Primary care physicians - family doctors - will almost become extinct in the coming few decades, predicted the chief scientist of the New England Research Institute, who said that non-physician clinicians such as nurses, Internet diagnoses and hospital specialists will replace much of their function. Prof. John McKinlay, a former head of the Boston University Center for Health and Advanced Policy Studies, was unable to deliver his lecture at Wednesday's session of the third Jerusalem International Conference on Health Policy (because of a respiratory infection), but it was presented in his stead by Australian sociology Prof. Evan Willis. McKinlay argued that with the decline in acute infectious diseases and the increasing burden of chronic, lifelong diseases such as obesity, heart disorders, diabetes and the effects of smoking, a visit to a primary physician is already not often required and much more expensive than care by well-trained nurse practitioners and other physician assistants who can provide care at much lower costs. Those primary physicians that remain will be "gatekeepers" who refer patients to others and often not see the patient again. The general practitioner is already "becoming marginalized," he added, and medical students realize this, with most of them wanting to be specialists. The changing face of medicine is causing rivalries among doctors in the same specialties and between specialties, argued McKinlay, who was speaking primarily but not only about American medicine. "Primary care is increasingly unattractive work," he continued. "Medical journals regularly publish articles about high levels of dissatisfaction among primary doctors, who are more likely to retire early." He added that the invention in 1820 of a primitive stethoscope, a tube that could be placed on the patient's chest instead of the doctor's ear, was the first step in the "distancing" of the doctor from the patient. The invention was motivated by the inventor's desire not to get infected and infested by the pathogens and lice of their poor patients, McKinlay said. But with high-tech diagnostic machines, many doctors have forgotten how to conduct a physical exam, which only decades ago was regarded as an art. Nevertheless, the primary physician still offered listening and empathic skills to help patients with emotional and social problems, and these may be given short shrift in the new age. McKinlay's views were disputed in informal talks with participants, including many Israelis, who argued that there would always be a major role for family doctors who get to know their patients well, and when properly trained, can represent their patients in their fight for the best care. Meanwhile, at a separate session of the conference, Dr. Galia Gai of the University of Haifa's Social Sciences and Health Faculty called for immediate implementation of mental health service reform. Although the Health Ministry has said that starting January 1 it would transfer its responsibility for mental health care to the four public health funds, the insurers have all said they are not ready to carry it out. Gai said that this reform, meant to reduce the stigma of psychiatric and psychological care, was part of the 1994 National Health Insurance Law. Its implementation was delayed 12 times, she said, due to opposition within the Health Ministry, the Finance Ministry and the health funds. But the Health Ministry's mental health services budget has been eroded over the years, and the health funds are better able to supply them, she argued.