As a physician who has recruited more than 50 specialists to our region, I am concerned that patients' access to the highest quality care will become more difficult for several reasons: outrageous charges for drugs and devices, rising costs of delivering health service without rising reimbursement, intense federal regulation causing lost productivity, increasing medical education costs and shifting gender demographics toward more female physicians, who must balance professional work with personal needs.

Ultimately, these factors yield one outcome: Patients who want appointments with good doctors won't get them.

Picture the Internist who delivers care to sick adults. This primary care specialist completed three years of specialty training after eight years of medical school and college, then successfully passed the board exam. She enters practice at age 30. Having spent $400,000 on education, she has $200,000 of debt. Internists like her are the premier providers of care to our adult population and are much in demand, thanks to aging baby boomers.

Yet, no young doctors will do this work.

Last year, Rush Presbyterian St. Lukes and Loyola University graduated more than 40 physicians trained in Internal Medicine. None will work as traditional primary care doctors. All but 6 chose to complete several more years of training as cardiologists, gastroenterologists, oncologists or nephrologists.

Of the six who will practice Internal Medicine, three chose to be "Hospitalists," who deliver care only to hospitalized patients. Three joined "boutique" practices, where they are highly paid to be on 24-hour call for entitled individuals, but do not accept Medicare or private insurance.

Why? The rewards of primary care no longer outweigh the sacrifices doctors must make, so young doctors seek other fields. The satisfaction of making a real difference in patients' lives remains, but it is overwhelmed by extraordinary regulatory oversight. Paperwork, form completion and arduous but arbitrary standards for record-keeping sap the enthusiasm of physicians.

Medicare, the primary payer for office visits, has not significantly raised payments in eight years while costs of delivering care in the office rose more than 25 percent. Flat reimbursement and rising costs shrink physician incomes, and young doctors find it difficult to pay their enormous educational debt. As regulations from Medicare, insurance companies, pharmacy prescription services and hospitals add hours of hassle, young potential Internists pick anything else. The problem worsens as our population ages and more patients acquire Medicare.

"Universal Health care" threatens to cause "Universally unavailable Health care" by adding people to the mix, creating competition for appointments, increasing waiting times and shortening visits. Soon, an aged adult will have difficulty getting an appointment with his or her physician of choice. The long-awaited appointment may be brief and may not accommodate necessary preventive health maintenance.

Even without a crystal ball, I can foresee that internists will hire nurse practitioners and physician assistants for routine patient care. Soon doctors will be overseeing patient care instead of personally delivering it.

Perhaps hospitals and large health care systems, the likely employers for young internists, will attract these doctors with offers to pay off student loans or to supplement salaries beyond Medicare fees. Since they will recapture that money in some way, other costs will rise.

Indiana University School of Medicine is expanding its class size, and we expect medical students will soon be trained in Northwest Indiana hospitals.

Some may choose primary care, but this will be certain only if specialty training slots are restricted, effectively forcing doctors into primary care.

Until our educators, regulators and legislators face this problem, the future will be a bitter pill. Perhaps when our senator can't get a doctor to see his mother, somebody will take action.

The opinions expressed are solely those of the writer. Dr. Alexander A. Stemer is president and CEO of Medical Specialists Centers of Indiana.