If you are old enough to remember Marcus Welby, MD, you probably know he isn't on TV anymore, and he is rarely found practicing medicine in real life.
Dr. Welby was the kindly white-coated family physician who seemingly could cure anything with just a quick exam and a little common sense.
Millions of Americans don't have a family doctor these days, a review by Scripps Howard News Service found. There aren't enough primary care physicians in many places. And those who do have a "regular" doctor often have trouble getting an appointment. When they do, it's often rushed.
There's evidence that many patients are referred to more expensive specialists -- or find them on their own - simply because family doctors don't have time to handle what should be routine care.
Looking at 1 billion office visits between 2002 and 2004, a study in the Annals of Family Medicine found that half of all specialist visits were for routine and preventive care that didn't require specialists, who typically charge more than double a primary care doctor.
The country probably won't have enough primary care doctors to meet our needs in the next decade or two, not even a generalist for every 3,500 people -- the government's benchmark for family doctors, which many experts say is too high.
Medical schools are expanding -- 10 new ones have opened in the last few years, or soon will. Enrollment at existing schools is set to go up by 30 percent by 2015. The schools pledge to turn out more primary care doctors and fewer specialists, while policymakers from President Obama on down promise to better reward primary care because it is healthier and cheaper.
But convincing young doctors to commit to primary care remains a hard sell.
"Many of my students are drawn to family medicine, but at some point tell me they just can't do it, because they've seen the schedules and demands of primary care and see it's just not doable,'' Dr. Allan Goroll, a professor at Harvard Medical School, recently told senators considering health reforms.
Many view family doctors ideally as medical quarterbacks calling plays for teams of nurses, physician assistants, therapists and social workers so each patient gets the necessary preventive care, screening and routine sick care. Only the very ill need to be seen by the doctor.
"For patients with multiple, complex chronic illnesses, purchasers and payers are recognizing that someone needs to be accountable for effectively managing care,'' Dr. Christine Cassel, an internist, wrote in The Journal of the American Medical Association last year. "21st Century primary care must include responsibility for managing and organizing all aspects of a patient's medical journey."
A few health care systems have networks that revolve around a patient with a regular family doctor, who in turn coordinates a team of nurses, physician assistants, specialists and a host of other caregivers, all linked by electronic records.
One is Geisenger Health System in central Pennsylvania, a network of 700 doctors in 55 practices, three full-service hospitals, plus specialty hospitals and outpatient surgical centers.
Patients get round-the-clock access to primary and specialty care to keep time in hospitals to a minimum. Electronic health records are accessible to all providers, and patients can view their lab results, schedule appointments, get reminders and e-mail medical questions.
Doctors are paid extra for managing patients. And after less than two years, hospital admissions of Medicare patients have declined 20 percent, while total medical costs are down about 7 percent.
"The most dramatic change that we've seen from this is the reduction in hospitalizations," said Dr. Glenn Steele, medical director for Geisenger.
"We have to figure out how to make the job of primary care doable once again,'' said Dr. Thomas Lee, president of the physicians network at Partners Health-Care System in Boston, where executives are trying to figure out how to make the system financially rewarding for primary care doctors to quarterback patient care.
"The root cause is all about money," added Dr. Ted Epperly, president of the American Academy of Family Physicians.
Epperly's own 50-member group practice in Boise, Idaho, is run as a three-clinic community health center that also trains 33 family medicine residents, doing everything from prenatal care and delivering babies to geriatric care, and uses an array of non-physician professionals along with electronic medical records and innovative scheduling.
"The only way you get paid to care for a patient is if you see them,'' Epperly said. "We need to get off that treadmill and pay doctors not on volume of patients, but to keep their patients healthy. That's the outcome we want to pay for."
Yet a review of primary care practice by Scripps Howard News Service found that thousands of doctors don't want big offices with lots of assistants. They want to see, touch and speak to their patients in person.
"We are the medical home. We're all about working with our patients on a wellness plan, not a 'take-care-of-disease-as-it-comes-up' plan," said Dr. Bernard Kaminetksy, medical director for MDVIP, a network of "concierge" family physicians whose patients pay $1,500 a year to be one of only 600 people under care.
The opposite view is held by Dr. Alan Dappen, who runs doctkr (cq, for Doc-talker) Family Medicine in Vienna, Va., a practice heavy on technology, but still with a small staff. He is quite happy not to see his patients, except when they need it. Instead, he stays in touch with them around the clock by e-mail and telephone, scheduling office visits sparingly and making an occasional house call.
"Cutting the middle man (insurers) out of the equation allows me to give patients what they need without wasting their time on unnecessary in-person visits," Dappen said. "This also frees up my schedule so that I can spend more time with those who really do need an in-person visit."
Dappen charges $90 for a 10-minute office visit, $30 for a phone or E-mail consult, with discounts for patients who pay ahead and smaller charges for services from a nurse practitioner. Yet, because he's so accessible, Dappen said patients rarely have to seek care in an emergency room, and typically don't have to spend more than about $300 a year for primary care and urgent care.

(E-mail Lee Bowman at bowmanl(at)shns.com. Distributed by Scripps Howard News Service, http://www.scrippsnews.com)
With DOCS-NURSECARE