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Cardiologist arrest.

If a certain New Yorker had gone to medical school instead of into comedy, he'd undoubtedly be a family doctor.

"I don't get no respect," Rodney Dangerfield, M.D., might mutter. "Other day I'm going to work. Halfway through the crosswalk I see this classmate of mine, guy's a neurosurgeon. He's driving the big car. He's wearing the diamond Rolex. He's got the hundred-dollar haircut. I wave my lunch bag at him. I say, |Hey, how come you're driving a Bentley and I'm hoofing it?' He gives me one of those little Tom Brokaw grins and says, |Money talks and GPs walk.' I'm telling yuh, I don't get no respect."

For America's general practice and family physicians, the imaginary Dr. Dangerfield's riff is a cruel truth. Patients love them, but academically and professionally, medical general practitioners (GPs) have little stature and are rapidly becoming an endangered species. In contrast to other industrial nations, where doctordom divides evenly between general and specialized practitioners, 70 percent of the doctors in the United States are specialists. "Right now we have about 100,000 more specialists than we need and 100,000 too few primary care doctors," says George Lundberg, M.D., editor of the Journal of the American Medical Association.

Never has the United States so desperately needed family physicians; not only are they the first line of defense against disease and trauma but they are vital in combating the huge costs of specialized health care. They are as important for what they decide not to do--such as order expensive lab tests, imaging scans or surgery--as for what they do, which is perform simple and less costly in-office procedures and write prescriptions. One hour of a cardiologist's handiwork clearing deadly clots on the surgical table costs many times more than a preemptive visit to a physician who measures-- and tells you how to lower--your cholesterol level. A worst-case analysis suggests that our preponderance of specialists could cost the United States $240 billion of the $800 billion spent annually on health care.

Why the tremendous generalist-to-specialist imbalance? Market forces and consumer preference play a role, but you can't understand how the United States got so swamped with specialists unless you foray into the culture of American medical schools. While the schools push aspiring healers away from general practice, they churn out an ever-widening guild of narrow specialists at an alarming and inflationary rate. Ultimately, this has meant more people struggling with rising health care bills and a growing number of families who need a plane ticket to reach the nearest GP.

The family doctor is out

Medical schools have a powerful incentive to emphasize specialties over general practice: Esoteric specialty departments confer prestige which in turn helps schools lure government research grants.

That economic truth goes beyond administrative budget-balancing to directly affect what medical students learn. The internal medicine and surgery departments at med schools consistently bring in the most grants, and as a result, the heads of those departments have considerable power to put together curricula that reflect their own preferences. Generalist studies swing little, if any, weight in this balance of power, because they teach doctors to provide workaday care, not to make the flashy technical breakthroughs that lure research dollars.

Consequently, top academic medical centers provide few chances for students to observe the practice of primary care, and it's rarely a prominent feature of the curriculum. On-faculty GPs, moreover, tend to be scarce. By the third and fourth years of medical school, students are taught by professors of specialties and never get the chance to learn from or be inspired by a generalist. The natural result is that the faculty tends to view aspiring GPs with about the same respect as a fighter pilot views an infantryman.

"Family practice tends to be at the bottom of the medical school totem pole," notes American Association of Medical Students President Elizabeth Morrison, a family medicine graduate of Brown University. "The perception is that if you are really smart, you should be a specialist in research instead of a community physician."

Even if would-be GPs manage to ignore medical schools' not-so-subtle slant against general practice, they find still more obstacles to overcome. As medicine becomes more and more complex, general practice looks like an utterly daunting option. After four years of study, many would-be doctors can only see how much they don't know. To compensate, they scramble to narrow the spectrum of responsibility facing them.

And why shouldn't they? The lion's share of prestige goes to specialists. They also get more money and the pleasure of digging into esoteric subjects about which they can become certified experts. Without any role models on the horizon, with the prevailing ethic discouraging it, and with less money offered by it, the wonder is that anyone chooses primary care.

The rise of specialty medicine fits a historical pattern that is American to its core. Before World War II, most doctors were trained to address the full spectrum of medical need. Specialties like surgery and psychiatry were but fractions of what they are today. Referrals were rare, and many now-familiar disciplines did not exist at all. In 1931, 87 percent of physicians were generalists, and through the war years two thirds of doctors were general practitioners.

