Two women were sitting at a table near the window of a restaurant in Pittsford. The waiter had just taken their orders, while a young man fussed with salt-and-pepper shakers before filling the women's glasses with ice water. No sooner had the server stepped away when one of the women, a round-faced redhead probably in her late 40's, leaned forward and asked, "So, how is Gordy doing?"

"Luckily for him, they found it in a routine examination," her friend replied.

It's a not-uncommon story: someone goes to the doctor for a checkup or for a minor complaint, but while they are there, the doctor notices something else. Hopefully, it's in time for the problem to be effectively treated. But if the number of primary-care physicians continues to drop, the situation could be different a decade from now.

Primary-care physicians are often seen as gatekeepers, a term that has both positive and negative connotations. Their job is surveillance, protection, and health management. Fewer medical students going into primary care combined with a wave of retiring older doctors is putting a serious strain on the US health-care system. And industry analysts and doctors in the field say it's going to get much worse.

In some respects, the health-care system is built on the shoulders of primary-care physicians. These are the internal, family, and pediatric medicine doctors that Americans tend to see on a regular basis.

There are three legs to primary care, says Dr. Wallace Johnson, a primary-care physician with the University of Rochester Medical Center. One, he says, is seeing patients who walk into their doctor's office with acute symptoms such as sore throats or backaches. The second is seeing patients for age-specific preventive medicine like breast and prostate exams.

"But the most important aspect of primary care, and the thing that will suffer most with a worsening physician shortage," Johnson says, "is the comprehensive care of chronic medical conditions that really lead to early mortality, to lots of suffering, and to the high costs that have plagued the American health-care system over the last decade."

Consider diabetes, a complex disease that is expensive to treat and can lead to a multitude of problems when it isn't properly managed: infections, blindness, kidney failure, and wounds that won't heal. But diabetics live longer today, often without complications, because their primary-care physicians are vigilant about medication, diet, weight, and exercise.

The data doesn't paint a promising picture. The number of US medical school graduates entering residencies in primary care has dropped by 50 percent over the last decade, says a report issued last year by the American College of Physicians.

A similar report by the American Academy of Family Physicians presents the same findings. The decline has occurred as the US population has grown, and the crisis is expected to escalate as the Baby Boom generation ages.

There are 1,234 primary-care physicians in the nine-county Greater Rochester region, says Nancy Adams, director of the Medical Society of Monroe County. Her organization is about to release information showing that the number of primary-care physicians in Monroe County has held steady during the last few years.

"But there are some red flags," Adams says. "The average age of our physician population is 51, for all doctors. If you look at what type of student training is being chosen over primary care, and you see the number of physicians approaching their retirement years, you'll see there's a point soon where these two lines are going to cross."

Also, one-third of the area's primary-care physicians are not accepting new patients at this time, Adams says, which is tightening the field. The situation is worse in the outlying areas, such as the Southern Tier, with its sizeable elderly population.

"It's not easy to recruit doctors to come here," Adams says, "and it's even harder down there."

Rochester is doing better than other parts of the country, Johnson says, because of the UR's School of Medicine and Dentistry, which graduates about 100 students per year. But like other medical schools throughout the country, Johnson says, the UR is seeing fewer students choose primary care. From 2004 through 2008, only 15 out of 100 students in internal medicine ended up choosing primary care. In the class of 2009, there was one.

About 20 percent of the students who choose primary care stay in the area, Johnson says, but that number, too, is decreasing. 

The reasons why fewer students are choosing primary are fairly clear, says Dr. Marc Berliant, chief of the URMC's general medicine division.

"To put it mildly, medicine isn't as much fun as it used to be." he says. "Don't get me wrong, it's still a wonderful career, but there are so many obstacles in your way. We used to have doctors that were in their 70's and you couldn't get them to retire, they loved it so much. It's not like that today."

Foremost is salary. Primary-care doctors are paid significantly lower salaries than specialists. Starting salaries range from $100,000 to $120,000, while more experienced doctors earn between $140,000 and $160,000. It's hard to crack $200,000. But $200,000 is a starting point for some specialists. And depending on their area of expertise, many will go on to earn much more. ROAD (radiology, obstetrics, anesthesiology, and dermatology) has become industry shorthand for big money.

Debt is another factor, Berliant says. The average debt load for most medical school graduates is about $140,000. A higher salary means loans can be paid off that much quicker.

But money, though certainly important, isn't always the main reason fewer students are choosing careers in primary care, Berliant says.

"Prestige is part of it, too," he says. "Primary care has a bit of an image problem. It seems a little stodgy. It just doesn't seem as cool and edgy."

Some of that has to do, Berliant says, with how students are introduced to primary care.

