Two Hopkins-based health care authorities have proposed bold measures to to increase the number of primary care doctors in America, including a requirement that all medical school graduates spend two years working in poor communities.
The proposals, in today's Journal of the American Medical Association, come as Hillary Rodham Clinton and her committee of health care reformers grapple with ways to end the nation's reliance on specialists -- an imbalance they say has fueled costs and left many poor communities without basic medical care.
Dr. Michael E. Johns, dean of the Johns Hopkins School of Medicine, proposed in a JAMA editorial that the federal government require all medical school graduates to work as primary care doctors in the National Health Service Corps, an existing program that would be greatly expanded to include as many as 36,000 physicians.
The young doctors would work in rural communities, Indian reservations and inner-city neighborhoods that have long been spurned by doctors, who tend to gravitate toward more affluent areas.
In return, they would be paid salaries and partial reimbursements for their medical school tuition.
Meanwhile, Dr. Barbara Starfield of the Johns Hopkins School of Hygiene and Public Health has proposed a program that would attack the problem at virtually every tier of the medical system. The measures, she said, would provide greater financial rewards, intellectual challenges and prestige to doctors who choose general medicine.
Under her plan, state licensing authorities would control the number of specialists and generalists allowed to start practices. Also, insurers would cut reimbursements to specialists if they treat patients who are not referred by generalists and would increase reimbursements to primary care doctors.
Additionally, the federal government would improve research grants for generalists.
Nationally, 15 percent of medical school graduates say they are going into primary care. The nation would be better served if half of all doctors were generalists, said Dr. Starfield, who heads the Department of Health Policy.
Dr. Johns announced recently that Hopkins would begin requiring second-year medical students to spend one "rotation" in primary care. In rotations, students treat patients under the supervision of more highly trained residents and staff physicians.
Dr. Abdul Nayeem, president of the Maryland Academy of Family Physicians, said the chief responsibility for training generalists belongs to medical schools because most students have already chosen their specialty by the time they graduate.
Yesterday, Dr. Johns said curriculum changes in progress at Hopkins and many other schools will not be enough to end the imbalance toward the specialties.
Under his proposal, medical school graduates would be split into two groups. Those intending to specialize would complete a one-year internship, and then work in the health service corps before beginning a residency in their specialty.
In contrast, students declaring careers in primary care would complete three years of post-graduate training -- their internship and two-year residency -- before entering the corps. They would enter the corps with a higher rank and collect a higher salary than the would-be specialists, who would enter with less training.
Also, the government would reimburse the generalists for three years of medical school tuition, and the specialists for merely two.