Is Health Care Too Specialized?

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.

CHART: NOT AVAILABLE

CREDIT: [TMFONT 1 d #666666 d {Source: American Medical Association}]CAPTION: Total number of doctors in the U.S.

Primary-care* doctors