Jack Colwill set a contextual framework by discussing definitions and implications of generalism. Colwill is Professor and Chairman of the Department of Family and Community Medicine at the University of Missouri-Columbia. He directs the Robert Wood Johnson Generalist Physician Grant Initiative and is a member of the Council on Graduate Medical Education, which advises Congress and the Secretary of Health and Human Services on physician supply."In 1990, we had roughly 500,000 practicing physicians in this country, which yielded a ratio of roughly 200 physicians per 100,000 population. The curve is going upward. With no change in graduate medical education, with no change in the numbers of students, the overall physician-to-population ratio will increase by approximately 25 percent in the next 30 years. As the number of physicians has increased, the proportion of generalists--general internists, general pediatricians, and family physicians--has dropped. At the same time, interest in the medical specialties has skyrocketed. Surgical specialties are the exception; interest in surgery has remained relatively stable. That is really a reflection of the fact that, back in the 1970s, the surgical specialties decided that they needed to exercise 'birth control.' As the total number of surgical residency slots was reduced, students recognized a shift in opportunity and their interest in surgery leveled off accordingly.
"There is a general consensus that we need to be educating more generalists. The question is: How do we get there? One approach could well be market forces. However, this approach would be complicated because our teaching hospitals are highly dependent on residents in the various specialties to meet service demands. Even if the market can get the job done, it will probably take 20 years or so to change the distribution of residency positions. Another approach would be to provide incentives, which we have done for a number of years in a number of ways: student-loan programs, financial incentives to medical schools, and legislative action to prompt state medical schools to increase their production of generalists. Still, only about 10 medical schools have at least 35 percent of their graduates becoming generalists. There is the 'birth control' approach adopted by the surgeons, but this raises antitrust questions. Finally, there are various regulatory approaches. While a few years ago, I would have very strongly advocated incentives, a reality-check suggests that the supply of generalist physicians is not likely to increase, and the supply of specialists is not likely to decrease, unless we incorporate some type of regulatory approach."
Arnold Epstein updated the audience on generalism and the Clinton health plan. Epstein is serving as Senior Advisor on Health Care to the White House. He is a general internist on leave from Harvard Medical School and the Harvard School of Public Health, where he is Chief of the Section on Health Services and Policy Research at Brigham and Women's Hospital."The current mix of generalists to specialists runs about 35:65 or 30:70, depending upon who is counted as a generalist in the equation. Given observations in other industrialized countries and in managed-care organizations in the United States, we think that something closer to a 50:50 ratio might be more appropriate. The Health Security Act includes mechanisms to address the balance and number of generalists and specialists in the work force and to support academic medical centers, which provide the bulk of our training. Regarding work force: if adopted, the Act would establish a national council--comprised of private-sector individuals appointed by the Secretary of Health and Human Services--that would direct an allocation process for training slots, with the goal of bringing us to a 55:45 ratio of generalists to specialists over a period of years. The 55 percent figure includes general internists, general pediatricians, family practitioners, and obstetrician-gynecologists. This council would also facilitate a reduction in the overall number of trainees.
"In addition, the Health Security Act would establish a pooling mechanism to provide funds for training programs and teaching hospitals. Funds in the pools would come from Medicare, regional alliances, and corporate alliances. One pool would reimburse teaching programs for the direct costs of medical education_salaries for medical trainees and their supervisors. This pool will increase over a phase-in period to $5.8 billion in 1999. In providing funds to teaching programs, rather than to hospitals as is now done through Medicare, the goal is to encourage the training of primary-care practitioners in ambulatory sites such as community health centers, health maintenance organizations, or other networks. Another pool would provide funds to teaching hospitals to help cover the additional costs associated with training, which are currently referred to as the indirect costs of medical education. Overall, the administration's goal is to provide strong support for teaching hospitals and other sites for medical education while establishing a structure that will enable us to bring the physician work force into better balance."
