Practicing Their Beliefs : Family Medicine Offers Less Pay and Prestige, but Some Harbor-UCLA Residents See Other Rewards

By DEBORAH SCHOCH

April 9, 1993 12 AM PT

TIMES STAFF WRITER

For a time, Dr. Shaila Serpas considered becoming an obstetrician. She even toyed with being a surgeon. But in the end, she returned to the notion of family medicine.

She didn’t want to limit herself to delivering babies or carving out inflamed appendixes. She wanted to watch those babies grow up. And she wanted to treat their parents and siblings.

“I wanted to be more involved,” she said.

Serpas, 29, is an anomaly in American health care: a young doctor who has turned her back on high-paying specialties. She is a second-year resident at Los Angeles County Harbor-UCLA Medical Center, the hospital of last resort for thousands of South Bay residents lacking health insurance. As such, Serpas is one of 19 family medicine residents being trained on the front lines of the urban health crisis.

She enters family medicine at a crucial time. A decades-long boom in specialized medicine has seen the proportion of doctors in general medicine--family practice, pediatrics and internal medicine--dwindle from 87% in the early 1930s to 33% in 1990.

Worried that the imbalance is driving up medical costs by hampering preventive medicine, policy-makers across the country are studying ways to bolster the ranks of medical generalists. Harbor-UCLA, for instance, plans to start training more residents like Serpas.

“The problem is the country has trained the wrong physicians for the past 25 years,” said Dr. Patrick T. Dowling, chairman of the Harbor-UCLA department of family medicine. “It’ll take a long time to get the proper balance of providers. It’s really a critical period in medical education.”

What Serpas sees each day challenges old-fashioned notions of both “family” and “medicine.” On a recent afternoon, she hovered over a cherubic baby brought to the Harbor-UCLA Family Health Center for a checkup.

What is the baby eating? Serpas asked. The baby’s mother recited a list of rice, fruits and vegetables. Staying away from candy? The mother nodded her head.

And how are you doing? Serpas asked, turning to the pretty young woman in a sweat shirt, braces glinting on her teeth.

The teen-age mother’s eyes filled with tears.

The painful story spilled out: She left the baby’s father after he had hit and threatened her. She got a restraining order but still faces a court hearing.

Serpas handed the mother a tissue. She asked some gentle but probing questions, then urged her to return for her own appointment.

The incident speaks volumes about the way Serpas and her colleagues approach medicine: how treating one family member can lead to treating others, how family practice requires a broad view of medical care.

These residents treat uninsured patients, broken families, children lacking immunizations, mothers lacking prenatal care. They work rotations in a wide range of hospital departments, including an overflowing emergency room where people can wait 12 hours or longer to see a doctor.

Like her other colleagues in the Harbor-UCLA program, Serpas became an exception in medical school when she chose a residency in family medicine. She was, in fact, among only 11% of her medical school classmates at the State University of New York at Stony Brook to do so.

She fits the image of a family doctor committed to public service. Before entering medical school, she went to work at 19 in a United Nations refugee camp on the El Salvador-Honduras border.

The crowded conditions bred disease; she became ill with typhoid fever and malaria. Frustrated that she could not do more to help the refugees around her, she decided she wanted to be a family doctor serving people with little access to health care.

One of her colleagues at Harbor-UCLA, Dr. Lowell Kleinman, 29, a third-year resident, got his introduction to community medicine watching his godfather run a one-doctor medical practice in the Greenpoint section of Brooklyn.

“He’d see everyone. He’d remember their histories. . . . He knew everyone for 30, 40 years. They’d come to him from all over the city,” Kleinman said.

Another physician in the program, first-year resident Dr. Kristine Potter, 28, also had a role model: the doctor who treated her entire family in a small Illinois town.

A lack of contact with family physicians in medical schools is one of many reasons medical students turn away from family medicine and toward specialties. Sometimes, in fact, family medicine is looked down upon in medical schools as less prestigious than specialties.

Potter, who went to medical school at UCLA, recounts how one physician stopped her in a hallway to inquire what field she had chosen. When Potter mentioned family medicine, the doctor grew upset and told her she was intelligent enough to do something more “worthwhile.”

From a salary standpoint, what’s worthwhile is specialized medicine, an important consideration for students leaving medical school with a median student loan debt of $50,000. In 1991, the median income for doctors in family practice was $98,000, compared to $200,000 or more for obstetricians, surgeons, anesthesiologists and radiologists, according to the American Medical Assn.

Indeed, years of specialization are taking their toll. The California Academy of Family Physicians reports that, as of last year, 34% of its active members were nearing retirement age.

They are not being replaced at a rapid clip. Only about 15% of the graduates of California medical schools entered family medicine in 1981-91, according to the academy. The rate was 13.5% at UCLA, 11.3% at USC and 19.2% at UC Irvine.

“We are regarding highly technical, procedurally oriented specialists much more than we are the generalists,” said Dr. Jordan Cohen, dean of the SUNY Stony Brook Medical School and head of a national task force on generalist physicians.

