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

May 07, 1993|By Michael Ollove | Michael Ollove,Staff Writer

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.

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