Medical Students Favor Specialties

The Clinton administration, which has made health-care reform one of its highest priorities, believes that the U.S. is facing a crisis in primary care. The government says that the country is in dire need of primary care doctors, citing other countries which have a 50-50 ratio between generalists and specialists.

Though possessing the resources to encourage more students to go into primary care, Harvard Medical School is not taking as active a role in pushing students towards primary care as the government would like.

Currently, 30 percent of American physicians practice primary care. Only about 15 percent of Harvard medical students are entering the field, according to Dean for Medical Education Dr. Daniel D. Federman.

"The government has made a conscious decision that there should be more primary care doctors," he says. "But this is not the trend among medical students."

Despite Clinton's call to arms, Harvard has not created a policy mandating the even ratio.

"We have not adopted a school policy that 50 percent of our students will go into primary care," says Federman. "We are strengthening our primary care offerings and giving them a glimpse of general practice, but we will not push our students toward that field."

Eleanor A. Drey, a second-year medical student and head of the pri- mary care group run through the MedicalSchool's student council, agrees with Harvard'spolicy.

"I could see some way of mandating increases,but to set actual numbers would penalize schoolswhere primary care has traditionally not been thefocus," she says.

Drey believes, however, that Harvard should domore. "I think more students would considerprimary care if they could," she says. "If theMedical School, like the Law School, was willingto subsidize students to pay off debt, thenstudents would not be driven by fear."

The fear Drey speaks of is real. Traditionally,primary care physicians--or generalpractitioners--have been paid significantly lessthen doctors who specialize.

The American Medical Association (AMA) does notsupport Clinton's 50 percent policy. Dr. Harry S.Jonas, assistant vice president for medicaleducation at the AMA, says "I don't think the pushfor an equal ratio makes any sense."

Jonas says the Clinton administration has usedmisinformation about the number of primary carephyscians in other countries in determining itspolicy of an even ratio between generalists andspecialists.

"We should talk about physician to populationratios," Jonas says. "We already have moregeneralists per population than England."

"The AMA believes that we should do everythingpossible to encourage people to choose primarycare careers, because the trend has been going somuch the other way," he says. "For the governmentto try to legislate numbers goes against our grainbecause we believer that students have the freedomof choice."

Jonas cites examples from recent historyto show how the government has miscalculated thenumber of physicians needed nationally.

"In 1965, the government decided that there wasa shortage of 500,000 physicians. Now the samepeople that were saying we had a shortage say thatwe have 100,000 too many," he says. "If we were tohave total managed care, some of the HMOs say thatwe wouldn't need any more primary care doctors."

So while medical schools and the governmentshould work together to change the distribution ofdoctors, "they should use positive incentivesinstead of regulations," says Jonas.

He adds that "planning for a work force is verydifficult because there are changes in thepopulation. If there are new advances in medicineor if tomorrow we had a brand new epidemic likeAIDS, the medical scene would change completely."

Larry Ronan '78, a graduate of the MedicalSchool and director of the combined residencyprogram in medicine-pediatrics at MassachusettsGeneral Hospital, would like to see the MedicalSchool work toward the national goal.

"It's part of the national reform to entailmany more generalists," he says, "I want studentsto get a superb experience in family practice atthe clinical and academic levels."

One possible way the Medical School couldimplement the Clinton directive would be to admitmore students who display an interest in primarycare.

But the admissions office does not do this andhas no plans to change its policy in the future.

"Our policy is not to pick students on what wethink they are going to do," says Dr. GeraldFoster, associate dean of admissions and associateclinical professor of medicine. "We pick the beststudents we can that will be leaders in theirrespective fields."

Unlike Harvard, Boston University MedicalSchool has instituted a 50 percent goal forgeneralists. Dr. John F. McCahan, dean foracademic affairs, notes that at most 25 percent ofmedical students at Boston University will enterprimary care fields.

"We have an aim to make a half-and-half balancebetween primary care doctors and specialties,"McCahan says. "We will train students in primarycare centers. We will work on the admissions endand bring in students that will opt to go intoprimary care.

Despite not instituting a formal goal ofan even ratio between primary care givers andspecialists, Harvard Medical School doesaccommodate those who want to be generalists.

