THE VIRGINIAN-PILOT
Copyright (c) 1994, Landmark Communications, Inc.
DATE: Friday, October 14, 1994 TAG: 9410140559
SECTION: LOCAL PAGE: B1 EDITION: FINAL
SOURCE: BY MARIE JOYCE, STAFF WRITER
LENGTH: Long : 135 lines
When newlyweds Shannon and Tom Pope talk about why they want to be doctors, they talk about Tom's grandfather.
A general practitioner in Petersburg, he has built lifelong relationships with his patients and played a big part in their lives.
That is the kind of practice the Popes want. That is why the first-year students at Eastern Virginia Medical School want to be family doctors.
After years of declining interest in general practice, medical school students are rediscovering primary care as a profession.
In a sense, that means the old family doctor is coming back - but in a more technical and sophisticated form, able to offer services now done by specialists.
Now medical school officials, wanting to see the ranks of general practitioners grow, are looking for ways to sell students on a discipline that offers less money and prestige than the high-tech specialties.
Nationally, about a quarter of graduating medical students say they plan to go into primary care, according to a survey done by the Association of American Medical Colleges. That is an improvement over previous years but still well below the association's goal of 50 percent.
At EVMS, about 31 percent of graduates go into primary care.
Since the late 1980s, government and the medical establishment have worried about a shortage of primary care doctors.
A primary care doctor, or generalist, is the first physician most people turn to for treatment of anything from a headache to a broken toe - the first line of defense for acute care, health maintenance and disease prevention. Generalists include internists, pediatricians and family practice doctors.
But medical schools have been producing more specialists, like orthopedic and cardiac surgeons, than primary care physicians.
``We were over-training specialists and subspecialists,'' said Dr. Donald Kassebaum, vice president of the medical college association.
This worried the government
and private insurers, because specialists charge more than primary care doctors.
It is also a problem because generalists are the doctors most needed in poorer city neighborhoods and in rural areas, Kassebaum said.
These worries led to the birth of programs like the new Center for the Advancement of Generalist Medicine at EVMS.
As part of the new EVMS program, first-year medical students like Tom and Shannon Pope are getting early exposure to primary care. The school hopes to sell them on the rewards of general practice.
They spend time each week in a generalist's office, watching and sometimes helping out with jobs like interviewing patients about their family medical history. Previously, students spent most of their first two years cloistered in science classes.
But selling students on primary care is not the only element of the generalist program. Director Verdain Barnes wants to train a new breed of doctor.
In the future, Barnes said, patients will turn to their family doctor or internist for treatments that now are done by specialists.
For instance, if a patient has congestive heart failure based on hypertension, his family doctor would treat the hypertension. The cardiologist would take over when the patient needed more radical treatments.
This system would make primary care more challenging and attractive to students, said Barnes.
It also would cost less. The easing of the primary care shortage may have as much to do with market forces as medical schools.
Health maintenance organizations and insurance companies are pushing patients to see primary care physicians. Medicare, the government health insurance program for the elderly, has upped reimbursement for general practitioners. The Clinton administration made reliance on family doctors a key priority of health care reform.
This year, Kaiser Permanente, the California-based health maintenance organization, began offering starting internists the same salary as starting cardiologists, said Barnes.
That is good news to Barnes. In recent years, he said, a family doctor would do well to earn $80,000 a year. A subspecialist could expect to bring in twice that, and a doctor in a very technical and invasive specialty like orthopedic surgery could earn more than half a million.
The difference isn't lost on students who might leave medical school with $50,000 to $100,000 in student loan debt, he said.
When Barnes started his internal medicine residency at Johns Hopkins in 1965, he entered one of the most competitive programs in the country.
``When I went to Hopkins, they wouldn't even talk to you if you weren't in the top 10 percent of your class,'' he said. Today, ``if you're a warm body and have a reasonable intelligence, there's a program out there in internal medicine that will take you.''
Technology is behind the change, Barnes said. When he was a resident, doctors had fewer tools.
Advanced diagnostic procedures like coronary artery catheterization didn't exist, and to treat congestive heart failure, a doctor chose between two medicines, Barnes said.
General practitioners handled almost everything. ``In the beginning, there only was primary care,'' said Kassebaum, who did his residency in internal medicine in the 1950s. ``There were probably two other things you could go into, like cardiology and chest disease.''
The next decades saw an explosion in medical technology, and created a demand for doctors trained to use cutting-edge techniques and tools. Today there are more than two dozen drugs to treat congestive heart failure, said Barnes. ``The general feeling in medical school was if you did generalist medicine, you were in some way defective as a physician,'' Barnes said.
Shannon and Tom Pope have heard about this bias, but they don't care. ``We've heard that, but my opinion is so different,'' said Shannon. ``The family doctor is the one who has to know the most about the most things.''
They know they will earn less money than in a specialty, and they have tried to budget themselves to avoid taking out many student loans.
Family practice suits the small-town lifestyle they want. ``It's nice to know that when Mr. Jones comes in, you know his face, you know who he is, you know about his family situation,'' said Tom.
And family practice is flexible enough to allow Shannon to adjust her schedule when the Popes have children. It's hard for a surgeon to do that, she said.
This lifestyle is part of what Barnes is selling. Not everyone is suited to the supertense life of a cardiac surgeon, he said.
He believes medical schools will meet the challenge to train more generalists. Maybe, he says, the pendulum will swing the other way.
``I suspect 10 years from now, the federal government will be saying, `Where are the subspecialists.' '' ILLUSTRATION: Color photo
PAUL AIKEN/Staff
Newlyweds Tom and Shannon Pope, students at Eastern Virginia Medical
School, want to follow in the footsteps of Tom's grandfather as
family doctors. They know they won't make as much money, but they
like the flexibility and small-town life general practice allows.
Graphic
STAFF
MORE DR. WELBYS
SOURCE: Association of American Medical College
[For complete graphic, please see microfilm]
by CNB