When Dr. Richard Kirkpatrick placed an ad in the New England Journal of Medicine 10 years ago to hire doctors for his Longview clinic, he received 72 resumes. A 2001 recruitment effort garnered 30 applicants. A 2003 ad yielded 10 resumes. And a 325-letter blitz last year to every internal medicine program director in the United States? Zero. Nil. Not one response.

“The demand for primary care physicians is increasing because of a growing and aging population,” Kirkpatrick said. “At the same time, fewer doctors are becoming primary care physicians and are opting for more lucrative and less demanding careers as specialists.”

The shortage of primary caregivers — also known as family doctors or general practitioners — is a growing concern across the United States as well as in Cowlitz County. Over the long haul, it could make finding a doctor more difficult or cause longer waits to see the doctor you already have.

Income disparity

The number of U.S. medical graduates entering residencies in family medicine and internal medcine has dropped by half in the last decade, according to the American College of Physicians. There’s a predicted nationwide shortfall of 35,000 to 40,000 primary care physicians by 2025, according to the American Medical Association.

In the next 10 years, 30 percent of Washington’s primary care providers plan on retiring, Kirkpatrick said, and there are few prospects for replacing them. The shortage will be especially acute in rural areas, medical experts say.

Kirkpatrick attributes the shortage partly to the vast difference in income between primary care providers and specialty doctors, such as cardiologists or radiologists. According to an article last year in Academic Medicine, between 1998 and 2006, the number of graduates choosing anesthesiology residencies increased 150 percent, while the number choosing family practice decreased 51 percent.

“You’ve been in college or medical school for 12 years, you’re 30 years old, you have no home, no savings and $200,000 in student loan debt,” Kirkpatrick said. “You can make $150,000 in internal medicine or $450,000 as a cardiologist. Why would anyone with any brains go into internal medicine?” (Internists are general practicioners for adults.)

Another disparity lies in the amount Medicare reimburses primary care physicians compared to specialists, Kirkpatrick said. Many insurance companies base their reimbursement rates on the Medicare fee schedule.

“When a Medicare patient walks into my door, if I have a fee of $100, the clinic gets (only) $55,” he said. “Of that $55, most of it goes to overhead to keep the clinic running — insurance, salaries and property taxes and business taxes. PeaceHealth and Kaiser, as nonprofits, don’t have to pay those taxes. We do.”

In the last 10 months, Kirkpatrick Family Care has lost two of its internists and expects to lose at least one more, Kirkpatrick said. The three were foreign doctors Kirkpatrick was able to recruit because Cowlitz County is designated as a “Medically Underserved Area,” meaning the county does not have enough doctors to care for its population. The foreign doctors must work three to five years in an MUA before the United States government will grant them a Green Card.

Dr. Vivek Murari left Kirkpatrick’s clinic in December to take a job at Legacy Salmon Creek in Vancouver as a hospitalist — a physician who treats patients only while they’re in the hospital. The workload is markedly less, he said.

“The average number of patients I see now is 10 to 12 a day,” Murari said. “When I left Dr. Kirkpatrick I was seeing an average of about 20, sometimes 25.”

Murari said his move to Legacy was based largely on a higher salary and shorter hours.

“I loved the job. It was a wonderful clinic and Dr. Kirkpatrick is a wonderful man,” he said. “But the salary difference is huge. If I had a choice with the same amount of hours and the same amount of pay, I would do primary care again.”

Dr. Vlad Bogin was with Kirkpatrick Family Care for more than six years before taking a more lucrative job with a pharmaceutical company last July.

“It’s a very high workload (at the Kirkpatrick clinic) plus being on call. It’s a tough environment,” Bogin said. “I believe there are more people who are going to leave. I am concerned about this (shortage) that a lot of primary patients will be out of health care.”

Bogin said he also is concerned the poor economy and local unemployment will mean more patients will be dependent on Medicare and Medicaid and unable to find doctors who will accept them. The Kirkpatrick clinic, like many other private clinics, has capped the number of Medicare patients they will treat.