Perhaps the foremost initiative is the NewPathway program, created in 1986, which placesstudents in non-clinical settings to learn moreabout the patient-doctor relationship.

Federman, Walter professor of medicine andmedical education, says, "[The New Pathway] doesnot resemble a family practice course in any way,but it still instills the values and respect thata patient deserves." The program includes acase-based tutorial that encourages students totake a holistic look at diagnoses.

Students endorse the New Pathway. Richard S.Hamilton, a second-year medical student, says thatthe program "gave him an understanding of thehuman aspect of medicine."

Hamilton expressed interest in primary care andsays the psychosocial issues addressed in the NewPathway are more relevant to a primary carphysician who serves as the care-giver throughouta patient's lifetime.

Jonas also supports the New Pathway. He notesthat "Harvard is based around many high teachresearch hospitals. The Medical School needs tofind the right balance between specialized andgeneralized training."

In addition to providing programs suchas the New Pathway, the Medical School employs alarge number of general practitioners asprofessors.

Ronan, also an instructor in pediatrics, saysthese professors are not as visible to students asthey should be. "Students need more exposure toprimary care people in academic and communitysettings," he says.

Craig S. Vinch, a fourth year student who hasbeen matched in an internal medicine residency atBeth Israel, concurs.

"We're exposed to many primary care doctors inthe Harvard system, but they don't come in tolecture during the first two years," he says. "Idon't think that the contact we have with themright now tells us much about the life of aprimary care doctor. Seeing primary carephysicians that are successful and not bankrupt isnecessary."

Third, all students must spend twomonths in an ambulatory car clerkship. The MedicalSchool has created a new department of ambulatorycare and prevention. They have hired Dr. ThomasInui, a top primary care physician, to head thedepartment.

Ronan says much of the future of primary careat Harvard rests on Inui's leadership.

"Everything is in place for more students toenter primary care," says Ronan. While he claimsthat Harvard has "the richest primary care systemand opportunities in the country," he adds that"we have not maximized community-basedexperiences."

He refutes Harvard's reputation as a specialtyand academic medicine school, saying "there is aconsensus at the medical school that we mustincrease generalist physician outcome.

Harvard may be behind in offering primary carincentives, but it is on the verge to be wayahead."

Currently, Boston University Medical School ispursuing its goal for an even balance among theirstudents between generalists and specialists.

The University employs sixty family physicianson its faculty and has received grants to changethe curriculum and support students to go intoprimary care. Boston University Medical Schoolalso maintains close relationships withneighborhood health centers to develop facultyeducation.

Tufts Medical School has recently voted tocreate a department of family medicine. No otherBoston schools currently have departments ingeneral medicine, according to McCahan.

In general, medical schools areaddressing the problem and encouraging studentstowards primary care. But according to students,faculty and administrators, support needs to comeat many different levels.

"We can't do it alone. A lot of factorsdiscourage students that are not in a medicalschools' control," McCahan says.

Ronan thinks that the mindset of society hascontributed greatly to the dearth of generalists."The culture itself has devalued clinical care,"he says.

Federman agrees with this idea. He says:"Reimbursement policies of the past sixty yearshave rewarded surgeons who perform a certainprocedure better than physicians who take the timeto counsel patients."

Ronan says the market forces that elevatedspecialties have turned into cultural beliefs thatlook down on primary care physicians.

Efforts at the national and medicalschool level may have contributed to an increasein student interest in primary care.

Jonas, Drey, and McCahan believe that greaternumbers of students are expressing interest andapplying for primary care internships andresidencies.

Nirav R. Shah '94 will attend SUNY-BuffaloMedical School in the fall and says he has astrong interest in primary care. "Clinton's healthplan has not necessarily given the financialincentives, but it made the field moreattractive," he said. "Now, colleges push for morestudents that are interested in primary care."

Paveljit Bindra '94 will enter Harvard MedicalSchool and believes that "doing primary care is apersonal choice." Although Harvard focuses onresearch, he does not think he will be swayed formhis goal of becoming a generalist.

Many students believe that entering any medicalfield, but especially primary care, must be anindividual choice. "It would be a waste if peoplewere dragged into primary care," says Drey.

