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Medical schools churn out specialists, despite nation's need for family doctors

THE BALTIMORE SUN

An article in yesterday's editions of The Sun on primary care doctors incorrectly described a $1,100 medical test, an echocardiogram.

+ The Sun regrets the errors.

Bill Welder knew AIDS up and down by the time he graduated from the Johns Hopkins School of Medicine in 1991, and he could recognize any number of exotic cancers. He had only a dim idea, though, what chicken pox looked like, and a case of teen-age acne might stump him.

These might have been inconsequential holes in a young doctor's medical education were he planning a career in immunology or oncology. He wasn't. Dr. Welder wanted to practice family medicine back home in the Appalachian Mountains of West Virginia, where the word "aides" still mostly refers to those nice people who help out at the school. What's needed there among the potato and dairy farms -- and in rural and urban areas across the United States -- are doctors eager to treat chicken pox, strep throat and high blood pressure -- common ailments.

But Hopkins does not encourage its students' interest in the common, says Dr. Welder, who is now completing a residency at Lancaster General Hospital in Pennsylvania. "The view there was that family medicine was a waste of your time and talents," he says.

Hopkins, by its own admission, does a particularly poor job of producing doctors who go on to practice general medicine rather than one of the specialties.

But among American medical schools, that makes Hopkins different only in degree, not in kind. As health care reform has taken the spotlight, the consensus has grown that American medicine is suffering from a severe case of over-specialization and a shortage of primary care doctors.

"We're probably turning out too many doctors and the ones we're turning out aren't the right kind," said Jack M. Colwill, chairman of the Department of Family and Community Medicine at the University of Missouri and a member of a commission that advises the federal government on physician manpower.

According to recent estimates, the United States has as many as 100,000 too many specialists and 100,000 too few primary care doctors. It's about to get much worse. If Hillary Rodham Clinton's task force emphasizes managed care -- as expected -- and proposes universal medical coverage -- as promised -- it could take up to a generation to produce the number of primary care doctors such changes would require.

Health policy experts estimate that at least three-quarters of patient-doctor contacts are for matters that can be handled by a primary care doctor, generally identified as someone practicing in pediatrics, family medicine or general internal medicine. Yet, today, fewer than one in three doctors are in primary care. Many of those same experts insist that American medicine should achieve to a one-to-one balance between specialists and generalists.

The trend now is in exactly the opposite direction. According to one recent survey, only 15 percent of today's medical students say they are planning to go into primary care.

The imbalance is not simply an academic one. There is mounting evidence that the explosion in specialty medicine is costing Americans money. The United States has by far the highest per capita health care costs among Western industrialized nations. It also has by far the worst ratio of primary care doctors to the general population. Many believe that there is a close relationship between the two.

According to a recent spate of studies, specialists order more tests, perform more procedures and hospitalize more patients than primary care doctors treating essentially the same symptoms. "By their very nature, [specialists] will do more," says Barbara Starfield, head of the division of health policy at the Johns Hopkins School of Public Health and author of a study comparing the U.S. health system with other Western countries. "They are looking for the unlikely, the rare. They think zebras, not horses."

Specialists and generalists approach problems from opposite directions, Dr. Colwill says. "The primary care doctor looks for the most likely things that are wrong with the patient, and then progressively looks at the less likely possibilities," he says. "The specialist, though, is there to rule out every possibility, even though the likelihood is quite low."

No love for Marcus Welby

Such talk is all but guaranteed to prick the sensitivities of specialists who grouse that primary care doctors all too often mistreat patients because they don't know the limits of their knowledge. Only last weekend, an official with the National Institute of Allergy and Infectious Diseases lambasted primary care doctors for the needless deaths of thousands of asthma sufferers.

It was a demeaning remark, but not inconsistent with the nation's generations-long depreciation of primary care. We may love Marcus Welby, but only as a television character.

It is easy to understand why doctors prefer to specialize. They make more money for doing so because the American medical reimbursement system traditionally has placed far greater value on procedures -- the tests and operations typically performed by the specialists -- than on preventive medicine, the strongest suit of the primary care doctor.

So, for example, Dr. Michael P. Zimring, an internist with offices -- at Mercy Hospital, says Blue Cross Blue Shield will reimburse him $75.70 for an hourlong examination during which he may discuss ways to avoid heart disease. Down the hall, a cardiologist can perform an electrocardiogram, a procedure that typically takes between 20 minutes and an hour, and charge $1,100.

The reimbursement system, says Dr. Zimring, forces him to spend less time with patients and to see more of them just so he can make a living. "I find myself doing fewer complete physicals and scheduling more office visits that are about specific complaints," says Dr. Zimring.

The reimbursement system has deposited primary care doctors at the bottom of the salary scale in the medical profession. According to Medical Economics magazine, the average general practitioner last year netted $88,820 and the family doctor $101,160. At the top of the scale were cardiovascular surgeons who on average netted nearly $300,000.

