You start life off financially in the hole, and I did consider that," Shirmohammad said.

But he wanted long-term relationships with patients, and he liked the variety of family practice. Trinity Family Physicians, the practice he started two years ago with his wife, Dr. Stephanie Eldridge, in southwest Pasco County, sees the full range of ailments in patients ages 8 to 108.

The husband and wife team say they're handling their debt and consider the opportunity to care for entire families worth the trade-off in salary. They're trying to encourage new doctors to consider their path by inviting medical students at the University of South Florida and Florida State University to shadow them at Trinity.

Rightly or wrongly, many medical students equate family medicine with a frustrating life, experts say, with poor working conditions and compensation.

Another factor: Residency programs are centered around hospitals, which have greater need to train specialists than family doctors.

The effect is seen in the 37 residency programs in family medicine that were closed in recent years. At the same time, training slots in specialty fields rose by nearly 25 percent, notes the medical education council's Robertson.

Family medicine is not the only route doctors can take to get into general care, he added, but choosing that track is a strong indicator of who would stay in the field. Medical students who opt for residencies in internal medicine, another pathway, are much more likely to become specialists.

Limited training slots

In recent years, Florida has opened three new medical schools in Tallahassee, Orlando and Miami.

But concern is growing that there are not enough residency positions in the state to provide post-graduate training to the increased numbers of doctors Florida is going to be educating. And doctors tend to settle where they do their training.

"We're building this stockpile of future physicians that we will absolutely need," Dr. Anthony Silvagni, chairman of the Council of Florida Medical School Deans, recently told the Board of Governors, which oversees the university system.

But he noted that it doesn't matter "how many more medical school students you add." Graduate training slots determine "how many you finish with."

Silvagni, who is dean of the College of Osteopathic Medicine at Nova Southeastern University, also notes that residencies alone won't fix the problem of the supply of doctors willing to provide general care to adults.

In 2008, only 26 percent of Florida's medical school graduates went into primary care residencies in the state, according to a new report. That number included those training in obstetrics/gynecology in addition to traditional general care specialities like family medicine.

Meanwhile, adding slots is expensive. Consider that Medicare and Medicaid, the government's health programs for the elderly and the needy, spend about $12 billion annually on graduate medical education, according to the Association of American Medical Colleges. That's the biggest funding source of these programs.

Besides, absolute numbers don't tell the whole story: The United States doesn't produce enough doctors to fill all available residency slots. So foreign doctors come in to fill the positions.

In fact, back in 1997 the worry was that the nation was producing too many doctors. So Medicare funding for new residency slots was frozen.

Now politicians such as Democratic Florida Sen. Bill Nelson and U.S. Rep. Kathy Castor, D-Tampa, want to create more Medicare-funded slots, with an emphasis on training more doctors to provide primary care.

Redirecting doctors

But as with almost everything else in the health care debate, the merits of that idea are in dispute. Some medical experts say we don't need more doctors — we just need to get the doctors we have to stay in primary care and to practice in under-served communities.

Approaches under discussion include loan forgiveness and changing how doctors are paid. Critics note that today it's more financially rewarding to treat problems than to prevent them. If that fee model changed, doctors might follow the money back to primary care.

"We've been adding a lot of doctors to our health care system over the last 20 years, and we've dug ourselves deeper and deeper in a hole," said Dr. David Goodman, a professor of pediatrics at the Dartmouth Institute for Health Policy and Clinical Practice, whose research indicates that simply having more doctors practicing in a community doesn't lead to better overall health outcomes.

He added: "Just doing the same that we've done before is going to lead to the same result."

Letitia Stein can be reached at lstein@sptimes.com or (813) 226-3322. For more health news, visit www.tampabay.com/health.