Kirkpatrick said he bears no grudge against Murari and Bogin for leaving his practice.

“How can you deny them? If someone comes over here, it’s kind of the American dream to use your ability and knowledge to get ahead,” Kirkpatrick said. “I wish we had money in our clinic to pay them for what they’re worth. They were at the top of their class. I would say the people of Longview were lucky to have these guys for the time we had them.”

Big organizations have advantage

Larger medical groups in Cowlitz County, such as PeaceHealth and Kaiser Permanente, are feeling the shortage crunch as well. Finding new hires is getting more competitive all the time.

“The number-one search is for family medicine and the second is for internal medicine,” said Carol Shea, a manager for PeaceHealth’s resources department and a recruiter for the five primary care clinics located at St. John Medical Center.

Shea admits her job recruiting for the PeaceHealth clinics may be easier than for a small clinic like Kirkpatrick Family Care. In the last 3 1/2 years since Shea began recruiting, the number of primary care providers — physicians and clinicians — in St. John’s clinics has grown from 60 to 110.

Just as importantly, St. John’s retention rate is higher than the industry standard, Shea said, and many of the doctors “have been here a really long time.”

“Many doctors prefer an employed model where they can just concentrate on taking care of people,” she said. “When I’m interviewing, I ask ‘What do you find most challenging about being a primary care physician?’ And most will say it’s fighting with the insurance people and not being able to take care of patients. It is attractive to them to be able to focus on any patient that comes through the door.”

“It’s difficult in the ‘for-profit’ market (such as Kirkpatrick Family Care), and it’s becoming more difficult to keep a business viable because of overhead, equipment, malpractice,” Shea said. “It’s not as attractive as it once was to be a partner.”

Most of the medical staff at Kaiser Permanente in Longview is for primary care, and it’s becoming more difficult to fill any vacancies, said Dr. Jennifer Bard, who recruits for the local Kaiser office.

“We have definitely had difficulty filling open positions for the last several years,” she said. “We have a network and a history of physicians approaching us, but that’s certainly changed over the years.”

Now, Bard has had to send out flyers and use other recruiting services. “It’s definitely gotten tighter,” she said.

Thankfully, Bard said, the retention rate at Longview office is “really good. We’re at least blessed with not having a lot of doctors leave,” though she’ll be looking to replace three doctors who are retiring this year.

To attract more medical students to primary care, Bard said those already in the business need to work more closely with the students.

“I think we really need to get a message out. We need to sell ourselves to the students in their first and second year of medical school,” she said. “We need to sell the great parts of primary care providers like patient relationships, getting to know families — a little more of the feel-good parts of the practice.”

Filling the gap

The American Medical Association and other physician organizations are calling for changes to help physicians with medical school debts and are looking to develop ways to recruit primary care doctors, according to American Medical News.

Kirkpatrick said he partly blames his own profession for not attracting more doctors to primary care, largely because of the gap between what insurance and Medicare pays doctors like him and high-priced specialists.

“There are 27 to 29 people on the federal board to determine how Medicare payments are meted out, and of those, only two or three are primary care providers,” he said. “All the specialist organizations like cardiologists have very high-profile lobbying firms representing them. I think that for a long time, everyone’s known about the disparity, but we have not protected ourselves and had the priority of making money. It’s partly our fault for not saying, ‘How come a cardiologist makes $500,000 and we make $120,000?’ ”

Kirkpatrick said the current system “can’t keep going the way it is.” He predicts that in the future, primary care givers will make 20 percent more from Medicare, but specialists will take a big hit. “I think the disparity will close.”

A calling

Kirkpatrick said he would still encourage medical students to consider primary care, despite the challenges posed by the economy, low Medicare payments and endless insurance paperwork.

“I would say that being a primary care physician is becoming sort of a calling versus a good business deal,” he said. “I do believe there are a lot of young caring people out there.

“I think it’s the best job there is,” Kirkpatrick said. “If you’re a lawyer, you might have to defend a creep. If you’re an accountant, you might have to help someone cheat on their taxes. But a primary care physician — you get to help people all day, every day.”