"They always say, 'Ask your friends,'" she said. "All my friends went to doctors who couldn't take me."

Miriam Raskin

Courtesy of Ms. Raskin

Search for a doctor wasn't resolved until a friend died.

Raskin didn't know it but she was up against a growing health issue facing Americans -- a shortage of primary care doctors, generalists who are supposed to be a patient's initial medical contact.

She eventually found doctors who would take her on but soon she found herself searching again.

"Through no fault of my own, I lost three doctors over a number of years," Raskin said.

The first doctor she found after leaving her original primary care physician moved on to the Veterans Administration, and the second one left the area, she said. She thought she found a great fit when her daughter's doctor agreed to take her as a patient.

"In no time I realized I could not see this doctor -- I could only see her assistant," Raskin said.

It was back to searching. Again she found many physicians had closed their practices to new patients -- especially those who, like Raskin, are on Medicare.

"They take a limited number of patients on Medicare. They don't want to play with the paperwork," she said.

Finally when a friend died, Raskin tried an unusual approach to finding a doctor. She asked her dead friend's doctor to take her on, she said.

"As luck would have it -- you have to understand my sense of humor -- my friend died," she said. "She and her husband had a wonderful doctor."

"I got him because I filled in the place of my dead friend," she said. "I don't know if it's possible to get a doctor on your own merits -- especially if you're on Medicare."

'Where will all these patients go?'

The shortage of primary care doctors is a national problem.

A report from the American Academy of Family Physicians noted that the country needs 140,000 family doctors by 2020.

"To do that, we have to graduate 3,700 family doctors a year," said Dr. Richard O. Schamp, associate professor and interim chairman of the Department of Community and Family Medicine at the St. Louis University School of Medicine. "We're not doing a third of that," he said. "We're graduating 1,300 to 1,400 a year now. We'd have to triple that to meet that target."

Statistics from other countries indicate those that have the "best outcomes and have the best economic analysis" have a 50-50 ratio of primary care doctors to specialists, he said.

"The ratio in the U.S. market is quite a bit lower than that," Schamp added. He estimated it is 35-55 and that a goal would be to raise the percentage of primary care doctors to 40 or 50 percent.

St. Louis University is apparently bucking the national trend of medical schools graduating fewer primary care physicians. Over the past three years, the school moved about 40 percent of its graduates into primary care residencies, he said.

St. Louis area physicians see the effects of the shortage of primary care doctors.

Kate Lichtenberg, D.O., is a doctor in family practice in Bridgeton and president of the St. Louis Academy of Family Physicians. "I can tell you I saw two patients this morning who were new to me whose doctors had recently retired," she said.

As the youngest member of her practice, Lichtenberg is still taking new patients but that will probably change in a few years. And she may feel the ramifications of the shortage when her partners retire in the next five to 10 years. "My partners are certainly getting toward the end of their careers," she said. "They have huge practices and suddenly we're going to be faced with 'where are all these patients going to go?'"

Dr. Scott Anderson, M.D., with Esse Health, the St. Louis area's largest independent physician group, hasn't been taking new patients for quite some time.

"That's sort of the nature of the business," he said. "All of a sudden you become more crowded. I think it's a problem that's become worse recently."

Not only are fewer doctors opting to become primary care physicians but "primary care doctors who used to go into internal medicine are now becoming hospitalists," Anderson said. Hospitalists are primary care doctors who care for patients while they are in the hospital, sometimes eliminating the need for the patient's own doctor to make hospital rounds.

The idea is to make care more efficient, but Anderson, who likes checking on his patients when they are hospitalized, doesn't find it to be so. "I don't like it at all, and I'm surprised the insurance companies pay for it," he said. "The internist who goes to the hospital is a rarer breed today."

Internists aren't fashionable

The shortage of primary care doctors stems from the fact that medical students look to more lucrative specialties when they launch their careers.

"I think internists aren't very fashionable," Anderson said. "It's viewed as a not very exciting field."

Perhaps the surge in specializations stems from internists' relatively low pay. For example, Medicare pays primary care physicians in the St. Louis area $35.05 for a 25-30 minute visit with an established patient with a complex medical condition, compared with the $348.46 paid for a diagnostic colonoscopy, a service that takes about the same amount of time. The physician administering the colonoscopy would make almost 10 times the internist's pay.

The gap in pay makes the process of finding a new primary care physician arduous. So hard, in fact, that Congress recently addressed a piece of the problem. Medicare had been scheduled to automatically cut its payment of physicians by 10 percent. In July, the House of Representatives and Senate overrode President George W. Bush's veto of a bill that would protect doctors from the Medicare cuts.

Anderson said internal medicince can be an underpaid speciality, but that's not always the case.

"In our group, we're handsomely compensated and I think we compete favorably for new recruits," he said. "It's also a prestige perception. In this day and age, medical students are encouraged to specialize, especially at the prestigious medical schools."

Anderson found this true in his personal experience. He graduated with doctoral and medical degrees from Duke University and also went to Washington University.

"I was trained to the hilt," he said. "The expectation at Barnes was that I would become a specialist. They offered very little help frankly in finding an internal medicine job because they never did it. It was difficult for a physician like myself who wanted to become a patient's main doctor to get off of that pathway."

Dr. Gary Wasserman, an obstetrician-gynecologist with St. John's Mercy Medical Group, often finds himself providing primary care to his patients.

"I think each individual gynecologist has to look at what the scope of responsibility and the level of comfort" in providing primary care, he said.

While he will do blood work and perform other screening functions, when the results are abnormal "it's time to get another practitioner involved in the patient's care," he said. "It's really best to get a generalist involved because they do that everyday."

That could be a nurse practitioner, a physician's assistant, an internist or a family doctor, he said. "I think it's good for them to establish that relationship so that they know that person and know not only their medical condition but some of the other factors that are involved in their total being."