imageOne of the joys of being an underinsured/sometimes uninsured, but healthy, 25-year-old: every time new insurance asks me for a family doctor or a shot record, I don't have A and I have no idea how to get B. I'm the asshole who shows up and continually has to ask if it's okay if I don't know answers to any number of questions about my medical history, but I'm sure I got all my shots at some point since the early 80s.

Salon has a story on the death of the family doctor (not the literal death of the actual family doctor, which is a rather touching Hallmark TV movie), which made me think about the medical histories of those in my age bracket. I've lived six different places in the past six years (so I'm also the asshole who's apparently a bigger credit risk), with whatever doctor I could find whenever I needed said doctor's care. Most of it was Urgent Care for various bugs and a sleep center for a bout of insomnia I've had for about a year now. I've had no primary care/family physician, largely because routine checkups take absolutely forever to schedule, and most of the doctors in said categories are out in the suburbs near the nice schools and the families with the kids and the insurance and whatnot. And it's a common story across many of my friends, particularly those who grew up without regular insurance - a family doctor, even simply a routine doctor is a luxury we really don't have.

What we need, and most of us want, is the Norman Rockwell version of a concerned, empathetic family doctor we can trust to sniff out the rare or serious illness, manage the ordinary, while also being a medical cleric who knows his patients. What we need is a family friend to whom we can turn for reassurance, comfort and, yes, even bad news.

But primary care physicians -- those trained in family medicine and general internal medicine -- are an endangered species. It's only a bit of hyperbole to say that, if the trend continues, the family doctor will become a fond memory, a nostalgic reminder that the medical system once had a more human face and sense of community.

Of all the various elements of the 1950s that conservatives are trying to bring back - women in the kitchen and out of the work force, sexual prudishness, the overuse of the word "keen" - this is the one that it would be great for them to actually fight for, tooth and nail. We're never getting milkmen back again, but having a personal doctor who knew you and the mole on your back and your lack of gastrointestinal tolerance for enriched breads was a really, really good thing that "the market" has largely done away with. You make more money being a specialist, and you still get paid for the initial consult when someone comes to you for back pain that's actually a tumor.

Currently, roughly 200,000 family practitioners and general internists practice in the U.S. One-third are over 55 and are likely to retire within five to 10 years. Meanwhile, an alarmingly low percentage of students are choosing to become primary care physicians.

Take a look at the changing choices among the approximately 16,000 students who graduate from U.S. medical schools each year. In 1998, of the 2,930 graduates entering internal medicine residencies (specializing in the diagnosis and treatment of most common illnesses), 54 percent planned on entering primary care practice. By 2005, 2,668 opted for general internal medicine residencies, with only 20 percent of them planning on entering primary care practice. That means that at present, less than 600 graduating seniors per year plan on entering general internal medicine practice.

Primary care residencies, where residents learn to manage common illnesses and perform minor surgical and obstetrical procedures, show the same ominous trend. Between 1997 and 2005, the number of U.S. graduates entering primary care residencies dropped by 50 percent. We can now expect the combined family practice and general medicine residencies to deliver 1,000 to 2,000 U.S.-trained replacements annually. No matter how you slice the figures, five to 10 years down the road, today's difficulty finding a primary care physician will seem like a minor inconvenience.

The author's main point is that we have to sell the idea of being primary care physicians rather than simply address the economics behind the decision to get away from the practice, which sounds great. But there's a critical facet of this plan left untouched - we need people to have health insurance that actually allows them to expect a family doctor as a routine part of healthcare, rather than a childhood luxury. For the great mass of increasingly underinsured people, a copay for an in-network physician (or a submitted charge for an out-of-network physician) makes more sense when the problem gets worse. You may stop short of insurance-by-emergency room, but you still have to pick and choose your visits, and the visits that are going to be lopped off the lists are your routine checkups and drop-ins for developing problems.

Shorter this post: the big problem with our healthcare system is that it sucks for everyone. As much as we'd all love it if a new generation of young, soulful doctors came into family practice with a whole new attitude (this fall on ABC), we have an insurance system that encourages skipping extra steps and getting as little healthcare as possible to fix any given problem. We can make all the TV shows and send out all the proselytizers and forgive all the debt we want, but when the family doctor is the guy telling you that you'll have to see the other guy you already suspected you'd have to see - and you're paying for both visits - it's hard to justify both visits.