Doctors in the Wrong Places

BENJAMIN L. CARDIN

April 07, 1993|By BENJAMIN L. CARDIN

WASHINGTON — Washington. -- Any reform of our health-care system needs to involve an end to our over-dependence on specialty-care doctors in favor of less costly primary-care physicians for most of our health-care needs.

This switch from specialists to primary physicians will involve considerable change. Instead of Americans deciding for themselves when to see a specialist, we need a primary-care system in which doctors first evaluate and treat most medical problems, and decide when more specialized care is needed.

This change from specialists to primary-care doctors is essential if we are going to provide universal, affordable access to health care, but it's a change that runs contrary to current trends. Projections show that the number of sub-specialists in internal medicine will increase by 205 percent between 1978 and 1998, while the number of general internists will grow by only 77 percent. During the mid-1980s, the proportion of medical-school graduates expressing interest in primary care declined from 36 percent to 23 percent.

A general surplus of doctors compounds the oversupply of specialists and subspecialists. In the last 30 years, the number of doctors has doubled. The Graduate Medical Education Advisory Committee predicts that by 2000 there will be a surplus of 135,000 doctors.

We've got the doctors to meet our health-care needs, but not practicing the type of medicine we need. Studies show that primary-care doctors are critical to any health-care system because they are less expensive, use fewer costly, technology-oriented procedures and provide preventive care that often can deal with problems before they become serious. Access to primary-care medicine is especially important in rural and inner-city areas where medical care is often hard to find.

Yet the United States has a lower proportion of primary-care doctors than other Western industrialized countries. Only 35 percent of American doctors are primary-care physicians compared with 63 percent in Great Britain and about 50 percent in Canada and Germany.

One obvious reason our current system favors specialists is money: A recent study by the American Medical Association shows that the median income for family-practice doctors is $93,000; for surgeons, radiologists and anesthesiologists it is about $200,000. These big specialist incomes are especially attractive to medical residents who owe large medical-school loans, often amounting to more than $50,000.

Medical schools have not done nearly enough to train primary-care doctors. While health-care analysts believe about half the physicians entering practice should be primary-care doctors, only two of our 125 medical colleges have a majority of graduates going in that direction.

A national strategy that will change the trend and encourage more doctors to pursue careers in primary-care medicine would include four points:

* A National Physician Work force Commission should study the needs for various specialties and make appropriate recommendations. The Secretary of Health and Human Services should be given authority to allocate graduate physician-training positions based on the medical needs projected by the commission.

* We need to expand our National Health Service Corps, which helps fund the medical education of health-care providers. We need to allocate more money and direct much of it to training primary-care physicians.

* Primary-care doctors must earn more, relative to specialists. Medicare has already altered its payment rates, but we must do more to narrow the income gap between specialists and primary-care doctors.

* We must change the Medicare rules so that they encourage the growth of more primary-care programs instead of funding clinical training programs. Ironically, primary-care training programs, with lower practice income, are expensive to run, compared with specialty training programs.

No matter what changes occur in our health-care system, it's obvious that we must do more to encourage the instruction and training of primary-care doctors. Of course the need for highly trained specialists will continue, but we must have a responsible balance that meets our nation's needs.

Rep. Benjamin L. Cardin represents the Maryland's 3rd Congressional District in the U.S. House of Representatives. He is a member of the Health Subcommittee of the Ways & Means Committee.

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