Doctors

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.

The cost of health care is actually falling. The expense of employee health benefits declined last year -- by 1.1 percent nationally and 1.5 percent in Maryland.So isn't this the perfect time for our legislators in Annapolis to monkey around with the very programs that have produced these savings?That's what the General Assembly is doing. It's on the verge of restricting the cost-effective quality-control methods of the health-maintenance organizations and managed-care plans that are revolutionizing the American health industry.

NEW ORLEANS -- Top officials of the American Medical Association are appealing to doctors to show restraint in criticizing President Clinton's plan to overhaul the nation's health care system, even as members of the group vowed to seek major changes in the proposal.At a meeting yesterday that displayed the group's divisions over tactics and strategy in the coming battle over the nation's health care system, Dr. Joseph T. Painter, president of the association, said doctors should look for answers, not adversaries.

As the U.S. grapples with a shortage of primary care physicians, many in health care fear that access will sharply decline as health reform adds millions more Americans to the ranks of the insured. A new study highlights a trend that could make things worse: Many medical schools produce more researchers and specialists than front-line doctors, especially those willing to work in underserved areas and among minorities. Public medical schools such as the University of Maryland ranked higher than private medical schools such as John Hopkins University in meeting a "social mission."

If you were a poor woman in Louisiana and had a baby by normal delivery, your doctor would have been reimbursed $330 by Medicaid in 1989. Private insurers in that state paid an average of $860 to doctors for the same delivery.If you were a heart patient in New York, your doctor would have received just $15 from Medicaid for an electrocardiogram. He would have been reimbursed nearly triple that by Medicare for the same procedure.If you were a doctor, which of those patients would you least prefer to see -- the one covered by private insurance, the one with Medicare or the one whose bills are reimbursed by Medicaid?

NEW YORK -- Now that Deep Blue has bested mankind's chess champion, it may be time to revisit another far-fetched vision of the computer age: digital diagnosis. After all, if one machine's logic can muscle through 200 million chess moves a second to win a uniquely human game, why shouldn't another harness the power to synthesize signs and symptoms of disease?Computer-based diagnostic systems have been in development for more than 20 years. Not unlike mechanics' car-engine diagnostic systems, these programs typically incorporate artificial intelligence, or ''expert judgment,'' and one or more algorithms to come up with an assessment of clinical signs and symptoms leading to a list of diagnoses.

Next time you have outpatient surgery, you might wake up at some point and chat with the doctors. You might, as Brian Ritter of Jarrettsville did the other day, start talking about your kids. Or tell the surgeon, "I'm really pretty comfortable."All while the doctor is drilling the polyps out of your nose.Under pressure to discharge patients the same day, doctors have found ways to shield patients from the pain and anxiety of surgery without subjecting them to anesthetics that leave patients dazed and groggy for hours.

Doctors are beginning to organize their own independent groups to bargain with managed care companies in Maryland, in the belief that physicians themselves are the ones who know best how to give and direct others to give top-quality care at the lowest price.Alliances of doctors seem to come in two general forms: specialists who band together and offer a single price to insurance companies in exchange for exclusive rights to their patients, or primary care doctors who come together with the eventual goal of directing all patient care, including specialist referrals and hospitalization.

A growing number of Maryland doctors have announced intentions to open their own office-based centers for endoscopy and other medical procedures used in their specialty.The reason is that insurance companies are directing care away from more expensive hospitals, and doctors who don't have an alternative service center lined up could find themselves dropped by many health insurers.In the past two months, about 35 doctors or groups of doctors have applied for exemptions from state regulations in order to conduct procedures in their offices that can be performed without anesthesia or a sterilized environment.

Doctors are said to make lousy patients. Now comes a study indicating that many docs avoid being patients altogether. Researchers at Johns Hopkins School of Medicine decided to examine how well doctors took care of their health after previous studies suggested that doctors' bad habits -- among them smoking and drinking -- influence what they tell patients. Using annual health surveys completed by graduates, they found that a surprising number of physicians -- about one in three -- had no regular source of care, even though they had ready access and were better educated and could more easily afford it than the average American.