Young Doctors Shun Front Line of Health Care : Medicine: Being a family physician is appealing to fewer residents. A proposed bill would mandate more primary-care residencies.

Dr. John Casebeer sees it all in a typical workday.

Most of his colleagues from the residency program at UC Irvine Medical School focus on one aspect of medical care. But this family physician, in his third year of residency, tackles myriad procedures each day: checking blood pressure, stitching wounds, administering shots and peering into countless infected ears.

Life on the front line of health care gets pretty hectic at times, he admits, but he wouldn’t have it any other way.

“It may sound hokey,” said Casebeer, 30, from the small Santa Ana clinic where he works, “but this kind of work really appeals to me, to my personality.”

Being a family physician, however, appeals to fewer and fewer young doctors these days. Many shun the traditional image of the family doctor, instead selecting more highly specialized--and lucrative--branches of medicine, such as radiology, neurology and oncology.

To stem the flight from primary care, the California Academy of Family Physicians has taken legislative aim at the University of California medical school system, where two-thirds of all of California’s future doctors gain their education and initial on-the-job experience.

A bill, co-sponsored by Assemblyman Phillip Isenberg (D-Sacramento), would mandate that half of all graduates of the five UC medical schools accept primary-care residencies and 20% of the total train as family physicians.

Primary-care physicians include family physicians, general internists, pediatricians and obstetricians/gynecologists.

Residencies are various periods of time in which new doctors train for a particular medical discipline. Residencies are usually considered a career choice, because most doctors continue in the direction they have chosen during a residency.

Under the proposed legislation, if primary-care resident positions fall below the 50% requirement, the UC medical school would lose about $45,000 for each number of positions it would take to reach that 50% goal.

Opposed by the UC system, AB 3593--which has a 10-year sunset clause--is inching its way through the Legislature. Although passed by the Assembly in May, it has been languishing in the Senate, and was recently voted down in the state Senate Education Committee.

The bill is up for a second chance Wednesday in the Senate Rules Committee. If the request for reconsideration is approved, it would be allowed another hearing by the Education Committee in early August.

UC officials said they are confident that the bill will not get to a floor vote, much less the governor’s desk.

“It’s gasping,” said Adele Amodeo, coordinator for health legislation for the UC system.

Amodeo said that while the UC medical schools, located in Irvine, Davis, Los Angeles, San Diego and San Francisco, recognize that a shortage in primary-care physicians exists, the regents maintain that regulating residencies at the university system’s medical schools is not the solution.

University officials contend that such a regulation deprives medical school graduates of the freedom to choose their careers and make the income they desire as doctors.

Residents who are interested in and possibly more adept at, say, brain or open-heart surgery, should not be forced to commit their lives to becoming family physicians, they argue.

“Can we suspend the Bill of Rights for our students?” Amodeo asked. “This is really an issue of freedom of choice.”

In any case, Amodeo argued, the bill is unnecessary because about 50% of the university’s residency slots are already being filled by primary-care physicians.

Proponents of the bill, however, point out that the bulk of those primary-care residents are internists--those who study internal organs and diseases--and most internists move on to more specialized disciplines.

For that and other reasons, Isenberg and the California Academy of Family Physicians, which is lobbying for the bill’s passage, say that the state needs a law that would restrict shifts away from primary-care practice, thereby correcting what they call an “inappropriate distribution of primary-care physicians.”

The position that primary-care physicians are inappropriately distributed is based on a 1987 California State Health Plan, prepared by the state Health and Welfare Agency, which established “standards of adequacy.”

For instance, the low standard of adequacy for primary-care physicians--or the minimum number of doctors needed--is 83 for every 100,000 people. The high standard of adequacy for primary-care physicians for that size population is 117 doctors. A ratio higher than that would indicate a glut in a certain specialty.

Of the state’s 58 counties, the report states, 36 have not met the low standard for primary-care physicians. The standard of adequacy is a guide that suggests how many positions of a certain discipline are needed to safely and efficiently serve the population.

Those underserved counties include rural areas in Northern California as well as the Southern California counties of Riverside and Ventura.

And while Orange County has 99 primary-care physicians per 100,000 people--well above the low standard of adequacy--the University of California system as well as other medical schools are not churning out enough primary-care physicians to meet the needs of the next decade in urbanized areas.

The trend away from primary care in general and family physicians in particular is chilling, considering that a primary-care physician is usually the first medical expert a sick person encounters, according to a report published in June by the family physicians academy.

The state’s total number of physicians increased 6.9% between 1986 and 1989, but the number of family physicians during the same period dropped 2.75%, or 732 doctors, through a combination of retirement and career selection, according to the report.

In 1989, family physicians constituted roughly 12% of total practicing physicians in California, but today that number has edged down to 11%, the report states.

Simply said, most young doctors are opting for higher-paid specialty practices that require intensive technical expertise, but that do not best serve the general public on a day-to-day basis, the report says.

According to the report, as many as 8,000 additional family physicians are needed in California to meet the statewide low standard of adequacy for that discipline.

“This trend toward increasing sub-specialization and away from generalism portends dire consequences for the health care system,” the report concludes.

For medical residents, who work 80 hours-plus a week for three years and longer, however, the issue of specialist versus non-specialist is often moot.

Money was not the main issue when selecting their career, they say. Rather, it was the challenge of the work and the exposure to the specialty during medical school that influenced the decisions.

Dr. James Lee, 31, an anesthesiologist in his third year of residency at UCI Medical Center, said he discovered the specialty during his last year in medical school.

“I just fell in love with it,” Lee said during a recent break between surgeries. “It’s very cutting edge.”

Lee said that family physicians expect to see long-term results in their work, while surgeons expect to see changes in their patients within hours. Anesthesiologists monitor changes on a minute-by-minute basis.