At Harbor-UCLA, family medicine residents say that, even though specialties pay more, those entering family practice can expect a more flexible career.

“You can do anything. You can work for a public health service, you can work for an HMO. You can go into private practice,” Kleinman said.

Another reward is that family physicians often establish a closer, long-term relationship with their patients. That, however, can mean long hours and erratic schedules.

Serpas, who is married, was nine months pregnant with her second child this winter when she was called at 3 a.m. to deliver the baby of a woman to whom she had given prenatal care. Despite her own condition, Serpas delivered the baby, feeling an obligation to provide the woman with what she calls “continuity of care.”

Three weeks later, Serpas gave birth to her second son. She took only two months off before returning to work. Now, with the help of her husband, she is juggling the demands of medicine, child care and feeding schedules.

One recent Saturday, she was on 24-hour call and could not leave the hospital. So she waited in the cafeteria for her husband to arrive with the baby. She sat in a far corner, nursing, her two telephone beepers on the table in front of her.

“I can’t tell my patients to breast-feed and not breast-feed myself,” she said.

She was able to finish nursing before the beeper sounded.

To learn their skills, residents undergo rigorous training and work as much as 60, 70 or 90 hours a week. They do one-month or two-month “rotations” in a spectrum of fields: pediatrics, obstetrics, gynecology, surgery, cardiology, neurology, psychiatry, geriatrics, dermatology and the emergency room.

When residents are on call overnight, they stay in a tiny room on the hospital’s eighth floor. The decor is quasi-military: two bunk beds, lockers, a sink.

Much of the residents’ training takes place across Carson Street at the Family Health Center, an outpatient clinic near a doughnut shop in the Royal Plaza strip mall. Residents talk passionately of the need to offer continuous, preventive care in the clinic to keep patients out of the emergency room across the street.

In one such effort, Serpas organized a mobile clinic in which residents provide free immunizations and other health care services to homeless people in several South Bay communities.

Another example is a new quit-smoking program designed by Kleinman.

Many doctors simply do not talk to their patients about smoking, he said. But at the Family Health Center, asking patients if they smoke has become routine, like checking weight and blood pressure. Patients who smoke get black stickers on their charts; nonsmokers get red stickers.

To date, the survey shows 27% of clinic patients are smokers. Doctors are encouraging patients to sign contracts promising they will quit, with the three classes of residents competing for the most contracts signed. As of last week, 30 patients--about a third of the smokers surveyed--had entered contracts, and the doctors will assist them in quitting.

Experts say that such preventive care helps keep health care costs from escalating. They say poor people commonly resort to emergency room care when their problems worsen, becoming more expensive to treat.

“We have so few primary care sites that the only thing left is the emergency room,” said Dowling, of Harbor-UCLA. He added: “It is the family doctor” for the Los Angeles County health system.

To address such problems, the Clinton Administration is reportedly considering financial incentives, such as low-income loans or scholarships, to ensure that at least 50% of all medical school graduates train as generalists. Today, fewer than a quarter of the medical graduates nationwide are entering general medicine.

In California, a bill that passed the Legislature last year would have required the University of California to ensure that 20% of its residency slots go to family care physicians. Gov. Pete Wilson vetoed the measure, but the bill has been reintroduced this year.

And, for the first time, the UCLA School of Medicine this year will make family medicine one of its required clerkships, or rotations. All third-year students will devote four weeks to family medicine.

At Harbor-UCLA, meanwhile, the family medicine residency program is expected to expand from 19 to 40 residents in the next four to five years, Dowling said. That growth will be part of a larger shift, as Harbor-UCLA seeks to train more residents in family medicine, general internal medicine and pediatrics, said Dr. William H. Swanson, hospital medical director and associate dean of the UCLA School of Medicine.

“It’s quite clear that society needs more generalists,” Swanson said.

Residents in the Harbor-UCLA program hope such thinking will create more opportunities for family doctors.

Kleinman, who says he is $70,000 in debt from medical school, has received offers of $70,000 to $110,000 a year, a far cry from the more than $200,000 offered to a medical school friend entering neurosurgery. Kleinman hopes to join a community-oriented group practice in the Bay Area.

Dr. Angel Perez, a first-year resident who grew up in Wilmington, said he may work for an HMO or in a group practice for a few years and eventually hopes to practice in the Wilmington-San Pedro area.

And Serpas plans to be a family physician in an underserved community near the Mexican border in California, New Mexico or Texas. She expects her annual income will be far less than the $98,000 median pay for family practitioners.

With a slight grin, she says: “I want a salary that’s enough to pay the bills and pay for the children’s college--but not to live on the hill in (Palos Verdes) and drive a Mercedes.”

LOSING GROUND

Chart shows number of general practice and family medicine physicians as a percentage of the total number of physicians, 1965-1990.

1965:

--general/family practice: 71,366 (24.4%)

--total number of physicians: 292,088

1970:

--general/family practice: 57,948 (17.3%)

--total number of physicians: 334,028

1975:

--general/family practice: 54,557 (13.9%)

--total number of physicians: 393,742

1980: