Opinion: Primary care doctors are disappearing. Many are overworked and underpaid.

James Kildare. Marcus Welby. Michaela Quinn. Leonard “Bones” McCoy. 

These are the names of some of TV’s more famous general medical practitioners. 

They’re all fictional.

So too increasingly are their real-life counterparts. 

Once the dominant model in medicine, the general practitioner or primary care physician, the person who could discuss, diagnose and treat most of what ails us (or at least get the process started), is disappearing. More than 100 million Americans do not have a primary care doctor, primarily because fewer and fewer medical school students are choosing that career path, just 15 percent by one recent measure. 

It’s a long downward trend with no end in sight.

Would-be doctors these days more often choose specialized medicine, such as anesthesiology and dermatology and within them, subspecialties like adult cardiac anesthesiology and pediatric dermatology. 

Partly it’s a matter of payoff. 

In 2020, the average medical school student graduated with $207,000 in debt. Medical specialties pay more. The average annual compensation for a plastic surgeon is $619,000; for a doctor practicing family medicine, it’s $255,000. Pediatricians, who tend to see all manner of childhood ailments, make even less. 

Partly, it’s a matter of lifestyle. 

A primary care physician in the U.S. health care system likely faces long days of seeing many patients — an average of more than 20 per day. The median time of actual doctor-patient visits is 18.9 minutes. That’s barely enough time to get reintroduced, and a major frustration for both doctor and patient, though perhaps unavoidable as primary care providers struggle to cover rising costs. Quantity supersedes quality. 

Specialists confront fewer time constraints and business pressures. The job is simply less stressful. Most ophthalmologists can keep regular hours. A sleep medicine specialist isn’t likely to be woken up by a midnight emergency call. The trendy term “lifestyle medicine” is used to describe employing lifestyle interventions to treat chronic conditions, but for many doctors, the quality of their lifestyle informs the practice of their medicine. 

The growing scarcity of primary care physicians means patients will increasingly suffer. There is a loss of general and specific knowledge. General practitioners can broadly apply what they’ve seen and learned. If they can’t effectively treat the patient, they refer to a specialist, but remain involved because they have specific knowledge about that patient, such as what medicines they are taking, relevant allergies and comorbidities. They can help coordinate care because they are the only health care professional who knows and sees patients in their entirety.

Specialists work in silos and different systems. They speak other languages. They may know what they know well, but there’s a good chance they don’t know everything. Resulting care can be fragmented. 

Current health systems and practices don’t help. Relatively poor salaries for primary care physicians depresses the pool of practitioners. Payments schedules for traditional primary care tools like preventive screenings can be minimal. There’s more money in just going straight to a specialist. Everything is directed to emphasize specialized care while minimizing primary care. 

There are remedies, obvious if not easily implemented. 

First, compensate primary care physicians what they’re worth, which is no more or less than their medical peers. In most First World countries, doctors’ salaries are roughly the same, whether they are surgeons, radiologists, hospitalists, dermatologists, emergency room doctors or primary care physicians. Primary care physicians should have smaller panels of patients, enabling them to spend more time with each patient.

The specialty a would-be physician chooses as their life’s work should be determined more by their interests, skills and personal goals, rather than by the size of a potential paycheck.

More broadly, medical schools, health systems and regulatory agencies should redirect resources to efforts that promote primary care. It’s that simple. 

For patients, the only current recourse is to find a “concierge doctor,” who for an upfront, often hefty, surcharge will provide the knowing, personalized, holistic services once the province of primary care physicians. 

Brenner is a physician-scientist and president and chief executive officer of Sanford Burnham Prebys and lives in La Jolla.