“That’s one of the exciting things about it,” he said.

Nevertheless, proponents of AB 3593 say that as more young doctors like Lee find rewards in specialty training like anesthesiology, primary care will inevitably suffer.

Tom Riley, a lobbyist for the California Academy of Family Physicians in Sacramento, contends that passage of the bill is vital to the future of health care in California.

Without a sufficient number of family doctors, he said, access to affordable medical care would be blocked for many middle- to low-income families.

“We’re battling on all fronts,” he said optimistically. “Everybody (at the academy) is real optimistic.”

Isenberg, however, acknowledged that his bill is in trouble and may not be passed.

“It’s slim,” he said in a phone interview from his Sacramento office. But, he added, the bill’s troubles may be more the result of counter-lobbying by the UC system than the proposed legislation’s merits. “The university has gone hysterical on the subject.”

Despite the bill’s poor prognosis, Isenberg said he will continue to urge its passage and if it dies in committee, he said he would draft a similar bill next year.

The measure, he argued, could be a major boost in the battle to cut the spiraling cost of health care.

Indeed, according to the Journal of the American Medical Assn., as much as $5 billion a year in the United States could be saved if half the nation’s doctors were primary-care physicians.

Isenberg also said that taxpayers, who subsidize the total cost of the UC residencies, should see a greater return on their investment in the form of more front-line physicians, who diagnose and treat 80% of all illnesses, but who receive less pay for their time.

The average cost to the state for training a primary-care physician is $204,300, versus the average cost of training a specialist at $226,000.

“Everybody agrees that we need more primary-care physicians,” Isenberg said. “The question is how do we get there? The university is really the place to start. If you can change the university, you can change the system. I don’t know of any other recourse.”

Supporters of the bill include the California Academy of Physician Assistants, the Western Center for Law and Poverty, CareAmerica Health Plans, the California Medical Center of Los Angeles, the Consumers Union, Long Beach Memorial Medical Center and the California Nurses Assn.

The UC system is the only declared opponent.

Despite the strong support for the measure, UC’s Amodeo said the UC system is adamant in protecting residents’ rights. Choosing a medical specialty, she said, is a private decision that ultimately should be made by the incoming resident, not by a university bureaucracy.

Amodeo said that the university system is concerned about the rising numbers of graduating medical students going into highly specialized residencies. But with economics a strong factor, she said, she doesn’t blame them.

For instance, neurosurgeons, orthopedic surgeons, radiologists and plastic surgeons all make annual incomes that come close to, if not surpass, $200,000 a year. Some specialists, such as cardiologists, make nearly $300,000.

Primary-care physicians, on the other hand, normally make much less. And with huge medical school student loans coming due after graduation, it’s no wonder that residents choose disciplines that will help them pay those enormous bills.

Amodeo said that as long as the health care system continues to reward specialists at the expense of primary-care doctors, there will be an endemic problem filling those ranks.

She said that the philosophy of managed care, which is spurring growth in many health maintenance organizations, could make primary care more attractive to young physicians.

In recent years, a growing number of primary-care physicians have been courted by HMOs, such as PacifiCare Health Systems Inc. in Cypress and FHP Health Care Inc. in Fountain Valley.

“Knowing there’s a market out there will help students make their career choices,” Amodeo said. “The more opportunities they get to see primary care in a positive light, the more it will affect their career choices.”

Dr. Allyson Brooks, 28, is one primary-care resident who does not rue her decision to become an obstetrician/gynecologist, despite the almost endless hours shuttling between office visits and delivery rooms at UCI Medical Center.

But she wanted to be a “whole doctor,” treating women from puberty to menopause and beyond. “I like that aspect of the job,” she said. “It’s a very broad field.”

Like other residents, she saw her colleagues choose a wide variety of career paths. Some of the choices will eventually prove more lucrative than others. But more than the money, most residents seemed to gravitate toward the field that matched their personalities.

“People really identify themselves in terms of the arts (family physicians) or the science types (specialists),” she said. “It’s not so much money as personality.”

Prognosis for Primary Care While the doctor population is climbing--particularly in California--primary-care physicians are a diminishing group that is lower paid than colleagues who are specialists. Doctor’s Note There were nearly 600,000 physicians in the nation in 1991. California, with more non-military doctors than any other state in the country, has the fifth best population-to-doctor ratio.

State Physicians Population Ratio California 79,178 29.8 million 376:1 New York 56,910 18.0 316:1 Texas 32,716 17.0 520:1 Pennsylvania 32,075 11.9 371:1 Florida 28,710 12.9 449:1 Illinois 26,547 11.4 429:1 Ohio 23,979 10.8 450:1 New Jersey 21,687 7.7 355:1 Massachusetts 20,380 6.0 294:1 Maryland 17,205 4.8 279:1

Lower Pay Primary-care medicine is one of the lowest-paid disciplines; only psychiatrists earn less. The specialty includes family practitioners, obstetricians/gynecologists, general internists and pediatricians. Practice: Mean Income Cardiologists: $295,400 Radiologists: 282,400 Surgeons: 251,900 Anesthesiologists: 232,700 Pathologists: 220,700 Other specialties: 171,000 Emergency-room physicians: 165,400 Primary-care physicians: 151,115 Psychiatrists: 124,800 Going Solo Statewide, six out of 10 doctors prefer to practice medicine on their own rather than in a group or a health maintenance organization. Practice Size: Percentage Solo: 61.2 Two-physician: 10.4 Three-physician: 7.8 Four to eight physician: 13.3 More than eight: 7.3 Source: American Medical Assn., U.S. Bureau of the Census, California Academy of Family Physicians