COLUMN ONE : A Big Dose of Family Medicine : Half of Canada’s medical students become general practitioners while the U.S. produces ever more specialists. So experts look north for ways to promote lower-cost primary care.

Julie Gallagher decided on a life in medicine with a sense of mission. “I know it sounds like hogwash,” says the newly graduated Canadian MD. “But you enter medical school because you want to serve the people.”

All along, Gallagher has thought that the best way to “serve” would be to practice family medicine. Now she’s about to begin a residency in the field. Worries about money never stood in her way. After four years of medical school at the University of Toronto, she has a debt of $15,600.

Five hundred miles and a value warp or two west-southwest of Toronto, at the University of Wisconsin in Madison, Eric Gundersen shares Gallagher’s zeal, as he puts it, to “make a difference.” He has already worked on African famine relief and traveled extensively in Latin America, studying medical-supply delivery systems.

Like Gallagher, Gundersen believes he can do humankind a good turn through family medicine. He thinks he may do his residency among the needy of the South Bronx. But unlike Gallagher, Gundersen sees a number of obstacles. One of the biggest is financial: He expects to leave medical school with a $50,000 debt. He knows it will be hard to pay that off as a family doctor in an American ghetto.

“The loans aren’t the only thing that people base their (career) decisions on, but it’s one of those swing factors,” he says. “And it’s a bigger swing factor than people are willing to give it credit for.”

Gundersen’s dilemma captures a growing worry in American medical-education circles: the disappearance of the family doctor. For a number of reasons, primary medicine is out of favor among young American doctors-to-be; the high-priced, prestige-commanding specialties are in.

And of increasing interest to health-policy types: The trend simply doesn’t exist in Canada, a country that closely tracks most American trends.

In America, the number of medical school graduates entering the broadest-based areas of medicine--family medicine, internal medicine and pediatrics--has declined by 19% since 1986. As of 1989, only 11.7% of all those who finished American medical school were planning careers in family practice, and even smaller percentages wanted to become general internists or pediatricians.

Meanwhile, the popularity of such big-dollar specialties as anesthesia, radiology and specialized surgery has soared.

“The United States is moving toward a health-care system composed predominantly of sub-specialists,” warns Jack Colwill, chairman of the department of family and community medicine at the University of Missouri medical school.

For American patients, Colwill predicts, that will mean higher prices and more questionable “discretionary” procedures, as the growing ranks of specialists chase proportionately fewer shadows on their gaudy imaging screens.

It is also apt to mean fewer primary-care doctors to look after the surging ranks of the elderly, as well as AIDS patients and those with chronic conditions like diabetes or arthritis. Many health-policy analysts assume that too few generalists and too many specialists mean a less healthy population overall, though there is no data yet to prove it.

North of the border, meanwhile, Canada placidly churns out generalists and specialists year after year at a neat, more or less 50-50 ratio--just about what analysts here think the society needs. Medical students aren’t clamoring to get into the specialties. On the contrary, even at this country’s foremost high-tech medical schools--such as the University of Toronto--the competition is stiff for family medicine berths.

At a time when studies have shown that basic, wellness-oriented health care and a good bedside manner can sometimes have more impact than the most elaborate hardware-driven procedures, it may make sense to see why Canadian medical students flock to primary medicine. And increasingly, medical-education specialists are doing just that. Walter Rosser, head of the department of family medicine at the University of Toronto, says he has played host to half a dozen foreign fact-finding delegations in recent months.

The American delegates are coming to see whether Canadian medical-training policies might make sense for the United States, Rosser says. Like most Canadians, he is a stout believer in his country’s health-care policies, suggesting: “One could argue that the very survival of family medicine as a discipline in the United States depends on the introduction of a (Canadian-style) national health-care plan.”

Canada has a universal health-insurance system, one that is often advanced--and often dismissed--as a model for health-care reform in the United States. Curiosity about the Canadian system has grown particularly intense in this American presidential election year.

In Canada, physicians remain in the private sector, but the health-insurance system has been nationalized; thus, patients may consult whomever they want, but they know they can leave it to the government to pay their bills. (Canadian patients pay handsomely in the end, of course, come income-tax day.)

All political parties here, left to right, support the core idea of universal health coverage. American-style debate over the merits of public- and private-sector systems just doesn’t occur here.

