New Doctors Need HMO Training, Panel Says


A highly influential commission of medical scholars has concluded that it is time to train future doctors in California to fit into the managed-care system, even though it will forever change the profession.

The recommendations are aimed at resolving the conflict between the way doctors were taught to practice and the way they are now forced to practice due to the sweeping changes of managed care.

Medical experts say any changes that flow from the report could have a major impact nationwide as all medical schools wrestle with the problem of how to train the newest army of physicians.

The Commission on the Future of Medical Education, appointed in August by University of California President Richard C. Atkinson, calls for such changes as placing more emphasis on teaching business skills and training students in settings such as clinics rather than only in hospitals.


Atkinson appointed the commission, which is due to release its report this month, to assess UC’s vaunted academic health system. If embraced, no other state will have approved such an extensive overhaul of its medical school system.

School officials will be invited to respond, but no timetable for the proposed changes has been set. Even though all of the recommendations may not be adopted, the report is widely seen as the first step toward a modernization of the academic health system.

“We are seeing the death of a cottage industry and the birth of the industrialization of medicine,” said Dr. Molly Coye, former director of the state’s Department of Health Services and a member of the 28-person commission. “For the first time, we’re in a world where demand will drive employment. . . . We’re not far away from ophthalmologists driving taxicabs. The idea of sending out graduates to set up shop is no longer possible,” said Coye, who was among several commission members who presented a preliminary draft of the recommendations to about 100 UC officials and physician representatives in March in San Francisco.

The commission concluded that medical schools must deal with a number of perplexing issues, including:


* How to reduce the number of doctors, especially the number of specialists, as HMOs turn over more patient care to nurses, physicians’ assistants and other personnel.

* How to give medical students the business and computer skills so necessary to the economic and information-driven managed-care style of medicine.

* How to meet consumers’ growing demands for attention to alternative health methods as well as the spiritual, psychological and nutritional aspects of their health.

A new approach to training doctors is a matter of survival, said Atkinson’s liaison to the commission, Dr. Charles B. Wilson, a highly respected UC San Francisco neurosurgeon.

“We have to deal with the realities that are here,” said Wilson who, a few years ago at the age of 66, decided that he was “unequipped for medicine in the 1990s” and returned to school to earn a master’s degree in health administration at a business college.

“There are those who think we are abrogating our mission if we turn into a trade school. But it’s not an either/or decision. We’ve been producing what we want to produce, not what we need,” he said.

How the commission’s report will be received by the leaders of UC’s five academic health centers, the state’s three other medical schools (at Stanford University, Loma Linda University and the University of Southern California) and the current work force of physicians remains to be seen. The shift to managed care has angered many doctors. And there is reason to believe that altering medical schools to fit the managed-care model will be, for some, akin to joining the enemy’s ranks.

“I would suspect some members of the faculty would resist some of the changes we are talking about today because [the faculty members] were brought up in a different era,” said Dr. Thomas Langfitt, chairman of the commission and a member of the Institute of Medicine. “They fear we will lose many of the benefits that traditional medicine has brought us.”


More Business, Less Autonomy

To be sure, the commission’s report will paint a picture of future doctors that is a far cry from the Mercedes-driving, country club members of old. Future doctors will have far less autonomy and power and will probably garner less prestige and income. Nevertheless, their training looks to become considerably more complicated--and may even require more time, according to the commission.

Traditionally, medical training has been based on mastery of the biomedical model--the diagnosis and treatment of disease, Langfitt said. But trainees today should also have a sophisticated understanding of business management and computer skills, the commission concluded.

Quite simply, doctors must exhibit business acumen if they want to land a job, Coye said.

“We grew up in an era of ‘You name your price, and they will pay it.’ That is gone forever,” she said.

However, the future doctor’s A-to-Z knowledge of the human body and disease processes may not be as critical as it once was. Doctors will increasingly seek a treatment plan from computer databases of detailed “outcome data,” statistics based on previous experience.

“We believe that management training is important for all physicians,” said Dr. Neal Vaneslow, an expert on medical school education with Tulane University in New Orleans. “More and more, physicians are being called on to manage a pool of resources, either financial or human resources.”

According to the commission’s blueprint, doctors would direct teams that may include nurses, nurse practitioners, midwives, physician’s assistants, osteopaths, nutritionists and behavioral specialists such as psychologists and social workers.


“Physicians no longer have unique access to medical knowledge. Eighty percent of what doctors do can be done by nurses and physician’s assistants,” said Dr. Arnold Milstein of the Pacific Business Group on Health in San Francisco, citing recent studies. And, for doctors, he notes: “The really bad news is that patient satisfaction ratings [of the nonphysicians’ performances] appear to be higher.”

Nor would doctors be terribly distinguished from each other. The days of doctors carving out their own specialties are over, said Dr. Fitzhugh Mullan, a Washington-based expert on academic medicine.

Instead, medical students would train to become one of two types of doctors: those who focus on primary care and prevention, whom he calls healers, and doctors who specialize in treating particular diseases or ailments, whom he calls fixers.

