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                                                                                MEDICINE, Page 56

Is Health Care Too Specialized?


A new report charges that a shortage of primary-care doctors
is hurting U.S. medicine

By CHRISTINE GORMAN


    Knowing when to see a physician is one of the most basic
ingredients in maintaining good health. But in this age of
super-splintered medicine, figuring out which doctor to see has
become something of a nightmare. Is there a fire in your
midsection? It could be indigestion, gallstones, an exotic
infection, stress, maybe even cancer. Should you consult a
gastroenterologist, a tropical-disease expert, a psychiatrist
or an oncologist? Once a patient climbs onto the specialist
merry-go-round, it can be hard to get off. The medical bills
mount, and the frustration soars.

    A much better solution, most doctors agree, would be to
start with a visit to a primary-care physician who knows your
personal history, your family background and maybe even a bit
about the emotional pressures in your life. Unfortunately, in
the U.S. such well-versed generalists, who train in the fields
of internal medicine, pediatrics and family practice, may be on
their way to extinction. In 1963 half of all American doctors
were primary-care physicians. Today that number is down to a
third. And surveys of medical school graduates reveal that less
than 20% plan to enter primary care. By contrast, half of all
doctors in Canada and more than two-thirds of those in Britain
are primary-care providers.

    Much of the trend can be traced to America's infatuation
with high technology. "After World War II, we went into an era
of research and specialization in this country unlike any
other," says Dr. William E. Jacott, who teaches family medicine
at the University of Minnesota. The rewards of specialized care
with the latest diagnostic gadgets and surgical twists were so
obvious to both patients and physicians that no one could
quarrel with the movement. Primary care was de-emphasized at
many medical schools.

    Not long afterward, the number of specialties started to
explode. According to a report in last week's issue of the
Journal of the American Medical Association, more than half of
the 70 subgroups certified by the American Board of Medical
Specialties -- including such arcane areas as dermatological
immunology and pediatric pulmonology -- were created in the past
decade. Almost two-thirds of the 56 kinds of accredited
residency programs have come into existence in the past five
years.

    The proliferation has so alarmed the Accreditation Council
for Graduate Medical Education that it has declared a
moratorium on certifying new programs until next June.
"Specialization is very appropriate; we need it because of the
fast pace of medical research," says Dr. Carlos Martini, vice
president of education for the A.M.A. and author of the J.A.M.A.
report. "But when everybody becomes specialized, then it's a
problem. Someday, if we're not careful, we'll have people who
want to specialize in the left elbow and not the right one."

    Not everyone accepts Martini's assessment -- or at least
the accreditation council's action. "We can't correct all of
the problems in the distribution of health care by putting a
quota on medical education," says Dr. J. Lee Dockery, executive
vice president of the American Board of Medical Specialties. A
better way to boost the number of primary-care physicians, he
argues, is to provide them with more incentives.

    As matters stand, primary-care doctors, who tend to
emphasize low-cost preventive treatment, make one-third to
one-half the money earned by specialists, who can charge top
dollar for their high-tech procedures. For a newly minted doctor
who leaves medical school with an average debt of $50,000, it
is hard to resist the appeal of a lucrative specialty. Another
disincentive to primary care is the long and unpredictable hours
-- especially in rural areas where a doctor may be the only
physician for miles around.

    Some states are attempting to ease the burdens on general
practitioners. Pennsylvania, California and a few other states
are considering assuming the medical-school loans of physicians
who agree to enter the primary-care field. And Kansas, which
faces a shortage of rural doctors, is pondering a program that
would send family-practice professors from the state
university's medical school to fill in for solo practitioners
from time to time when they need a break.

    Some medical schools are also attempting to entice more
students into primary care, mainly by exposing them to the
satisfactions of the field. Third-year students at Jefferson
Medical College in Philadelphia, for example, rotate through
family-medicine clerkships that get them out of intensive care
and into private practices and clinics. And the University of
Minnesota identifies students with an interest in primary care
and places them under the tutelage of respected role models.
Both schools report a higher than average percentage of
graduates who decide to become generalists.

    But several state governments have become impatient with
the pace of change and are pondering more dramatic measures. In
recent months, legislators in California, Colorado and Kansas
introduced bills that would have mandated specific medical
school quotas. Schools that failed to graduate at least 50% of
students in primary care would have faced million-dollar
cutbacks in state funding. Although none of these measures
passed, they serve as a warning. Americans are frustrated by the
fragmentation of their health care and want someone -- either
doctors or lawmakers -- to restore the balance.