U.S. Needs More Family Doctors, Study Warns

The nation has a severe shortage of general physicians and a surplus of specialists, a trend that must be reversed soon if major repairs are going to be made to the ailing health care system, a federal advisory panel has warned in a report to be made public soon.

The study is expected to be taken seriously by the Bill Clinton Administration, both because it has set health care reform as an early goal and because the head of the panel, Dr. David Satcher, is said to be on the short list for the job of secretary of health and human services in the new Administration. And both Democrats and Republicans have indicated that health care reform will be at the top of the priority list for Congress next year.

“Anyone who puts universal access (to the health care system) up front is going to be very interested in finding ways to get physicians where we need them in order to deliver quality care,” said Satcher, president of Meharry Medical College in Nashville.

“This report is an attempt to address that problem,” he added. “I don’t think you can solve it overnight. We didn’t get into it overnight. Our plan is a long-range plan.”

Satcher, in an interview Sunday, declined to discuss the possibility of serving in a Clinton Cabinet, saying that it is “far too early” to speculate on any Cabinet selections.

Even if all uninsured Americans suddenly received coverage, such protection would be useless without access to general physicians--particularly in inner cities and rural areas where the shortages are especially bad, says the report, a copy of which was obtained by The Times. The report suggests solutions to the problem, including incentives to encourage doctors to enter general practice and to treat patients in inner cities and rural areas.

Only about one-third of all doctors today are family physicians, general internists and general pediatricians, and only one-sixth of all medical school graduates are choosing to become generalists, said the report, expected to be released in the next several weeks.

This is a dramatic change from 1961, when the ratio was 50-50, the study said. The ratio began to shift in 1962 when, increasingly, health professionals began choosing to specialize, the report said.

The numbers are far different in other countries. In England, for example, 73% of the physicians are generalists. In Germany and Belgium, the figures are 54% and 53% respectively. In Canada, where the government funds universal health insurance, 47% of the physicians are generalists.

Also, despite a doubling in the physician population in the last 30 years to 600,000, inner-city and rural areas continue to suffer from a critical shortage of doctors, making access to care extremely difficult, the report said.

“There’s no question about it, if you were to give everybody (an insurance) card tomorrow, you would still have to deal with the distribution of physicians, especially where they are most needed,” Satcher said.

Also, the proliferation of specialists adds to overall escalating costs, the report said. The cost of physician services is much greater because patients undergo more intense medical services per visit because of this large number of specialists, the report said.

“As long as you have this disproportionate number, you’re not going to be able to contain costs,” Satcher said.

The report is the work of the Council on Graduate Medical Education, created by Congress in 1986 to advise the HHS secretary and Congress on ways to improve the nation’s physician work force.

The report, targeting an ultimate goal of returning to a system in which half the doctors are generalists, recommended that a national physician work force plan be drafted. The plan would include creating national and state commissions that would determine local, regional and national physician needs. Under the plan, physician training positions and funding would be based on the types of doctors needed.

The report suggested that incentives be established to increase to at least 50% the number of medical school graduates who complete a three-year training program in family medicine, general internal medicine and general pediatrics and begin a generalist practice.

Financial incentives, such as loan and scholarship programs, should be used to try to double the number of entering minority medical students by the year 2000, the report recommended.

Further, the panel urged that more physicians be encouraged to practice primary medicine in inner cities and rural areas. This could be accomplished through the National Health Service Corps scholarship and loan programs, differential Medicare and Medicaid reimbursement for practice in shortage areas and through a reduction of administrative burdens, the report said.

Satcher predicted that physicians would respond to these needs, particularly to the crisis resulting from the shortage of qualified practitioners in underserved places.

“I happen to believe that medicine is a profession before it is a business,” he said. “I’m convinced that the right leadership can inspire a national spirit for that kind of service.”