Medical specialists shifting to primary care work.

Trend spurred by predominance of managed care

The growing influence of managed health care in Southern California is leading some doctors in the region to abandon their specialty practices in favor of primary care work.

Driving the changeover is a shift in the mix of doctors required for managed care vs. more traditional fee-for service care, according to Glenn Littenberg, former president of the medical staff at Huntington Memorial Hospital in Pasadena.

In traditional fee-for-service environments, approximately 60 percent of doctors are specialists, while only 30 percent are primary care physicians, said Littenberg. Primary care physicians include family practitioners, pediatricians and general internists.

By comparison, today's managed care environments require closer to a 50-50 ratio of specialists to primary care doctors, Littenberg said.

"In some specialties, it's currently hard to find work when you come out of training, especially in California. We're grossly overtrained in most specialties," Littenberg said. He cited anesthesiology and invasive cardiology as two specialty areas where some doctors are having particular trouble finding work in the current Southland market.

To improve their position, a "modest number" of specialists are either supplementing their specialty patient practices with primary care work or switching over entirely to primary care, said Littenberg.

Doctors can make the switch from specialist to generalist with relative ease, because there is no formal licensing process for physicians who wish to call themselves primary care doctors, explained Tom Mayer, senior vice president of medical affairs for Friendly Hills HealthCare Network, a physicians' network in La Habra.

"Almost every (specialist) makes the assumption that he's a primary care doctor who went on to get a specialized training. People tend to downplay the significance" of skills required to be a primary care doctor, Mayer said.

Sub-specialist suitability

While a growing number of specialists may be underemployed in the Southland's current health care market, only a portion of those specialists can effectively make the transition to primary care, according to Littenberg.

Specifically, a group of specialists known in the medical field as sub-specialists can make the switchover with relative ease, he said. Sub-specialists include such doctors as cardiologists and gastroenterologists.

Prior to studying their specialties, all sub-specialists must go through three years of general internist training, explained Littenberg. Conversely, most other types of specialists have little or no general practice experience in their medical training.

"For people without a general medical background, you're talking one to three years of additional medical training (to become a primary care physician). You would have to virtually stop your life to become retrained," said Littenberg. He added that many underemployed specialists who cannot easily make the switch to primary care end up either taking administrative jobs or leaving California for other states that have not yet become so entrenched in managed care.

Even if they could conveniently retrain themselves, many specialists balk at that prospect because of the large pay discrepancies between most types of specialists and generalists, said Mayer.

Income drops

"Some sub-specialty internists may be retraining as generalists, but I don't know of any (other types of specialists) who are training to become general practitioners. The income drop is as much as 50 percent. They'd rather move to Alabama" than make the sacrifice, he said.

The process of specialists converting to primary care is a relatively recent phenomenon. As such, there are still no set procedures for doctors to retrain themselves.

Some hospitals have recently began offering seminars to teach doctors about the changing health care climate in Southern California, according to sources. However, such seminars are brief and only focus on helping doctors make the transition from fee-for-service to managed care practices.

One of the only established retraining courses in the Southland to date is run out of San Diego by the Sharp Health Care System, according to sources.

Friendly Hills also plans to begin offering its own series of retraining programs beginning this year, according to Nancy Brown, the Friendly Hills senior vice president of education.

Unlike the Sharp retraining programs, which last for months, the Friendly Hills programs are being designed to function more like brief refresher courses for physicians, said Brown. Each course will last one week, with the first day devoted to general discussion of managed care and the remaining time devoted to specific retraining issues, she said.

"We're doing our first program in January, though we've only had sporadic interest so far," said Brown.

Littenberg said he doubts that retraining programs for sub-specialists would become the wave of the future in Southern California. Instead, he said, most doctors seeking to enter primary care practice would retrain themselves through less-formal means.

"I think these programs will be a minimal-and-passing fad. The real major changes will have to come at the medical school training level," he said.