Health care is one of the most hotly contested issues in the Presidential campaign, yet on one point there's wide agreement: The cheapest way to keep Americans healthy is with good primary care. Family doctors, general practitioners, internists, pediatricians--all promote clean living, try to nip disease in the bud, and increasingly, are the frontline soldiers in the battle to hold down soaring health-care costs. "Everyone needs a generalist for basic health care," says Dr. Robert G. Harmon, director of the federal government's Health Resources & Services Administration.
The problem is, there aren't enough GPs to go around. In the early 1960s, the mix of generalists to specialists was about 50-50. But then high-tech medicine took off, fewer med students chose primary care, and the ratio changed. By 1990, it was 30-70 among America's 500,000 doctors (chart). The upshot is that 1 of every 8 Americans has no access to a family doctor. In rural regions, where 25% of the population lives, nearly one-third of residents are without adequate primary care. A 1987 study by researchers at the University of Wisconsin in Madison found a 45% drop over 25 years in the number of GPs in 10 major inner cities. And the problem isn't confined to the poor and uninsured. Even in well-off communities, insurers that run so-called managed-care networks say a shortage of generalists is a big problem.
LOW PRESTIGE. The underlying reason for the shortfall is the shift in medical schools and teaching hospitals toward research and specialty medicine. The trend has been hastened by an explosion in technology--advanced imaging gear, new surgical procedures, and machinery that keeps 2-pound babies alive.
Doing good with this equipment is exciting, and it's where the money is. For students facing an average $55,000 debt after medical school, the $193,000 income of an orthopedist is a lot more attractive than the $87,000 for an average family practitioner. Prestige is also an issue. The American Board of Medical Specialties anointed family practice in 1969, but many medical schools still don't have departments of family medicine. Future family doctors often attract derision, and 75% of first-year primary-care students change their minds before graduation. Now, medical schools are revising their curriculums, offering free tuition, and radically changing residency programs to channel doctors into primary care.
Take the University of Minnesota's Rural Physician Associate Program (RPAP). The longest-running such effort in the nation, it was launched in 1970 after the state threatened to withdraw the school's funding unless it improved access to care in Minnesota's vast rural regions. The school sends about 30 of its 200 or so third-year students to outlying communities for nine-month clerkships, in hopes that they'll be more likely to set up practices there. This strategy worked with Arden Virnig and his wife, Patti Hook, who have hung out their shingles in Onamia, 100 miles north of Minneapolis. The outback experience also makes for better education. At teaching hospitals, students tend to see the 1% of patients who have the most serious--but least typical--ailments. So most new M.D.s haven't had "real training in primary-care problems," says Dr. Walter M. Swentko, interim director of RPAP.
After two decades, RPAP is a success. At 1 to 1,213, Minnesota's rural ratio of primary-care doctors to population is the best in the nation. And the program is now a model for other schools.
STACKED ODDS. The State University of New York at Buffalo is one convert. Five teaching hospitals in the area are pooling $5.1 million in insurance reimbursements to promote primary-care education at the medical school. The money is paying for training sites in urban and rural primary-care clinics, for more faculty in general medicine, and for research in that field. The goal, says Dr. F. Bruder Stapleton, chairman of pediatrics at the school and a director of the program, is to increase the number of doctors graduating in primary care from 35% to at least 50% by 1994.
Programs such as SUNY Buffalo's help. But the odds are still stacked against primary care. In 1990, appropriations under the Health Professions Educational Assistance Act--which gives hospitals money to help support family-practice residents--were cut to the lowest level in the program's 18-year history. And medicare, which can provide a substantial portion of a resident's salary, doesn't pay for many services that are provided outside of hospitals. That discourages teaching hospitals from offering graduate education in outpatient clinics, where residents would interact with a more typical patient population.
While medical schools and teaching hospitals grapple with these problems, there is some sentiment for legislating a more equal distribution of physicians, says Paul B. Ginsburg, director of the Physician Payment Review Commision, a group set up by Congress to study issues such as medicare payments and the supply of doctors. There is talk in Congress of limiting "the number of slots in residency specialties" at federally funded teaching hospitals, Ginsburg adds. In countries such as Britain and Canada, where the mix of generalists to specialists is 50-50 or better, such rules have helped funnel doctors into primary care.
The government is also trying to make primary care pay better. Under a plan devised by Ginsburg's group, medicare payments to GPs will rise by 30% over five years above the increase applied to all doctors' fees. The effect will be diluted somewhat by cost-cutting measures that are being imposed at the same time. "The administration kind of did a number on us," says Dr. Robert Graham, executive vice-president of the American Academy of Family Physicians. Still, he adds, the new fee structure is a step forward.
So is the surge of women into medi-cal school. Over the past two decades, the share of women among med students has risen from 9% to 38%. And women tend to go into specialties clustered around primary care. For instance, 65% of pediatric residents are women, vs. only 4% of surgical residents. As this trend spreads, primary care seems sure to get even more attention from politicians. That's because it saves money. For the rural and urban poor, lack of access to a family doctor--and the resulting failure to get checkupsand shots--means that care is often ob-tained in an emergency room when the patient is seriously ill, a much costlier alternative.
Beyond that, insurers are making GPs the gatekeepers in managed-care networks, giving them an unprecedented role in controlling health-care costs. Graham says family doctors are less technology-oriented than specialists. And over the years, GPs compile lengthy histories of patients, so each new ailment doesn't lead to a battery of tests. Specialists, by contrast, may be eager to try out high-tech treatments they have learned during seven years of training. "When your only tool is a hammer, you tend to relate to all problems as nails," says Graham. "You're going to use technology any chance you get."
MINOR MEDICAL. Recent studies prove his point. In March, researchers at New England Medical Center in Boston found that family doctors hospitalize patients less often and give them fewer drugs and tests than do specialists such as cardiologists. Such facts are spurring the drive to turn out more primary-care doctors.
This doesn't mean rejecting the life-saving gains made in medicine over the past few decades. Instead, it reflects an awareness that the majority of ills don't require a CT scan or heart surgery. As was the case 50 years ago, most people can be kept healthy by a doctor who cultures sore throats, gives vaccinations, and urges patients to stop smoking or eat less fat. The twist is that today this folk hero can also hold down the nation's health-care bill.