As the U.S. grapples with a shortage of primary care physicians, many in health care fear that access will sharply decline as health reform adds millions more Americans to the ranks of the insured.
A new study highlights a trend that could make things worse: Many medical schools produce more researchers and specialists than front-line doctors, especially those willing to work in underserved areas and among minorities. Public medical schools such as the University of Maryland ranked higher than private medical schools such as John Hopkins University in meeting a "social mission."
"The purpose of the study is not to denigrate the research of great universities," said Dr. Fitzhugh Mullan, professor of health policy at George Washington University and lead author of the study. "But we need to ask how medical schools can help with the whole spectrum of national needs."
The George Washington study, published Tuesday in the Annals of Internal Medicine, generally found that medical schools in the Northeast performed poorly, as did schools with significant National Institutes of Health research funding. Historically black colleges and schools in small cities had higher overall rankings.
The study also found that public schools graduated higher proportions of primary care doctors than private schools — the University of Maryland ranked 36th overall out of 141 medical schools. Johns Hopkins, which often is described as the nation's best medical school, ranked 122nd.
But Dr. Lenny Feldman, director of Johns Hopkins Urban Health Residency Program, said hospitals contribute to the country's needs in more than one way. Many Hopkins researchers and specialists are leaders in their fields, he noted.
The school has launched programs to bring cheap specialty care to the uninsured and primary care to those who tend to go to the emergency room. And Feldman's six-year residency program aims to annually produce four primary care physicians who eventually could become leaders in the field by opening a federally backed health center, directing a primary care clinic or becoming a city health commissioner.
That could lure more doctors to primary care. Although they are often drawn to more lucrative and prestigious specialty fields, he said, most still chose primary care because "it's a calling."
"Certainly there is a role for Hopkins innovating in the area of primary care," he said. "It's not been an area of emphasis for Hopkins in the past, but an area where Hopkins can excel."
The George Washington study's author, medical schools and observers say solutions will range from increased attention from the schools to incentives for new doctors who carry high tuition debts, as well as stepped up assistance from nurse practitioners and others.
The study counted the primary care doctors produced by each school, how many practice in underserved areas and how many are minorities, using data from 1999-2001 to follow students through their residencies and obligations such as the military to their actual place and type of practice. That makes this study different from others, including the well-known U.S. News and World Report ranking, which consider only where doctors do residencies and use many other measures.
Medical schools need to do more to meet the nation's needs, said Dr. Brian Smedley, vice president and director of the Joint Center for Political Studies Health Policy Institute, a research and public policy institution that focuses on minority issues.
He said medical schools, and also nursing and dental schools, will have to cooperate to produce more front-line providers and doctors who better reflect the population they serve. Also, he said, there needs to be balance in the earnings potential of primary care doctors and specialists, and less tuition debt for doctors.
"Some schools focus elsewhere, and that is appropriate in some cases such as with research," he said. "But they need to think of the overall needs of the population, and the study clearly shows that our educational institutions are not doing as good a job as they should in preparing for the health care needs of the country."
According to a Kaiser Family Foundation report, 11.8 percent of the U.S. population is living in an underserved area, including 4.7 percent in Maryland.
A recent study by the Maryland Hospital Association and MedChi, which represents physicians in the state, found that Maryland has about 4,596 primary care physicians, but nearly half of those are hospitalists, specialists who oversee a patient's hospital stay. There are about 52 primary care physicians for every 100,000 residents without the hospitalists.
The report notes that hefty medical school bills push doctors into more lucrative specialty fields and that reimbursements are lower for primary care doctors, especially through Medicare. The MedChi report also cited the state's expensive medical malpractice insurance as a deterrent.
"If the average primary care doctor is not making enough money to pay the mortgage and student loans off, people who are smart enough to become doctors are going to do other things," said Gene Ransom, MedChi chief executive officer.
Some helpful measures were included in the health care reform law, which aims to insure some 32 million more Americans, including large proportions of minorities and those in places without adequate access to care, said Ethan Rome, executive director of Health Care for American Now. The law designates $1.5 billion for primary care physicians who choose to practice in underserved areas and $410 million in funding to train low-income people who want to work in the health sector.
"These programs will increase the number of health professionals serving these communities and ensure that the new law fulfills its promise of providing quality, affordable care to all," said Rome, whose coalition fought for health care reform.
And some area providers, including hospitals fearful of a large influx in their emergency rooms, are finding ways to make primary care a viable option.
Thomas R. Mullen, president and CEO of Mercy Health Services, which runs Mercy Medical Center in downtown Baltimore, said the hospital negotiates with insurance companies to make reimbursement rates more attractive for primary care physicians. Officials also work with doctors to come up with more economical business models, such as encouraging doctors to join groups so they can share the cost of running a practice.
"We try to create a work setting that allows them to make more money so the job is more attractive," Mullen said." If we get paid more we can pay them more…. If we can lower the operating costs of practicing through management, they can make more money."