An Unhealthy Medical System

American medicine today faces a tremendous crisis. In what has become yet another capitalist venture, the costs of technology, medication, education and malpractice insurance have begun to exert more than their fair share of control over Hippocrates' healing art.

The U.S. medical establishment is more than aware of its affinity for lucre. No doctor will admit entering the profession for money's sake, and in reality it is doubtful that the long ordeals of medical school, residency and internship draw more of the nation's wealth-seeking students than Wall Street. Yet unfortunately, the medical establishment continues to offer monetary incentives to alleviate its problems--among them, the primary care crunch.

Absolute numbers of primary--or "hands-on"--practitioners (general, family, internal and pediatric care) are on the increase. But most physicians and health care specialists recognize that the percentage of the physician pool those primary practitioners make up is decreasing at an alarming rate. Thirty years ago, 46 percent of U.S. physicians practiced primary care. Today, that number has fallen to 30 percent. In a poll conducted in 1991, fewer than 15 percent of third-year medical students (those who will graduate this year) expressed an interest in primary care.

The primary care crunch is felt most acutely in inner cities and in real-life "Northern Exposure" situations. Many doctors view entering primary care as a sacrifice in itself. They need a great deal of convincing before they start practices in medically under-represented areas.

Physicians and health care experts acknowledge this trend, and express concern that the U.S. will be left without adequate levels of basic care. Instead, Americans face a glut of specialists who tend to charge more per visit. Specialists claim greater expertise and more experience. But they bypass a critical--yet less expensive--step in the health care process. It's a waste for a patient to visit a neurologist for a head cold checkup. It's a waste for the physician, as well.

The medical community's response is the opposite of what it should be; health care experts treat medicine as a competitive economic market. Some financial inducements have existed since the 1970s. Common incentives include educational loan forgiveness, adjustments to the relative value of Medicare's payment schedule, and tuition assistance in exchange for service in under-served areas ("Northern Exposure's" Fleischmann takes part in such a program). Barely a stop-gap measure, this kind of solution hardly cuts to the heart of the problem.

Not only are financial inducements aimed at the wrong target; they're also unsuccessful. Studies and figures demonstrate that reimbursement offers have had little effect. Tuition or loan forgiveness can save students and their families in excess of $100,000. That's a tremendous amount, to be sure, but it's less than the average annual salary for U.S. doctors. And it's far less than the average salary for most specialists.

Like federal administrations of late, the medical establishment suffers from a lack of foresight. By essentially offering financial rewards for careers it considers crucial, the medical community cheapens its profession and creates no vital interest in primary care--or in any other form of care, for that matter.

Plagued with too many specialists and too few primary care physicians, America needs new intellectual incentive systems for medical school and premed students.

The medical community has sought structural solutions. In a recent report, the Accreditation Council for Graduate Medical Education, which governs residencies and internships, found that "the nation has "oe few generalists and too many specialists." As a result, the council slapped a one-year moratorium on recognizing new sub-specialties. A number of organizations support a quota for medical school graduating classes: 50 percent of graduates must be primary care practitioners.

The American Medical Association, while advocating an increase in the supply of primary care physicians, justly opposes such coercive goals. These moves, seemingly motivated by pure apprehension, are made without any thoughtful consideration. They, too, tend to demean a worthy profession.

While it may be a large generalization, most students who enter medical school have a genuine interest in utilizing their science knowledge to improve the nation's health. Yet many fail to realize how much they can accomplish through personal contact with patients. Dictating quotas smacks of paternalism, and creating an incentive-based market only diminishes the hope those students have for the healing and caring ideal put forth by past generations of physicians.

Instead of attacking the problem near the end of students' education, the medical community must continually encourage pre-medical students and beginning medical students to enter vital fields. Major medical schools' trend of accepting only those science majors who have already completed extensive laboratory research--or who have otherwise professed devotion solely to the purely nonclinical side of medicine--will only perpetuate the trend toward sub-specialties. Students shouldn't have to strive to break new ground in cancer or AIDS research even before they receive their M.D.s.

The lures of modern research technology, prestigious prizes and dramatic results are understandably stronger than the prospect of performing hundreds of school physicals every year. Long hours, less pay and lower status are discouraging factors for bright, promising premedical students.

Intellectual stimulation of such students will garner far more results than will financial incentives or regulatory controls. Introducing premeds to the complex and enlightening decisions our pediatricians and family practitioners make every day is just one way of generating enthusiasm for the vast rewards of practicing primary care.

No one says a family practitioner needs to sit in an office all day taking throat cultures and patching bruises. Extracurricular organizations both inside and outside of medicine, as well as the opportunity to continue research projects and publish papers, can all be part of a healthy medical career. Activities and projects can also alleviate the burnout which claims so many overworked doctors.

By presenting primary care as a vital and stimulating field, rather than just another way to make money in medicine, the medical establishment can create a new generation of doctors genuinely concerned with health issues and with improving public health. Only by doing so can we cure our ailing health care systems and the doctors who make it work.

Ivan Oransky '94, an executive editor of The Crimson, is also a pre-med student.