The new face of family practice

MINNEAPOLIS — Dr. Charlie Abraham studied medicine at the University of Damascus, but these days he's far from his native Syria. Instead, he's treating patients at the Family Medical Center in Minneapolis.

"Everybody is trying to come to the United States," said Abraham, a first-year resident in family medicine. "You get good training and make better money here."

As more U.S. doctors opt for better-paying specialties such as cardiology and orthopedics, residency programs for family physicians in the United States are increasingly drawing doctors from abroad.

In the 2006 school year, 28 of the 78 first-year residents in family-practice programs in Minnesota came from foreign medical schools. At Hennepin County Medical Center, eight of 10 places were filled by foreign graduates. At the University of Minnesota's Smiley's Clinic in Minneapolis, five of six places were filled by foreign doctors.

A shortage of doctors afflicts the primary-care field, which includes family medicine, pediatrics and internal medicine. For patients, that often means waiting longer to see a family physician and more rushed care once they get there.

"Primary-care practices in the United States now depend on luring physicians away from other countries," Dr. Thomas Bodenheimer, a professor of family medicine at the University of California, San Francisco, wrote in an article published in the New England Journal of Medicine.

Bodenheimer's article — "Primary Care: Will It Survive?" — is the latest in a series of warnings about the decline of primary care. Many health experts agree that good primary care results in better health and lower costs overall.

But it's easy to see why it isn't at the top of doctors' preferences. Medical students are frequently saddled with more than $100,000 in student-loan debt. And for a confluence of reasons, including flat or declining payments from government programs such as Medicare and increased demands from private insurers, family-medicine doctors often work longer hours and often for less pay.

The median income for doctors in family practice is about $150,000; doctors in specialties such as dermatology, radiology and orthopedics average twice as much.

Dr. David Luehr, president of the Minnesota Medical Association and a family physician at the Raiter Clinic in Cloquet, said his annual salary was flat for several years. Unless salaries go up for family doctors, Luehr sees a point at which it might be hard to continue attracting foreign medical graduates.

"We're really going to see a shortage a decade out from now," Luehr said.

At the University of Minnesota, the starting salary for a family physician is $115,000 to $125,000. In rural areas, family physicians with years of experience might earn up to $300,000 because they do the full scope of care, including pediatrics and obstetrics, said Dr. Macaran Baird, head of family medicine and community health at the university.

It's physicians who work in urban environments who often face the biggest challenges since poverty, crime and family problems all affect the health of their patients.

Patient visits are about 20 minutes, but doctors now have a variety of new tasks to complete. They're expected to educate patients on how to stay well, in addition to treating them when they're sick. Insurers have introduced "pay-for-performance" programs, which require more documentation from doctors to get paid.

Abraham arrived in the United States as a postdoctoral fellow and for three years did glaucoma research at Northwestern University in Chicago. After failing to land an internship in ophthalmology, his first choice, he entered the residency program at Hennepin County Medical Center' Family Medical Center.

He said he has new respect for what his colleagues do.

"The family doctor is actually the first line of diagnosis," he said. "If you come in with a stomachache, the doctor has to figure out if it's a gastrointestinal problem or heart problem or gynecological."

Abraham said he's had to learn the intricacies of the U.S. system. For example, when he was a medical student in Damascus, there was limited access to the newest research on the Web. Here, there is a broad range of resources.

Ultimately, experts warn that recruiting doctors from other countries is unsustainable. These doctors' home countries need them as they upgrade their health-care systems.

"I don't know when that stream will run out," said Baird of the University of Minnesota. "But it seems to me it will."