Sandeep Jauhar is a cardiologist and the director of the Heart Failure Program at Long Island Jewish Medical Center. He writes regularly for The New York Times and The New England Journal of Medicine. Intern: A Doctor's Initiation is his first book. Information about the book is available at www.sandeepjauhar.com.

Guest Blogger Sandeep Jauhar--

Most knowledgeable observers agree that healthcare in this country is in crisis. Aside from the well documented problems of access, cost, and inefficiency, there is now a looming doctor shortage. According to a recent report, the country can expect a shortage of nearly one million nurses and 24,000 doctors by 2020. This deficit is most acutely felt in primary care.

Unfortunately, fewer and fewer medical school graduates want to go into primary care. Let me try to explain why with an example. Some time ago, I saw a new patient in my cardiology clinic. He was an elderly man from Haiti who spoke only French, so I had to start off the visit by calling for an interpreter. When I finally got someone on the phone, my patient told me that he had been having palpitations. Since his E.K.G. was abnormal, I decided to order some tests.

Midway through the visit, the man asked me if I would serve as his primary-care doctor. Though I am a cardiologist, I still practice some general internal medicine, so I said yes. But frankly, I was ambivalent.

He was 66, which meant arranging a colonoscopy to screen for colon cancer and checking a prostate-specific antigen level. The P.S.A. is an imperfect test, but I did not have time to discuss the pros and cons of it, so I made a mental note to do so later.

The man also was going to need counseling about smoking cessation and coronary risk reduction; pneumonia and tetanus vaccinations; forms filled out for his social worker; and (based on his history) screening tests for alcoholism and major depression. There was more to do, of course, but this was more than enough to keep me busy.

However, I wasn’t about to bring any of this up. Even if my patient had spoken English, each topic would have taken too much time out of my busy clinic day.

Primary care has become untenable in the era of 15-minute office visits. A study published a few years ago in The American Journal of Public Health estimated that it would take over 4 hours a day for a general internist to provide just the preventative care that is currently recommended for an average-size panel of adult patients. “The amount of time required is overwhelming,” the authors wrote.

This year, family-practice residencies took only 1096 U.S. seniors, the fewest number in the past two decades. Those students who do match into internal medicine increasingly are forgoing primary care for sub-specialty practice.

One of the reasons, of course, is money. The average medical school debt is now $140,000+ and internal-medicine subspecialties, especially procedure-based ones like cardiology, are more lucrative than primary care. But a more important reason, I think, is that medical students increasingly view primary-care physicians as harried and overworked. With decreasing reimbursement and increasing medical liability costs, who needs the hassle?

Aging baby boomers are starting to become patients just as aging baby-boomer physicians are getting ready to retire. By 2017, the number of Medicare beneficiaries has been projected to grow from about 40 million to 56 million. Americans over 85 already are the fastest growing demographic group in the country. The nation is going to need new doctors, especially geriatricians and other primary-care physicians, to care for these patients. How exactly this is achieved will determine in no small measure the future of healthcare in this country.

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