President Clinton's call to increase the supply of family doctors could force hospitals such as Johns Hopkins and the University of Maryland into a battle to preserve their roles as specialty centers.
For Mr. Clinton's reform to work, teaching hospitals would have to train more than double the current number of physicians planning careers in primary care, a field that has been derided as low-paying and lacking the intellectual allure of the medical specialties.
The administration wants to reverse that perception, recognizing that specialists order more tests and perform costlier procedures than do generalists. Accordingly, it has cast family doctors as virtual heroes in its effort to slow the soaring cost of health care and bring preventive medicine to Americans who lack it.
Under the plan, the federal government would require that teaching hospitals train half of their residents in primary care and half in the specialties. The shift would take place over five years, but it would be a radical one. Today, 80 percent of the nation's 100,000 residents are in specialty training, 20 percent in primary care.
The plan doesn't require all hospitals to achieve a 50-50 split, only that the nation's full complement of residency slots break down that way. This leaves room for some hospitals to preserve their overwhelming preference for the specialties. But to make the numbers work, some institutions will have to transform themselves into centers for generalists.
"If an institution can't get enough slots in specialty care, they'll have to expand into primary care," said Dr. Gerard F. Anderson, a professor at the Johns Hopkins School of Hygiene and Public Health who served on Hillary Rodham Clinton's health task force.
"An institution like Johns Hopkins may be able to stay overwhelmingly specialty," he said. "But some other institutions that have trouble competing will need to expand their primary-care programs."
The plan has some hospitals worrying that they may have to surrender their roles as centers of excellence in such prestigious and high- paying fields as surgery, anesthesiology and radiology. Hospitals also worry that without a major restructuring of insurance reimbursements, their finances could be affected adversely.
Residents are the workhorses of many hospitals, rendering much of the hands-on treatment given patients. And when hospitals train a large number of specialists, they profit because insurers reimburse hospitals more for the services of specialists than they do for generalists.
"It's necessary for the financial survival of academic health centers to train and have on board a significant number of specialists," said Dr. Donald E. Wilson, dean of the University of Maryland School of Medicine.
The difficulty of meeting quotas for primary-care residencies will depend partly on how the government defines the term.
Originally, primary care was limited to family medicine, general internal medicine and pediatrics. But already, hospitals appear to have won a major concession: the addition of obstetricians and gynecologists to the field.
This development, judged virtually a sure thing by many with a stake in health care,could prove particularly valuable to elite institutions such as Johns Hopkins, Harvard and Stanford that have no programs in family medicine.
Whether the change in definition makes sense depends on whom you ask.
Dr. Michael E. Johns, dean of the Johns Hopkins School of Medicine, argues that it does in this instance because the obstetrician-gynecologist is the only doctor many women have. "They've been using them for years," he said. "That's what many women want."
Proponents of family medicine argue that obstetrician-gynecologists cannot realistically be expected to cure a skin rash or manage a patient's diabetes or hypertension.
At Hopkins, 74 percent of the residents are training in specialties such as anesthesiology, surgery, psychiatry, orthopedics, otolaryngology (ear, nose and throat), pathology and radiology. At the University of Maryland Medical Center, 65 percent of residents are in specialty programs.
Judging from these figures, the two centers appear to doing better than the national average when it comes to training generalists. But the figures can be deceiving.
At Hopkins, for instance, most of the residencies that would qualify as "primary care" are in internal medicine, a field that more often than not serves as an entry to a medical sub-specialty such as cardiology or gastroenterology.
No matter how primary care is defined, the system of allocating slots to hospitals is bound to be controversial.
fTC Originally, the job was to have been done by regional councils with jurisdictions over multistate areas. The councils were to include consumers as well representatives of health plans, health alliances and hospitals, which would be competing against each other for coveted specialty slots.
That approach was abandoned in favor of a national system of awarding positions to hospitals, although the mechanics have yet to be worked out. However it is done, it is likely that some hospitals will carry heavier responsibilities than others to supply an expanded work force of generalists.
Dr. Johns said he cannot imagine that Hopkins would be expected to abandon its position as one of the world's most prestigious centers of specialty medicine.
"That's what we're famous for around the world," Dr. Johns said. "That is the way we have differentiated ourselves. Society, in fact, should demand that we play an important role in training specialists."
But he conceded that market forces could drive Hopkins to train more generalists.
Already, the marketplace is placing greater emphasis on managed care, a system of delivering health care that relies heavily on general-practice doctors.
This has meant higher salaries for generalists. Last year, many received starting salaries in the $90,000 range, up from $40,000 to $50,000 seven years ago, although primary care still commands lower pay than does any of the specialties.
Mr. Clinton's plan would accelerate those trends. And if young doctors demand to be trained in primary care, Dr. Johns said, institutions such as Hopkins likely would respond.
Some hospitals have anticipated health care reform. The University of Pennsylvania Medical Center in Philadelphia recently established a residency program in family medicine and started buying up primary-care practices from the New Jersey shore to Reading, Pa.
Sinai Hospital is requiring its internal medicine residents to train in outpatient centers and to rotate in such areas as geriatrics; ear, nose and throat; orthopedics; and gynecology.
Dr. Bart Chernow, the physician in chief at Sinai, said that will prepare internists to treat a wide variety of ailments. "They shouldn't be able to say, 'Sorry but I don't do elbows,' " he said.
For many years, hospitals have been having trouble filling their family medicine residencies. This year, almost 95 percent of the slots were filled, up from 91 percent last year and 88 percent in the late 1980s.
Dr. Kevin S. Ferentz, director of family medicine residencies at the University of Maryland, said the Clinton plan also makes primary care more attractive for hospitals.
End Medicare subsidies
The federal government finances residency programs through the rates paid for Medicare inpatients. This rewards medical centers that tend to hospitalize patients rather than treat them as outpatients.
The Clinton plan would do away with the Medicare subsidies. Instead, the government would finance training programs through direct grants. There would be rewards for programs that train doctors in primary-care settings such as health maintenance organizations, but it remains to be seen whether hospitals giving up specialty slots would be net winners or losers.
Dr. Ferentz said the hospital industry has never really appreciated the role primary-care doctors play filling hospital beds, either through direct admissions or through referrals to specialists.
"We don't make as much money for the hospital as those who do cardiovascular surgery," he said. "Sure, they use operating rooms, order tons of lab work and X-rays. But we admit the pneumonias, the infectious problems and some obstetrics.
"The hospital needs bread-and-butter admissions. That's what family doctors do."