Michael Whitcomb discussed work force issues and questioned the validity of the 50 percent solution often bandied about in policy circles. Whitcomb is Director of the Division of Graduate Medical Education at the American Medical Association. At the time of the forum he was Director of the Program for Health Policy and Health Services Research at The Ohio State University. He has served as an advisor on manpower issues to a number of state and federal agencies including the Council on Graduate Medical Education and the Office of the Assistant Secretary for Health."I am going to share with you some information that might be viewed as politically incorrect, but I hope it will challenge your thinking about physician supply and refine our thinking about the policy goals that have been articulated. At issue here is the way we should approach reshaping the work force so that it better meets the needs of the country. Dr. Colwill has nicely framed the issues, and Dr. Epsten mentioned that we have accepted as one of our policy goals the notion that we should be striving for a 50-50 split of generalist physicians. The point I want to make is that to think about work force composition in terms of specialty mix--that is, generalist to non-generalist ratios--does not make a great deal of sense anymore. For example, England, Canada, and Belgium have vast differnces in the relative size of their work force. England has a work force of about 14 physicians per 100,000 population. Canada has about 230 per 100,00 and Belgium about 330 per 100,000. So you can see that, if you simply say 50 percent is a magic number, it turns out that you would have substantiallly different generalist work force sizes to meet the general patient-care needs of a society: England would have about 70 generalists per 100,000 population; Canada would have 114; and Belgium 165.
"I would point out that, at the present time, the United States has about 70 to 75 generalists per 100,000. The other thing we have in the United States, which does not exist to any comparable degree in other countries, is an elastic work force with respect to providing generalist services. That is, many physicians in our country are not classified as generalists, but provide substantial amounts of generalist care. I would suggest that we probably need to increase the supply of generalist physicians to a maximum of 100 per 100,000. To put this in perspective, if we move to a 50-50 composition for the year 2020, recognizing that the physician to population ratio will continue to increase, we would end up with a work force of about 130 or 140 generalists in the aggregate. No country in the world has a generalist-to-population ratio that approaches that number. Thus, we should probably shift our attention away from percentages and worry more about the total supply of physicians, along with the nature of the work force required to meet the needs of the population."
Robert D'Alessandri assessed approaches to increasing the supply of generalists in medical schools and residency programs. D'Alessandri is Vice-President for Health Sciences and Dean of the School of Medicine at West Virginia University. He has been active in health policy issues in West Virginia and has served on Hillary Rodham Clinton's Health Care Reform Task Force."If medical schools are going to change the physician mix in this country, they must make an institutional commitment to primary care and provide aggressive leadership to deal systematically with a need for more generalists in the work force. Our first opportunity to change the system comes in the medical school admissions process. Strategies here include involving community primary-care providers on admissions committees and admitting students with values attuned to service versus material gain, since this orientation is a predictor for entry into primary-care practice. In addition, schools must back up their admissions programs with curricula that emphasize primary-care experience. At West Virginia University, all of our students are required to do primary-care rotations. Our goal for the entire educational process is that at least 25 percent of students' education takes place in community primary-care settings. But changing where we teach our students is not enough. We need to change what we teach them. We must prepare them for managed care, for focusing on wellness and disease prevention, and for case management.
"The next step on the change continuum is in the area of graduate medical education, which needs to be integrated more fully into the system of physician education. Medical schools can work with communities to develop clinical-care networks, so residency training can come out of tertiary-care centers and into the community. We must work to involve community-based physicians in the supervision and teaching of residents. While there are many challenges to overcome with respect to community-based training, it will ultimately produce better physicians and better health care for the public. And lastly, medical schools can develop programs that support primary-care providers after they are in practice to reduce isolation and increase retention. One strategy we have pursued is linking rural areas to the medical center through a telecommunication network; we call it Mountaineer Doctor Television. All of these changes have made a difference at West Virginia University."