"I believe early on that students have to have a positive experience with a good mentor," he says. "It has to be someone who can spread that joy contagiously, where every day is exciting. This is hard, fast-paced, stressful work."

Matching students with the right teaching doctors is extremely important, Berliant says.

"Physician satisfaction is related to how we practice," he says. "It doesn't matter how much money is thrown at these students. If they don't get to work with someone who loves their practice, I don't think the outcome for them is going to be good."

Jason Kurland, a fourth-year medical student at UR, made a similar observation.

"Pretty much every specialist wants you to join their field," he says. "They'll come around and they'll make a pitch. I didn't encounter many people saying you should go into primary care. Some people will say it's not something you stay in."

Kurland is doing his residency on the Navajo reservation north of Albuquerque. He says that he plans to be a primary-care physician, because he likes the idea of helping a whole community of people. Med students often talk altruistically about helping people, he says.

"And there is this real desire to help," he says. "It's sincere. But what kind of work you're going to do often turns into a conversation about how cushy or not so cushy it's going to be. I didn't get into medicine to find out how cushy a job I could get. I knew I wanted primary care even before I got accepted into medical school."

Primary care presents doctors with something new every day, Kurland says. The challenge is that you have to know a lot about everything.

"It would make me crazy to have to do one facet of medicine all day every day," he says.

Thomas Carroll is doing his residency in internal medicine at the UR. He also plans to go into primary care, because it will offer him the opportunity to experience medicine in a much broader sense than specializing would. He compares it to working in an outpatient clinic.

"It's hard to put your finger on it," he says. "It's kind of like you are doing more detection work."

Someone comes to you and they have all of these symptoms, he says, and it's your job to figure out what's going wrong.

"It's more about initial diagnosis and management," Carroll says.

The detective side of patient care was what excited Berliant most when he was beginning his career 27 years ago, and he tries to share his enthusiasm with students.

"There is something about the challenge of having to make a diagnosis, sometimes within minutes, that really gets your adrenalin going," he says. "But the other thing that we get that you don't find in the sub-specialties is the relationship you have with your patients. You're with them over the long haul. You develop a connection that lasts years."

That bond with patients is more satisfying than procedures, Berliant says, which is the typical service of specialists.

"It's a two-way street," he says. "You're happy when they're doing well. And you definitely feel their pain with a gravely serious diagnosis like cancer."

If fewer doctors are dedicated to screening, early detection, and the ongoing maintenance of chronic conditions, the overall health of the American population will begin to decline, say Johnson and Berliant. Hard-won gains in disease management will be eroded. When that happens, Johnson says, the cost of care for everyone will go up.

"The thing to keep in mind is that communities that have vibrant primary-care medicine, that have enough primary-care providers have better health-care quality and they have lower costs," Johnson says. "And the impact of lower costs is particularly important in today's economy because major industries want to locate where health-care costs are lower."

And health-care reform, which could potentially bring millions of uninsured people into the health-care system, will strain the system further if steps aren't taken soon to increase the number of primary-care physicians, Johnson says.

"I think it's very tempting to look at the data and say primary-care doctors make less and stop there," Johnson says. "I think that's true. But I really don't think that's what, for lack of a better word, has killed primary care as an appealing practice."

The primary-care model hasn't kept pace with the more technology-driven specialties where the advances in medicine are obvious, Johnson says. By its very nature, primary care is not as technical, he says, but it has failed, too, to be more innovative with basic practices. Physician satisfaction is low, he says, because the job can be a daily grind of paperwork and a crushing patient load.

And, Johnson says, the "gatekeeper" model that plays a game of "Mother-May-I" with insurance companies has to change. Patients sometimes see their physicians as standing in the way of treatment.

"They detest the idea of seeing one doctor just to get an approval to see another doctor," Johnson says.

While this was originally designed to help better coordinate care, primary-care physicians have become overwhelmed with what Johnson calls paperwork and phone triage.

A better approach that could make primary-care more attractive to students, doctors, and patients involves using more physician assistants and managing-care nurses for routine care. Under this approach, the primary-care physician's time would be used more efficiently, while patients receive more attention.

The URMC is one of several locations in the country, Johnson says, testing pilot programs that are based on what experts call the patient-centered approach. Physicians continue to use the fee-for-service model. But they are better compensated for providing more comprehensive care and health management - educating patients, making sure that preventative testing is done, keeping referrals from slipping through the cracks, and avoiding duplicative tests. These are types of things that contribute to overflow in emergency rooms and avoidable hospital admittances.

"I think we have to do a better job of working together in this regard," Johnson says. "Everybody's interest is aligned when primary-care physicians are rewarded for practicing good medicine, and not for just bringing people across the doorstep."