Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, August 10, 1993 TAG: 9309110281
SECTION: EDITORIAL PAGE: A6 EDITION: METRO
SOURCE:
DATELINE: LENGTH: Medium
Indeed, magnetic resonance imaging scanners and other sophisticated equipment, combined with the expertise of specialists, have made it possible to diagnose diseases earlier and to offer sophisticated treatment for illnesses and conditions that once were hopeless. They have made immense contributions to medicine and the human condition.
The problem is that our captivation with high-tech medicine has come at the expense of basic, primary care from family doctors. To the specialist has gone the spoils, among them: federal money for graduate medical training and most research grants. Not surprisingly, specialists enjoy the greatest power and prestige at most medical schools.
Add to that picture the fact that primary-care physicians earn 50 to 60 percent less than specialists - and that the average medical school graduate leaves school $56,000 in debt. Again, it is not surprising that only 14 percent of medical school graduates choose to take primary-care training, as opposed to 31 percent in 1976, and that only 30 percent of U.S. physicians are trained in and practice primary care.
But where has this left us? Inadequate primary care is one of the reasons why infant mortality in America is higher than in 26 other nations - 10 per 1,000 live births in 1991 compared to 4 in Japan, 7 in Great Britain and Canada. Life expectancy is slightly lower than in Canada and many Western European nations. Yet the United States spends more per capita on health care than any other country - 40 percent more than Canada, the second-biggest spender.
The bottom line is that health care in the United States is getting marginally worse results for a great deal more money. A clue as to why can be found in studies cited by the Alliance for Health Reform in urging national policy changes that would encourage more physicians to go into primary care:
The New England Medical Centers' Health Institute found in a 1992 study that specialists order more tests, perform more procedures and hospitalize patients more often than do primary-care physicians treating similar symptoms.
The Journal of Family Practice found in a 1990 study that the hospital bills of patients being treated by family doctors were significantly lower than for those being treated by specialists, yet the results were the same.
Several studies, in fact, have indicated there are significant savings to be realized in re-establishing the importance of the primary-care physician - a general practitioner, family practitioner, internist or pediatrician - responsible for caring for the patient as a whole, focusing on maintaining health and preventing disease rather than treating a particular body part.
As the nation tackles health-care reform, managed care is sure to play a larger role in trying to hold down costs. That will mean a greater demand for primary-care physicians who can examine, diagnose and, in most cases, treat patients, referring only those who truly need a higher level of care to more expensive specialists. Where will these Marcus Welbys come from?
Already, the Department of Health and Human Services has identified 2,000 rural and inner city areas as having a shortage of health professionals. Some 43 million Americans - including more than 630,000 Virginians - live in ``medically underserved areas.'' That designation is based, largely, on a lack of primary-care professionals.
Both Republicans and Democrats have introduced legislation in Congress to make primary health care a matter of greater national priority. Legislation introduced by Democratic Sen. Jay Rockefeller of West Virginia and Rep. Henry Waxman of California would redirect Medicare payments for graduate medical education toward more generalists and fewer specialists; allow Medicare funds used for education to go not only to hospitals but to community health centers and health-maintenance organizations where there is an emphasis on primary-care medicine; provide more support for training nurse practitioners and physician assistants, who can perform many basic health services at less cost than physicians; and fully fund the National Health Service Corps, which provides medical education to disadvantaged students in exchange for service in underserved areas.
Sen. Nancy Kassebaum, R-Kan., also has introduced legislation that would encourage primary-care practices and increase nurse-practitioner and physician-assistant training.
Reform of the nation's health-care system will require better health maintenance, which needn't come at the expense of advances made possible by specialization. In whatever health-reform package that emerges, primary care should be a primary priority.
by CNB