Alan Nelson spoke about the importance of integrating physicians' training, hospital privileging, and practice. Nelson is Executive Vice-President and CEO of the American Society of Internal Medicine. He has served as President of the World Medical Association and President of the American Medical Association."The work force problem will never be adequately addressed unless we make generalist careers more attractive. Incentives for gifted students to enter generalist fields are necessary because forcing a physician into a field by default results in dissatisfied doctors. Cranky doctors cannot provide the best care for their patients. Incentives include fair reimbursement, but they certainly are not limited to payment arrangements. Lifestyle and greater control over one's professional life, freedom from the paper blizzard that accompanies taking care of 30 patients a day, and restoration of earned respect are also important factors. The key is to understand that incentives are necessary--neither controlling the front-end spigot nor shoe-horning people into career paths will do the job without them.
"My next point has to do with the need to revise the curriculum for training internists. In the first place, the academic community has not adequately provided opportunities for students and residents to experience the real world of primary-care practice through mentorships in which trainees can see first-hand the rewards of longitudinal relationships with patients. Neither have they uniformly provided residency training that teaches the necessary skills for confident and fulfilling primary-care practice. Relegation of primary care to a triage role diminishes its attractiveness to any bright, motivated, modern young man or woman.
"My third point has to do with the dual role that many internists fill, and fill well, and the need to avoid unnatural and unwise restrictions on the scope of practice just so the provider panel of a health plan will conform to some arbitrary provider mix. A sizable proportion of primary-care services is provided by subspecialists--this is the elasticity to which Dr.Whitcomb referred--a fact largely ignored in work force projections. Any changes in system design must be accomplished in such a way that form follows function."
Harry Jonas addressed the topic of incentives and broadened the scope of the discussion by highlighting the importance of cooperation when planning and implementing strategies to increase the supply of generalist physicians. Jonas is Assistant Vice-President for Medical Education at the American Medical Association and Secretary to the Liaison Committee on Medical Education."I would like to take the privilege of being the last speaker to raise a question that I hope will stimulate the discussion to follow: in our attempts to increase the supply of generalist physicians, how can we unify the medical education community in support of this concept? The question reflects a concern related to introducing the whole subject of societal decision making into the process of career choice. In the past, medical schools have made decisions based upon their own goals, and we have counted on a sense of social responsibility to ensure that the nation's needs would be met. Federal and state agencies are placing much more pressure and, potentially, many more constraints on individuals and institutions. I'll try to illuminate this issue by giving an example. Since the overriding theme of our session is theory versus practice, I hope you will consider the practicality of my argument, as well as its conceptual merit.
"This example has to do with the use of financial incentives to influence medical student and resident career choice through the Primary-Care Loan Program. Funding under this program is now limited to those who commit themselves absolutely to a generalist career upon entry to medical school--before they have been exposed to the wide variety of educational experiences available to medical students. This program reflects the use of federal funds to influence federal priorities, but the result might not be what was expected. There is already evidence of at least one school returning program money to the federal government because not enough of their students were willing to commit to a career choice that offered no flexibility. I think this indicates the importance of evaluating the impact of any incentives that are introduced. The Primary-Care Loan Program experience suggests that it is preferable for loan forgiveness programs to be elected later in the curriculum, when students and residents can make informed decisions.
"I think that the objective of producing and retaining more primary care physicians will be best served by cooperative efforts, where the interests of the public, the government, medical schools, students, and residents are considered together. If we are to develop an appropriately trained work force that will fit in with the health-care system we adopt, now is really the time for the most knowledgeable and responsible professional and public leadership to exercise the best in improved communication and to work together toward that goal."
Dr. Jonas also served as moderator for the roundtable discussion that followed the position statements. The discussion ranged from the importance of language in the health policy debate (e.g. defining generalism primary care and coercion) to the role of communication-skills training in preparing students and residents for generalist practice. Much like The Annenberg Washington Program, this roundtable offered an arena for people with diverse ideas to raise issues, discuss their implications, and find common ground. The workforce issue provided perhaps the best example of this process: although there was consensus regarding the need to increase the supply of generalist physicians, discussion highlighted the implications of viewing workforce composition in terms of generalist-to-specialist ratios (e.g., 50:50) versus generalist-to-population ratios (e.g., 100:100 000). The exchange sensitized panelists and audience members to the assumptions driving educational and governmental policy initiatives and emphasized the merit of having a forum in which to discuss them.
