Solving the Primary Care Crisis

Primary care. These days, it's the hot topic in medicine. Everyone wants more primary care practitioners, and everyone has a proposal to solve the problem of over-specialization plaguing the health care system.

Congress offers financial inducements--including loan forgiveness and tuition assistance--to medical school graduates who practice primary care in underserved locations, whether as internists, general practitioners, family physicians, pediatricians or obstetrician/gynecologists.

Other organizations are taking a different tack. The American Medical Association's (AMA) Accreditation Council for Graduate Medical Education, responsible for governing residencies, recently lifted a one-year moratorium on accrediting new sub-specialties. They temporary suspension was designed to remedy the nation's problem of "too few generalists and too many specialists."

By some measures, the efforts are working. According to the Accreditation Council's Dr. James R. Weinlader, the council has been restricted by the Federal Trade Commission from taking a more active role in determining the numbers of specialists. But it is receiving more applications by hospitals for accreditation in primary care residency programs.

Having more residencies for generalists is a good step. The trouble is, neither the AMA nor the government program ensures that there will be enough residents to staff them. By focusing on medical school graduates, both of these efforts take the wrong approach to attacking the primary care crisis. Neither solution really addresses the problem of fostering an interest in primary care among students still in medical school.

For one, treating medicine as though it were the standard free market is misguided. That's essentially asking doctors and patients to put a fixed price on human life and well-being. And suggestions by the Clinton Administration that medical schools be required to place 55 percent of their graduates in primary care fields are, at best, paternalistic, shoving physicians into fields in which they have no interest.

What is needed is a less goal-oriented incentive system that takes into account the actual interests of doctors-to-be, rather than one that treats them like cards to be shuffled around in a deck. The ideal system would introduce primary care as an attractive career choice early in the educational process, and not force it down unwilling throats like bitter castor oil.

Indeed, such a solution already exists, if health care officials and legislators would only take a good look at it.

Enter the State University of New York (SUNY) Health Science Center at Syracuse. Fifteen years ago, this medical school in upstate New York developed a satellite clinical campus, in nearby Binghamton, emphasizing primary care, preventive medicine and health maintenance.

The Binghamton campus has allowed Syracuse in increase the size of each graduating class by approximately one-third, from 110 to 150. It also provides the opportunity for these 40 medical students to spend their last two years of schooling, typically spent on university hospital wards, in a community-based clinical environment.

Unlike programs which allow only an arbitrary number of specialists and exclude others from specialty practice, the Binghamton program still allows graduates the possibility of specializing after medical school. In fact, many participants do end up specializing, according to Dr. Steve Allen Jr., assistant dean for student affairs at the Binghamton campus.

The satellite campus also exposes medical students to primary care in its own environment, rather than the high-tech, dazzling world of academic medicine, which tends to focus on expensive specialists. It's only natural, as one Harvard Medical School faculty member recently told me, that faculty in an academic setting are more likely to extol its virtues over those of community-based primary care.

In short, the Syracuse program is very nearly a perfect solution to the primary care crisis. It doesn't mandate or preach primary care to the unwilling, but instead actively encourages it by providing an opportunity to be exposed to its practice.

Recognizing that the solution to a shortage of primary care physicians won't necessarily come from slashing the number of specialists, the program provides more slots designed specifically for those interested in primary care, without cutting the pool of those who might enter specialty fields.

There are those who would contend that allowing more students into medical school decreases the quality of the physician pool. But that's ridiculous. It's the equivalent of saying that today's medical students--selected from a highly competitive field of candidates, two-thirds of whom weren't accepted anywhere--will make better physicians than those who applied in a less competitive era, such as that of two decades ago.

In recent years, interest in generalist care among the national medical school graduate population has dwindled from near 50 percent to somewhere around 25 percent. Allen says that Binghamton campus graduates have mirrored the numbers at the main campus, and have been consistent with national averages. In 1989 and 1990, however, Binghamton had more graduates entering primary care fields.

Perhaps most reassuring is the fact the SUNY Syracuse medical students have a healthy interest in learning more about primary care. The Binghamton campus assignment was formerly made by random selection. But since it became a voluntary choice, Allen says, students make it often.

Moreover, the statistics alone may be deceiving. After all, some may ask, if Binghamton's figures approximate falling national averages, why brother with the special clinical program at all? Quite simply, because whatever number of primary care physicians Binghamton produces is more than would have been produced without the campus. And the country needs absolute numbers of such practitioners to serve its public, not percentages.

The other difference is that those Binghamton graduates who do end up in specialty practice have been exposed to the basic importance of primary care. As Allen points out, 85 percent of all physicians practice in a community, rather than an academic setting, which means that the training Binghamton campus graduates receive in their last two years of medical school makes them more prepared for real-life practice.

When medical schools give more attention and exposure to primary care, it fosters a healthy interest and generates more primary care physicians. Research-based institutions like Harvard Medical School would do well to take a close look at the SUNY program.

A suburban satellite campus in this area might accomplish the same goals. Many of the raw materials for such a campus, modeled on the SUNY program, are already in place. For example, many area physicians already hold faculty appointments at the Medical School. Harvard Community Health Plan, an extensive health care network in the region, is already a training site for third and fourth-year medical students.

When Harvard Medical School introduces innovations, other institutions take heed. If Harvard takes up the SUNY model, what started in Binghamton could blossom into a successful new design for medical education in the United States--and solve the primary crisis.