The response was anything but subtle when Kate Goheen mentioned during her medical school training that she wanted to become a family doctor.
"You're making the biggest mistake of your life," several physicians and professors told her, encouraging her to seek a much higher-paying -- and, some said, more prestigious -- specialty.
Goheen ignored the advice, but experts are concerned that primary care doctors like her -- who get to know their patients intimately and often oversee the health of families for decades -- are increasingly in short supply.
A nationwide shortage is expected to grow more severe when an additional 2 million to 4 million Californians, and 32 million people nationally, obtain insurance
"What we want to avoid is a situation where people have insurance coverage, but don't have access to care," said Dr. Steve Green, president of the California Academy of Family Physicians.
Adding to the demand: Baby Boomers will require increased medical attention as they age.
And they're not the only group getting older. Nearly one-third of all physicians are expected to retire in the next decade, just as more Americans seek care.
Estimates of the need are sobering: 45,000 additional primary care doctors across the country within 7 years, including 2,000 or more in California.
The national health reform law emphasizes primary care as a way to keep people healthy and
Yet only about 20 percent of American medical students go into primary care, according to the Council on Graduate Medical Education. Primary care typically includes family medicine, general internal and general pediatric medicine.
Medical schools often have students spend more time with hospital specialists using the latest high-tech equipment than they do with family doctors.
"Part of the solution is bringing medical students
Such doctors will be on the front lines of carrying out the national health reform law, yet the shortage will worsen "if we don't train, recruit and retain more primary care physicians," said Dr. Rick Minh-Luan To, a San Jose family medicine doctor.
Everyone could be affected as doctors attempt to squeeze in more patients.
"People should be expecting longer waits and shorter appointment times," said Callie Langton, director of workforce policy for the California Academy of Family Physicians.
Americans may need to rethink how they value the profession so that more people will enter the field, experts say.
Goheen, now in her third year of family medicine residency at Contra Costa Regional Medical Center in Martinez, said she has no regrets about her decision. She enjoys that in one day she may deliver a baby, meet with parents of young children and treat people in their 90s.
"I really like getting to know patients and seeing them for a long time," she said. "I'm seeing kids that are 2 now that I delivered, and it's just an amazing experience."
But she understands the financial pressures that lure people to specialties, especially since she has $175,000 in student loan debt.
Nationwide, the average primary care doctor earned $156,000 to $165,000 in 2011, the lowest pay of all the physicians surveyed, according to a Medscape study.
Many specialists made twice as much: gastroenterologists earned $303,000, urologists and anesthesiologists $309,000, and cardiologists $314,000. Radiologists and orthopedic surgeons topped the list at $315,000.
Salaries trend higher in the Bay Area, but the disparities are similar.
Dr. Sergio Urcuyo originally planned to become an ear, nose and throat specialist but changed his mind after his mother was diagnosed with pancreatic cancer. He saw how hard it would have been for her to navigate the health system without a primary care doctor to help oversee her care.
"For the first time in my life, I saw the health care system from the patient's side," he said. "Her primary care doctor was the one she relied on to help her get through her illness."
Urcuyo graduated from Contra Costa Regional's family medicine residency program in June and is now a faculty member there, with nearly $300,000 in student loans to repay.
In California, the shortage of primary care physicians is most severe in rural areas. Bay Area counties generally have the recommended 60 to 80 primary care doctors per 100,000 people, but the region will be challenged to meet the coming need, said Dr. Kevin Grumbach, chairman of the department of family and community medicine at UC San Francisco.
And not everybody has access to even the existing physicians. Many Bay Area doctors will not see Medi-Cal patients, and only Kaiser members have access to Kaiser primary-care physicians, Langton noted.
Groups such as the California Academy of Family Physicians are seeking more funding for residency training, arguing that the state's 309 openings each year for doctors to begin a family medicine residency are not nearly enough.
Medicare pays for most of such training nationwide, but Congress froze the number of residencies in 1996.
The national health reform law earmarked an additional $168 million to train 890 more primary care doctors than in the past, but this will not come close to offsetting the shortage of such physicians.
Today, Contra Costa Regional Medical Center receives 700 applications a year for the 14 annual openings in its family medicine residency program. O'Connor Hospital in San Jose gets 400 applications for its 8 positions.
On the bright side: The renewed focus on primary care is beginning to generate more interest among medical students, said Dr. Jeremy Fish, who directs Contra Costa Regional's family medicine program.
And salaries for family physicians rose by 6 percent last year because of the increased demand.
Kent says more medical students will be attracted to the field if they learn more about it.
"Those of us who are in primary care, despite the heavy workload, are generally very happy," he said. "I can't imagine doing anything else."
Sandy Kleffman covers health. Contact her at 510-293-2478. Follow her at Twitter.com/skleffman.
NEEDED: PRIMARY CARE DOCTORS
The nation needs 45,000 additional primary care doctors within 7 years, including 2,000 or more in California.
Two to 4 million Californians, and 32 million people nationally, will obtain insurance in 2014 under the national health reform law.
RESPONDING TO THE CALL:
About 20 percent of American medical students go into primary care, which includes internal medicine, pediatrics and family medicine.