Specialists insist they deserve more money than primary care doctors because of their additional training. But others say we have a reimbursement system that simply makes no sense anymore.

"I don't know who wrote in what tablet of stone that doing an hour of surgery is worth more than an hour of counseling in an examining room," says Dr. Robert Waldman, former dean of the University of Nebraska School of Medicine.

Almost certainly, though, primary care will have no resurgence unless the disparity is addressed. Without some significant change, medical school graduates not only will continue to stay away in droves, but existing primary care doctors may burn themselves out.

"I'm happy with what I'm making," said Dr. Zimring, who says his income is below six figures, "but I'm tired of working this hard."

But the discouragement to primary care is not simply financial. Medicine has grown increasingly complex.

That is precisely why Joseph Costa, a resident at University Hospital, is planning a career in pulmonary medicine. "I like having the feeling of having expertise in something," he says. "I like the idea of being someone who could be the definitive statement on a patient."

Dr. Welder, though, was drawn to primary care precisely because of its variety. "I can see a woman 18 weeks pregnant with bleeding, a woman with post-partum depression, a kid needing a physical for school, a man with blood in urine. I can take care of a woman with a lump on her breast, a couple where one has Alzheimer's and they're wondering how they'll get through the next days. I see child abuse, spousal abuse every day."

Other students have an altogether different impression of primary care. Malcolm Foster is a second-year resident at Hopkins Hospital in general internal medicine. After his residency, he is planning to go on in cardiology. "The word filtering down to residents is that primary care physicians are being forced to see more and more patients and are making less and less money," he says. "I'm finding specialists are a content group. The internists are like a bunch of workhorses."

'In no way encouraging'

At the nation's medical schools, the medical hierarchy couldn't be more apparent to students. The specialists are clearly the lords of the realm there, commanding research dollars, office suites and staffs of assistants. The generalists, if they are present at all, seem like mere afterthoughts.

So, too, does their subject matter. The emphasis in most medical schools today is on high-technological, hospital-based treatment. Medical schools provide little opportunity to see patients outside the hospital, where most treatment is actually provided. Students who go into primary care seem to do so despite medical school, not because of it.

Certainly that is true at Hopkins, which ranks number 117 among 125 American medical schools in the production of primary care doctors. Only 14.5 percent of Hopkins' medical school graduates go on to practice in primary care.

"It is in no way encouraging," says Joe Ferguson, a third-year Hopkins medical student who is planning a career in family medicine. "There are no models at all in family medicine."

Dr. Welder said he was barely exposed to any patients at all in his first two years of medical school, and Hopkins didn't afford him any opportunities to see patients outside a hospital.

In the end, he arranged his own rotations in family medicine, completing one in West Virginia, another in Virginia and a third in Canada's Northwest Territory.

Dr. Welder came to Hopkins already deeply influenced by a role model, a family practitioner in his hometown of Greenville, W.Va., (pop. 82) who delivered everyone in town and then put their pictures on his office wall.

"He just seemed so happy with his life and so involved in the community," said Dr. Welder. "That's the kind of doctor I want to be."

Across town from Hopkins, the University of Maryland School of Medicine has a better record in producing primary care doctors. It ranks No. 37, with nearly 30 percent of its graduates going on to primary care. That is still a far cry from the 50 percent now being recommended, and even Maryland students say the school is not altogether encouraging.

Jamie Harms, a 37-year-old family practice doctor in Arnold, recalled discussing with her faculty adviser her intention to go into family practice. "He looked at me and said, 'Family doctor? Do you want to be a dum-dum doctor your whole life?' "

Unlike Hopkins, Maryland does have a family medicine department, but students complain that they don't do rotations with nonhospitalized patients until their last year in medical school. By then, they've already made their decisions about specialties.

Earl Hill, a family physician in Pasadena and associate professor at Maryland, criticizes the school for its shortcomings.

"Medical schools can be held accountable for what graduates do if they are not providing equitable experiences," he says.

Dr. Hill's boss, Donald E. Wilson, the dean of Maryland's medical school, agrees that students should have more exposure to ambulatory care and says the school is considering curriculum changes. But he insists it is unfair to place the entire burden on the schools. "The question is always what is the medical school going to do about the problem. I say, what is society going to do?"

Exposing students to primary care, he says, will require resources the university, which faces budget cuts, does not have. General practitioners who agree to supervise medical students must be compensated for their time. One helpful step the General Assembly took this year, Dr. Wilson says, was the creation of a $750,000 fund to defray educational expenses for those going into primary care.

Medical school deans are now generally accepting of the notion that primary care must be encouraged. However, some, like Hopkins, insist all medical schools should not be lumped together. "Society has invested in Johns Hopkins and made us )) intensively research-oriented and as a result we tend to attract students who are interested in research and development," says Michael Johns, dean of the Hopkins medical school.

But some of its graduates insist that a balanced education is not the either/or proposition Dean Johns makes it seem.

"They cannot turn their backs on the fact that our country needs primary care doctors," says Dr. Welder. "That's just wrong."

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