Vinch says, "Even within primary care, peopleare drawn to different fields for differentreasons. It's hard to pinpoint why. It's basicallyup to the individual."

Drey and Vinch both voice opposition toguaranteed student loans that are tied toobligatory time as primary care givers in anunderprivileged area.

Vinch says the loans "discriminate on ethnicand on socioeconomic backgrounds," and do notguarantee that a doctor will continue to practiceprimary care.

"You might want to regulate exposure, but notchoice," Ronan says. "There are various levelswhere you can impact change and use bothincentives and regulations."

"I could see some way of mandating increases,but to set actual numbers would penalize schoolswhere primary care has traditionally not been thefocus," she says.

Drey believes, however, that Harvard should domore. "I think more students would considerprimary care if they could," she says. "If theMedical School, like the Law School, was willingto subsidize students to pay off debt, thenstudents would not be driven by fear."

The fear Drey speaks of is real. Traditionally,primary care physicians--or generalpractitioners--have been paid significantly lessthen doctors who specialize.

The American Medical Association (AMA) does notsupport Clinton's 50 percent policy. Dr. Harry S.Jonas, assistant vice president for medicaleducation at the AMA, says "I don't think the pushfor an equal ratio makes any sense."

Jonas says the Clinton administration has usedmisinformation about the number of primary carephyscians in other countries in determining itspolicy of an even ratio between generalists andspecialists.

"We should talk about physician to populationratios," Jonas says. "We already have moregeneralists per population than England."

"The AMA believes that we should do everythingpossible to encourage people to choose primarycare careers, because the trend has been going somuch the other way," he says. "For the governmentto try to legislate numbers goes against our grainbecause we believer that students have the freedomof choice."

Jonas cites examples from recent historyto show how the government has miscalculated thenumber of physicians needed nationally.

"In 1965, the government decided that there wasa shortage of 500,000 physicians. Now the samepeople that were saying we had a shortage say thatwe have 100,000 too many," he says. "If we were tohave total managed care, some of the HMOs say thatwe wouldn't need any more primary care doctors."

So while medical schools and the governmentshould work together to change the distribution ofdoctors, "they should use positive incentivesinstead of regulations," says Jonas.

He adds that "planning for a work force is verydifficult because there are changes in thepopulation. If there are new advances in medicineor if tomorrow we had a brand new epidemic likeAIDS, the medical scene would change completely."

Larry Ronan '78, a graduate of the MedicalSchool and director of the combined residencyprogram in medicine-pediatrics at MassachusettsGeneral Hospital, would like to see the MedicalSchool work toward the national goal.

"It's part of the national reform to entailmany more generalists," he says, "I want studentsto get a superb experience in family practice atthe clinical and academic levels."

One possible way the Medical School couldimplement the Clinton directive would be to admitmore students who display an interest in primarycare.

But the admissions office does not do this andhas no plans to change its policy in the future.

"Our policy is not to pick students on what wethink they are going to do," says Dr. GeraldFoster, associate dean of admissions and associateclinical professor of medicine. "We pick the beststudents we can that will be leaders in theirrespective fields."

Unlike Harvard, Boston University MedicalSchool has instituted a 50 percent goal forgeneralists. Dr. John F. McCahan, dean foracademic affairs, notes that at most 25 percent ofmedical students at Boston University will enterprimary care fields.

"We have an aim to make a half-and-half balancebetween primary care doctors and specialties,"McCahan says. "We will train students in primarycare centers. We will work on the admissions endand bring in students that will opt to go intoprimary care.

Despite not instituting a formal goal ofan even ratio between primary care givers andspecialists, Harvard Medical School doesaccommodate those who want to be generalists.

Perhaps the foremost initiative is the NewPathway program, created in 1986, which placesstudents in non-clinical settings to learn moreabout the patient-doctor relationship.

Federman, Walter professor of medicine andmedical education, says, "[The New Pathway] doesnot resemble a family practice course in any way,but it still instills the values and respect thata patient deserves." The program includes acase-based tutorial that encourages students totake a holistic look at diagnoses.

Students endorse the New Pathway. Richard S.Hamilton, a second-year medical student, says thatthe program "gave him an understanding of thehuman aspect of medicine."