The Canadian system is not without its problems. There can be long waiting lists for elective procedures here; there is a relative scarcity of the most technologically advanced equipment, and there are few mechanisms for fiscal accountability, since patients never see any bills.

But overall, the system’s statistics are impressive. Canada spends a smaller percentage of its gross national product on health care than the United States does (how much smaller is the subject of heated debate, since there are many means of measuring), yet every legal resident of Canada is insured. And Canadians have a longer average life expectancy than Americans and a lower infant-mortality rate.

The enthusiasm of young Canadians to go into family medicine is just another happy outcome of the system, Rosser and others say.

Consider the system’s effect on Julie Gallagher, the new Canadian doctor. Her $15,600 debt is about a third of the average American medical student’s burden of $46,000 upon graduation. She was able to keep her debt to that modest level because medical education in Canada is heavily subsidized.

While American medical students pay a median tuition of $6,000 per year at a public medical school, and $17,000 at a private school, Gallagher and her Canadian classmates at the University of Toronto have to pay just $2,300 per year. (Foreign students pay more.)

“It’s no big deal,” says Rajiv Gupta, a fellow University of Toronto medical student who estimates that his total debt for college and medical school will be about $26,000. “When I’m in full practice, I’ll be able to pay it off in one year.”

From graduation day onward, the life of a family doctor in Canada is a strikingly serene, secure proposition, especially when compared with the American version. For starters, Canadian physicians don’t have to dun their patients for fees--or tax their consciences by turning poor people away.

Doctors in Canada join professional societies, and these, each year, negotiate a fee structure with the 10 provincial governments. A price is set on every possible service, from a simple blood test to a multiple heart bypass. Working from this common schedule, Canadian doctors then report all the services they have performed in a given period, and the provinces reimburse them.

Gallagher figures she’ll be able to count on an income of about $70,000 to $90,000, after office expenses but before taxes, as long as she works full-time.

Though the provinces are beginning to make noises about cutting back reimbursements for unnecessary procedures, or about limiting reimbursements to doctors who seem to be billing too much, there is for now very little second-guessing of what doctors do.

Given such a predictable, profitable setup, it shouldn’t surprise that when she is asked why she selected a family practice over a specialty, one of Gallagher’s first responses is “lifestyle.”

“Lifestyle is the big factor,” she says with a smile. “You can be as busy as you like.”

That is a far cry from what American medical students say. In the United States, opinion surveys conducted by the American Assn. of Medical Colleges show, students have concluded that family medicine is a sure-fire formula for low pay, long hours and endless administrative hassles.

That’s because American insurers have been trying to rein in spiraling health-care costs and are increasingly reviewing doctors’ activities in hopes of cutting out the fat. More and more, doctors are finding their bills disallowed, their hospitalizations rejected, their claim forms bucked back to them.

For family practitioners, in particular, this means frustration, arguments and an avalanche of paperwork. (Family doctors, unlike better-paid specialists, often cannot afford to hire outsiders to handle their statements; they are more mired in paperwork because they tend to submit separate bills for each visit a patient makes, while specialists tend to submit charges for entire courses of treatment.)

“I know physicians in the United States who have full-time people in their offices who do nothing but answer calls from bureaucrats,” marvels Harvey Barkun, associate dean of medicine at McGill University’s medical school in Montreal and executive director of the Assn. of Canadian Medical Colleges. Such a thing is unheard-of in Canada.

In Washington, the General Accounting Office has calculated that, if America adopted a single-payer system like Canada’s, society would save enough on paperwork to cover the 37 million Americans who now have little or no insurance. Studies also have shown that in America, family physicians end up seeing more uninsured poor people than specialists do--and therefore lose more money than specialists.

The result is a deep frustration and disillusionment among American primary-care doctors--one that gets conveyed to medical students in a trice. A 1990 survey found that only 39% of all internists (generalists who care for adults) would enter the field again; 40% said they would discourage students from selecting the field.

American family doctors also complain about the sinking prestige of their profession. In the United States, highly trained specialists now come in for star-athlete treatment, but the plain-vanilla, primary-care doctors who administer flu shots and give well-baby checkups command comparatively little respect.

The attitude is self-perpetuating: The “best” American medical schools in many cases want to highlight their prestige-churning research programs, so they don’t even bother offering formal training in family medicine. “That gives a connotation that it’s second-rate,” notes Rosser.