“The fixers will be the offspring of today’s specialists,” Mullan said. “They will be teachers, consultants and custodians of the new technology. The healers will be today’s generalists.”

The healers will dramatically outnumber the fixers as usefulness and demand for specialists declines, several experts predict.

Given the growing emphasis on preventive care, more doctors need to be trained to work in clinics and other outpatient settings rather than hospitals and “the relatively insulated caves” of private offices, Milstein said. Hospitals will be reserved for the acutely ill and will be the purview of specialists, which he calls “hospitalists.”

Meanwhile, the generalists will be doing a lot more of what consumers really want: addressing patients’ physical and psychological health using any means available, including alternative health practices, he said.

“The sleeping giant has woken up and is hungry for a good thing,” Milstein said, noting the public’s interest in how behavior and the environment affect health.

Nutrition, psychology, spirituality and alternative medicine (including herbology, acupuncture, meditation and chiropractic) “were not even on the radar screen in the ‘70s in medical schools,” he said.

“We have been demeaning preventive health for years,” said Dr. S. Joseph Aita, executive vice president for Lifeguard Inc., in comments at the forum. “Medical students can’t fall asleep any more in epidemiology and nutrition classes.”

Moreover, doctors--particularly those who wish to land a job in California--should be “culturally competent.” Knowing a second language wouldn’t hurt, the commission said.

Changes Underway

Medical schools have already begun to respond to the changing nature of health care.

UCLA, for example, offers a course in which students interact with actors portraying patients to practice their communication skills. The school also offers a combined medical degree/doctoral degree track on the theory that those with doctoral degrees will be the professionals most likely to attract research dollars.

And, at USC, 60% of today’s graduates are going into primary care medicine, said Dr. Gary Dunnington, associate professor of surgery and senior associate dean of academic affairs.

Some UC authorities have questioned the need for sweeping restructuring by stressing the changes already in place.

But one commission member likened the present efforts at change to “rearranging the deck chairs on the Titanic.”

It’s not enough, agreed Wilson.

“We’re looking at moving the whole system,” he said. “We have a limited amount of time [in medical school]. And if something new comes in, something has to go. The question is, where will the resistance come from as we do what everyone said has to be done?”

The system doesn’t just train students, he noted. It treats patients, many of whom are poor, and conducts research. Whether the system can meet all those goals is uncertain.

Although the committee’s work so far has generated widespread praise, some medical leaders are skeptical that there will be funding to support the proposed changes.

For example, said Dunnington, managed-care companies, in general, have not been willing to pay for medical student training and other aspects of academic medicine.

“The most glaring obstacle [to the committee plan] is that managed-care groups have been unwilling to manage the burden of paying for medical student education,” he said. “They want the students. But when it comes to the cost, they say, ‘Don’t bill us for it.’ ”

And it’s not all about cost. Medical school faculty members are also devoted to research and ties to medical organizations--activities that make them better teachers of future doctors, said Dr. James V. Luck, chief executive and medical director of Orthopaedic Hospital in Los Angeles.

“If managed care is going to effectively become a part of medical education, they are going to need individuals willing and able to give up the time necessary to do that,” he said. “Being a medical educator is not a simple matter. It’s a major commitment, and it’s a discipline.”

One proposal that has been discussed nationwide is a mandate that managed-care organizations establish a fund for medical student education. But some observers believe that will not happen.

“I feel this committee has had the courage to take some very bold steps that are probably very appropriate. But a lot hinges on what happens to the current funding sources to medication education,” Luck said.

UC officials predict a decline in funding in the coming years due to cuts in Medicare and competition from HMOs that have eroded academic health center revenues. New sources of funding will have to be identified, Wilson said.

“People view public hospitals and academic health centers as responsible [for the poor] whether or not they can actually provide this,” Coye said.

Wilson concedes that change may come at the expense of a once-brilliant profession and the highly respected field of academic medicine. But, he says, consumers will benefit.

“There is growing concern around the country about the education and training of medical students and that it should change in ways that this commission is considering,” he said. “The public is the ultimate touchstone of what we’re doing.”


Changes in Hospitals

The average hospital patient doesn’t stay long, thus limiting the learning opportunities for medical students and residents.

Average length of Stay

1983: 6.1 days

1993: 4.9 days


Changes in Doctors’ Satisfaction

The new way of doctoring isn’t working, if current doctors’ satisfaction is a measure . . .

% reporting change in last three years:

* Amount of time with patient: -41%

* Ability to make decisions that are right for the patient: -38%

* Ability to remain knowledgeable and current: -20%

. . . physicians with a more traditional style of practice are generally more satisfied.

% very satisfied with the practice of medicine

* No managed care involvement: 35%

* Low managed-care involvement: 28%

* Moderate managed-care involvement: 17%

* High managed-care involvement: 18%


Changes in Consumers’ Satisfaction

All ethnic groups say they are less satisfied with managed care.

% rating their health plan fair or poor


Fee-for-service Managed care White 5% 13% Black 11% 23% Latino 9% 17%


Source: The Commonwealth Fund, 1996