After the war, however, Americans developed a crush on specialists. One reason was that insurers like to pay for what is done, not what is prevented. As a result, payment charts began to favor diagnostic and therapeutic procedures performed by specialists. Specialty incomes soared, sometimes reaching twice the pay of a GP. Medical educators and students naturally followed the money, which also came to include huge sums paid by the federal government to support specialized medical training and research. Specialty departments soon cropped up in medical schools and before long a few were offering a new "specialty" dubbed family medicine.

In the late seventies, when alarms began to sound about health costs run riot, a chorus of complaint came from behind the walls of academia. The medical school community recognized that among the factors fueling this inflationary engine, the most visible was that horde of specialists and their big-ticket machines. But in the decade since, little has changed except a hardening and widening of the conviction that, absent profound change, Americans face a crisis of our own creation. Whether in medicine's more radical precincts or the staid halls of the American Medical Association, the consensus is that something has to give, and quickly. If it doesn't, notes William Boyles, editor of the insurance industry trade newsletter Health Market Survey, "between here and five years from now we will pay tens of billions extra because of the policies of American medical schools."

That money will be wasted despite one of the more promising developments on the health care horizon: the ascendance of managed care, which is politely promoting a shift in consciousness by changing payment systems and using more primary care doctors at the front lines of treatment. Medicare is doing its bit by phasing in a payment scale that attempts to pay more for generalists' diagnostic and perceptive skills and less for scalpel work. And all 73 Blue Cross/Blue Shield plans already have at least one managed care unit, where a case does not get past a generalist physician without justification. Yet while wide application of this idea could reorient the market and send more patients to generalists, few believe it will be enough. In the last decade, the nation's supply of doctors grew 3.5 times as fast as the general population, but current estimates put the number of communities without any general physicians at 6,000.

Boyles, a frequent critic of what he calls the "perverse incentives" of the medical marketplace, says he believes more meaningful change will happen only with aggressive outside pressure: "We have to tell medical school applicants, |There are x number of slots for specialists. Those are all we need. If you want to go to med school, you have to be a primary care physician.' That is not a free-market solution, but this is not a free market."

Dr. Special and Mr. Hide

Another way to speed change is by exercising the very visible hand of government. Since the United States pays the freight for many internships and much of resident education, the feds could keep their checkbooks in their pockets until training institutions agree to limit specialties to no more than half of medical school classes. If the government made it clear that no more heart surgeons would be paid for, no more would be trained. The Canadians tried this heavy-handed approach in 1971 and it worked. Today, their ratio of GPs to specialists is a sane 50:50. At a minimum, the government should reconsider how it doles out the $200 million in primary care grants it now dispenses and end these grants to any university that is not doing its part to promote general practice.

American doctors' self-interest eventually will have to yield, as Canadian doctors' did, to the public interest, argues Robert Woods Johnson Foundation president Steven A. Schroeder, M.D. His foundation promotes primary care as a means of cutting costs and improving quality. If medical schools can't work a change on their output in five years on their own, Schroeder favors changing the medical system to require physician's assistants and nurse practitioners to handle much of the day-to-day primary care, with generalists supervising and carrying their own caseloads. Specialists would have to retrain. At the same time, medical schools would be forced to change the conditions that have produced the specialist surplus. And don't think that pushing more students to general practice condemns them to the poor house. A med school graduate can expect to make $100,000 a year in general practice, hardly a vow of poverty for a 30-year-old, even one with loans to pay off.

Without a change in policy and philosophy, medical schools will continue to turn out hordes of expensive specialists of ever-narrowing skill. America's deranged medical insurance system will continue to pay more for those specialists to do something--anything--than for primary care doctors to exercise Hippocratic common sense. And the mythical Dr. Dangerfield will keep trundling along, coughing the exhaust fumes left by his neurologist classmate and tromping through the debris of an economy foundering on its emphasis of complexity over simplicity, lavish outlay over modest expense, and specialized medicine over primary care.
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Title Annotation:medical schools educate too many medical specialists and not enough general practice and family physicians
Author:Dolan, Michael
Publication:Washington Monthly
Date:Dec 1, 1992
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