Hamilton expressed interest in primary care andsays the psychosocial issues addressed in the NewPathway are more relevant to a primary carphysician who serves as the care-giver throughouta patient's lifetime.

Jonas also supports the New Pathway. He notesthat "Harvard is based around many high teachresearch hospitals. The Medical School needs tofind the right balance between specialized andgeneralized training."

In addition to providing programs suchas the New Pathway, the Medical School employs alarge number of general practitioners asprofessors.

Ronan, also an instructor in pediatrics, saysthese professors are not as visible to students asthey should be. "Students need more exposure toprimary care people in academic and communitysettings," he says.

Craig S. Vinch, a fourth year student who hasbeen matched in an internal medicine residency atBeth Israel, concurs.

"We're exposed to many primary care doctors inthe Harvard system, but they don't come in tolecture during the first two years," he says. "Idon't think that the contact we have with themright now tells us much about the life of aprimary care doctor. Seeing primary carephysicians that are successful and not bankrupt isnecessary."

Third, all students must spend twomonths in an ambulatory car clerkship. The MedicalSchool has created a new department of ambulatorycare and prevention. They have hired Dr. ThomasInui, a top primary care physician, to head thedepartment.

Ronan says much of the future of primary careat Harvard rests on Inui's leadership.

"Everything is in place for more students toenter primary care," says Ronan. While he claimsthat Harvard has "the richest primary care systemand opportunities in the country," he adds that"we have not maximized community-basedexperiences."

He refutes Harvard's reputation as a specialtyand academic medicine school, saying "there is aconsensus at the medical school that we mustincrease generalist physician outcome.

Harvard may be behind in offering primary carincentives, but it is on the verge to be wayahead."

Currently, Boston University Medical School ispursuing its goal for an even balance among theirstudents between generalists and specialists.

The University employs sixty family physicianson its faculty and has received grants to changethe curriculum and support students to go intoprimary care. Boston University Medical Schoolalso maintains close relationships withneighborhood health centers to develop facultyeducation.

Tufts Medical School has recently voted tocreate a department of family medicine. No otherBoston schools currently have departments ingeneral medicine, according to McCahan.

In general, medical schools areaddressing the problem and encouraging studentstowards primary care. But according to students,faculty and administrators, support needs to comeat many different levels.

"We can't do it alone. A lot of factorsdiscourage students that are not in a medicalschools' control," McCahan says.

Ronan thinks that the mindset of society hascontributed greatly to the dearth of generalists."The culture itself has devalued clinical care,"he says.

Federman agrees with this idea. He says:"Reimbursement policies of the past sixty yearshave rewarded surgeons who perform a certainprocedure better than physicians who take the timeto counsel patients."

Ronan says the market forces that elevatedspecialties have turned into cultural beliefs thatlook down on primary care physicians.

Efforts at the national and medicalschool level may have contributed to an increasein student interest in primary care.

Jonas, Drey, and McCahan believe that greaternumbers of students are expressing interest andapplying for primary care internships andresidencies.

Nirav R. Shah '94 will attend SUNY-BuffaloMedical School in the fall and says he has astrong interest in primary care. "Clinton's healthplan has not necessarily given the financialincentives, but it made the field moreattractive," he said. "Now, colleges push for morestudents that are interested in primary care."

Paveljit Bindra '94 will enter Harvard MedicalSchool and believes that "doing primary care is apersonal choice." Although Harvard focuses onresearch, he does not think he will be swayed formhis goal of becoming a generalist.

Many students believe that entering any medicalfield, but especially primary care, must be anindividual choice. "It would be a waste if peoplewere dragged into primary care," says Drey.

Vinch says, "Even within primary care, peopleare drawn to different fields for differentreasons. It's hard to pinpoint why. It's basicallyup to the individual."

Drey and Vinch both voice opposition toguaranteed student loans that are tied toobligatory time as primary care givers in anunderprivileged area.

Vinch says the loans "discriminate on ethnicand on socioeconomic backgrounds," and do notguarantee that a doctor will continue to practiceprimary care.

"You might want to regulate exposure, but notchoice," Ronan says. "There are various levelswhere you can impact change and use bothincentives and regulations."