He was the obstetrician, the emergency room physician, the pediatrician — anything you needed him to be, for as many hours as it took. An office visit cost $5, or maybe Mama's homemade pie.
Fancy medical technologies like CAT scans didn't exist. Doctors had to talk to patients — not test them — to understand the source of their problems.
The year was 1972 in Lafayette, Tenn.
But the role of the primary care doctor changed as medicine became more specialized. New tests and devices arrived. Health insurance complicated costs.
The result: the diminishing of a breed of doctors like Holmes.
Now, with health reform set to bring 32 million people onto the insurance rolls over the next decade, there aren't enough primary care doctors to serve the masses, and fewer medical students are choosing primary care as a career path.
Bogged down with debt, worried about lower pay for longer hours and enticed by the innovations of newer fields, more medical students are opting for lucrative specialties that can earn triple the salary of primary care.
The nation is short 16,663 primary care doctors, and by 2025 that number will reach nearly 140,000, according to the American Academy of Family Physicians.
Resolving the shortage could take at least a decade because of the time required to train aspiring doctors, but experts say a start would be to change the pay structure, open up more residency posts and encourage medical colleges to produce more general practice doctors.
"The number of primary care doctors has stayed flat, but the American population has not," said Holmes, founder of Family Practice Associates at Southern Hills Medical Center in Nashville, Tenn. "The patient suffers if we don't have enough people to give them care."
Doctors Have Duty
Primary care doctors encompass pediatrics, internal medicine, general medicine, obstetrics and gynecology and family medicine.
"They are the first point of contact for a person in the health-care system," said Dr. Wayne Riley, president and CEO of Meharry Medical College. "There is a duty and obligation of the primary care doctor to coordinate all the patient's needs."
Holmes, as he practices medicine now in Nashville, and the six other doctors in his practice see 200 patients a day, sometimes more because patients might not have another place to go.
Holmes averages about 35 patients a day. If he works an eight-hour day, each patient, in theory, would have about 13 minutes.
But he and other primary care doctors increasingly are pressured to fill out paperwork and log patient health information into a computer, instead of a chart. The extra work takes away from patient interactions.
"I tell residents, put down the ink pen or the computer," Holmes said. "We're not looking for pretty papers. We're looking for hearts. Touch a patient. It doesn't even have to be a physical touch."
Family medicine encompasses all fields of primary care medicine, and doctors have to know a little about a lot. Medical students are put off by the breadth of their area of medicine, Holmes said.
"They sense it is too broad, too much," Holmes said. "All you have to know is the patient in front of you."
Getting to know patients doesn't bring money, though.
Under the current Medicare system, doctors who perform specialized procedures and more tests are paid better. Private insurance firms often base their reimbursements on Medicare's rates. So, if a primary care doctor doesn't do a lot of procedures, he isn't as well compensated.
Rewarding Outcome
The primary care field could be more attractive if doctors were paid differently for the care they deliver, said Dr. Robert Dittus, chief of the division of general internal medicine at Vanderbilt University Medical Center.
"We can't have a system that is just reimbursing for units of care provided," Dittus said. "If you do a lot of counseling, the reimbursement is poor and not tied to health outcomes. The specialties have control over policies around which the reimbursement system has been developed."
Health care reform is supposed to reward family doctors starting in 2013, when Medicare would give 10 percent bonuses to those who serve in areas with a doctor shortage. The U.S. Department of Health and Human Services says a shortage means having less than one doctor for a population of 2,000.
But some medical students, right now, decide not to enter primary care because of the current disproportionate pay rates.
"The average medical student's debt is $130,000, and for a young physician who is concerned about debt, there is a tendency to overlook primary care for other specialties," Riley said. "They think other specialties will be a quicker way for them to pay off their loans."
Primary care doctors earn about $150,000, whereas a specialty such as radiology can bring a $500,000 annual salary.
To close the gap in primary care, more than 4,000 medical students would have to choose primary care residencies each year for the next decade. But among this year's medical school graduates, only about 1,200 will go into primary care.
Dorie Saxon, a fourth-year medical student at Meharry Medical College, will graduate in May and enter a three-year residency program at Baylor College of Medicine in Houston to become a pediatrician.
Saxon is a rarity. She has less than $100,000 in medical school debt because of scholarships. Shadowing doctors in different specialties turned her on to pediatrics.
"It fit my personality," said Saxon. "Pediatricians have more of a relationship with the patient, and though they work longer hours, the work, to me, seems more enjoyable."
More Doctors Could Drive Down Costs
About 56 million Americans, often in rural areas, don't have adequate access to primary care because there are too few doctors close to home, according to the National Association of Community Health Centers, a Washington-based health advocacy group.
Getting more medical students into primary care ultimately should make health care less expensive, said Larry Kloess, president of Tri-Star Health System. Patients who don't get consistent preventive care or have to travel to get to a doctor can end up with more severe health problems that land them in the emergency room, where care is more costly.
Long Hours A Factor
The Journal of American Medicine found that medical students were more likely to choose fields where they could control their work hours. Primary care can start early and end later in the day as the doctor tries to fit in all patients. Many also have on-call hours to respond to after-hours concerns or work weekend shifts to see sick patients.
Making a dent in the primary care shortage could take 10 years or more, physicians in the field say.
"The training of a physician is very time-intensive and expensive," said Riley, Meharry's president. "The shortage will be exacerbated by the end of the decade when 32 million people will be added. We have to have the primary care doctors to care for them."
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