In Canada, he points out, every medical school has an established department of family medicine. “It’s a compulsory part of the education of every student,” he says.

And since Canada has less research money to throw around than America, Rosser adds, it tries to channel it into low-profile, high-social-impact research projects in preventive medicine. Dull but important primary-care studies, on such things as why old people don’t take their pills correctly, are given greater emphasis here--and that, Canadians say, adds status to family medicine.

“It’s not the kind of thing you do with a rat and a bench and a microscope, but it’s very important to the development of medicine in this country,” Barkun says.

At the residency level, still more factors work in favor of primary medicine in Canada. Here, new doctors are still considered wards of their universities, even if they work in tiny outpatient clinics, far from the campus. Their pay comes from the provincial government, and so do their marching orders.

“You’ve got to keep medical education relevant to the needs of the province, when that’s who’s paying for it,” says Rosser.

That contrasts sharply with the situation in the United States, where residencies are often set up by hospitals, not universities. Residents there are paid by the hospitals and end up doing what the hospitals want--which isn’t necessarily what the surrounding community needs.

Residents also get exposed to glamorous high-tech equipment that only large hospitals can offer--and this lures them further away from primary care.

Consider the experience of Gundersen, the University of Wisconsin doctor-to-be, who is now doing a clerkship at the university’s teaching hospital. It is a technological wonderland that boasts, among other things, three magnetic resonance imagers--breathtakingly expensive diagnostic machines that are found one to a hospital, at the most, in Canada.

“Research is the primary mission here,” Gundersen says, admitting that he finds the technology seductive. “Education gets the most lip service and the least funding. There haven’t been any major curriculum changes here since 1967.”

In Canada, McGill’s Barkun notes that for all his devotion to the Canadian way of educating doctors, he isn’t convinced that the Canadian system would graft well in the United States.

“Canadians have an awful lot in common with Americans,” he says. “I can tell you who won the Super Bowl, and I can tell you half the batters in the American League. But when it comes to health care, we are different. If you tried to apply the Canadian health-care system in the United States, it just wouldn’t fly. It’s a cultural thing. In the United States, anything that is tied to the government is looked upon as not right.”

Canadians, by contrast, simply don’t share Americans’ inborn suspicion of “big government,” he says, and the northerners are willing to experiment with state interventions in key areas of the economy.

But there is a flip side to Canada’s enviable abundance of family doctors: a brain drain of specialists. With the system stacked so generously in favor of primary care, specialists here can’t help noticing that they would be better paid, and treated with greater reverence, if they moved to the United States. So some do.

“It’s no longer fun to practice medicine here,” complains John Provan, a surgeon and dean of medical education at the University of Toronto.

The Canadian system forces technically oriented doctors like himself to spend far too much time jockeying for space in crowded operating rooms, he says. And with Canada now under tremendous fiscal pressure, specialists like Provan fear that things will only get worse.

Such views, held by ranking faculty members of their own medical schools, naturally leave Canadian medical students wondering whether the future in Canadian medicine will be as bright as the present is.

“I think eventually we’re all going to be on salary,” predicts Gus Dotsikas, another University of Toronto student. He doesn’t much like that idea. Some of his classmates have been taking American board exams, he says, just to hedge their bets. He even looked into the medical school at George Washington University.

“They wanted me to come up with evidence that I would have $34,000 a year,” he hoots, citing the figure that, two years ago, George Washington gave foreign medical students as a yearly expense estimate. (This year, the medical school is telling foreign students that they will need $40,900 per year to cover tuition, fees and living expenses in Washington.)

“I said, ‘Forget it!’ I don’t think the grass is greener on the other side. Yes, there’s an interest among medical students to go to the United States, but there are a lot more who believe in the Canadian system. I’d never leave Canada.”

Tracking a Medical School Trend

A larger proportion of U.S. medical school graduates are going into specialized fields than their Canadian counterparts. Percentage of U.S. medical graduates who becomes family physicians: ‘81: 17.3% ‘82: 18.2% ‘83: 17.7% ‘84: 17.0% ‘85: 15.9% ‘86: 17.0% ‘87: 18.3% ‘88: 13.6% ‘89*: 13.7% 1989: Canada: 52.9% U.S.: 13.7% * Latest figures available Sources: Assn. of American Medical Colleges, Health & Welfare Canada