Primary Care Secondary in Illinois

By: Paul F. CuadrosDespite a shortage of primary care doctors throughout the state, Illinois hospitals spend most of their time producing cardiologists, radiologists and other specialists.

Last year, 4,638 medical residents trained at the state's 35 teaching hospitals, according to the American Medical Association. But only 352 of these doctors were practicing family or general medicine.

Those numbers offer little relief for poor city and rural communities that are desperate for basic health care. And demand for primary care doctors will continue to grow as the state moves toward managed care, which emphasizes preventive medicine to curb skyrocketing health costs.

"We've got a system in place where we are producing ... far more specialists than the state needs, and too few generalists," said George O'Neill Jr., executive director of the Shawnee Health Service and Development Corp. in downstate Carterville.

Long gone are the days when the typical doctor looked like the caring family friend in a Norman Rockwell painting. Today, that doctor works in a hospital and practices specialties such as neonatology.

And while these doctors save lives every day, the trend toward specialization has left the state short of doctors whose job is to treat whatever ails their patients.

The state's medical schools should be producing twice the current number of primary care doctors, said Dr. Steven Wilk, chairman of the board of the Illinois Academy of Family Physicians.

And even that may not be enough: "The need is so great that even if you graduate 50 percent ... into the primary care fields, it would probably take until the year 2010 before we would come close," Wilk said.

But little will change unless Medicare and Medicaid begin paying more for care given in clinics and doctors' offices, where most primary care residents learn their trade. The two programs, which reimburse hospitals for the costs of training young doctors, do not pay for many of these services.

This financing creates an almost irresistible incentive to focus on specialties, which produces the largest payback.

Of the more than $380 million in state and federal funds spent on graduate medical education in the past year, $21.3 million is devoted solely to primary care training. That money, which funds a state pilot program, cannot compete with the $360 million pumped in from Medicaid and Medicare.

"It's ridiculous to spend the taxpayers' money to further contribute to the problem," said Michael A. Gelder, a consultant for the Illinois Primary Health Care Association, a coalition of community health centers. "We got in this boat because the financial incentives as well as the academic incentives were all pointing toward specialty care."

But for medical students, the lure of specialization begins even before they start their residencies.

Dr. Jaime J. Gomez, 34, was torn between family practice and obstetrics-gynecology while studying at the University of Illinois College of Medicine in 1990. He chose gynecology because he wanted to do surgery, he said.

"Family practitioners are limited as far as what they can do in a hospital with regard to surgery," said Gomez, who in June completed his residency at Cook County Hospital. He practices at Gottlieb Hospital in west suburban Melrose Park, while working two days a week at Alivio Medical Center, 2355 S. Western Ave.

Besides, he said, "primary care doctors don't make as much as specialists."

Hefty debt after medical school and the promise of higher wages and more prestige turn many young doctors into specialists.

Family practitioners earned an average of $111,800 in 1992, according to the AMA. An anesthesiologist will earn twice as much, about $228,500. While a doctor in general internal medicine makes $136,700, someone who specializes in cardiology will earn $261,900.

"I don't think there is any question that student indebtedness plays a role in making students decide what specialty they will go into," Wilk said. "But money is not the only factor."

Specialists also are "all the role models in medical schools, so most of them going through only see specialists as their teachers," added Dr. Raymond E. Hoffmann, president-elect of the Illinois State Medical Society, a doctors' group.

Of the 335 doctors who taught in Illinois medical schools last year, 296 are specialists, according to the AMA. Upon graduation, doctors complete their clinical training with three to seven years of residency at a teaching hospital, depending on their discipline.

In March, 1,052 students graduated from the state's seven medical schools: Chicago Medical School; Loyola/Stritch School of Medicine; Northwestern University; Southern Illinois University; Rush Medical College; the University of Chicago Pritzker School of Medicine; and the University of Illinois.

Three out of every four of those graduates chose to specialize, according to the Illinois Academy of Family Physicians.

That left just 263 students to practice family medicine, general internal medicine and pediatrics.

Southern Illinois compiled the best record for training general practitioners; 62 percent of its 1994 graduates chose primary care residencies.

"This school was founded with the very direct mission to train primary care practitioners for central and southern Illinois," said Dr. Carl J. Getto, the school's dean. "We select students for their interest in primary care ... and from non-urban metropolitan areas."

By contrast, Northwestern and the University of Chicago produced the fewest primary care residents in March-9 percent and 3 percent, respectively. Neither school has a family practice department

"If the institution doesn't feel that family practice deserves its own independent department, they're much less likely to feel that their students need education in that area," Wilk said.

But the University of Chicago's mission is to train doctors who pursue specialty careers in medical research or teach at medical colleges, said Norma E. Wagoner, dean of students at the medical school.

"We are one of the premier research institutions in the United States," she said.

Still, the school added an elective in family medicine for third-year students in 1992, and is considering making it a requirement, Wagoner said.

Four institutions-Chicago Medical School, Southern Illinois, U. of I. and Rush-require students to assist a family practitioner during their third year.

And last year, Rush launched a primary care institute to promote careers in general medicine and pursue primary care research, said Dr. Whitney W. Addington, director of the institute.

The school created the institute to address the "profound imbalance in the work force," said Addington, who also is president of the Chicago Board of Health.

Teaching Hospitals
Of the 23,937 doctors providing care in the state last year, only 3,063 were practicing family or general medicine, according to the AMA. Illinois hospitals employ 6,913 doctors; 92.4 percent are specialists.

Dr. John Schloff is one of the exceptions. "I went into family practice because I didn't really have a family doctor growing up," said Schloff, a second-year resident at the Family Medicine Center in west suburban Hinsdale.

Schloff and his wife, Dr. Brenda L. Schloff, who also works at the clinic, hope to set up a practice in a rural community.

In a small town, he said, "I'm sure an ear, nose and throat specialist would have a harder time finding patients, but with family practice you are taking care of every little problem."

Schloff is one of 823 primary care residents who have entered training programs at Illinois teaching hospitals over the last five years. Those same hospitals have filled 5,634 residencies in specialty care.

Since 1989, the teaching hospitals have filled 64.5 percent of their primary care positions, compared to 81 percent of their specialty residencies.

While many of those positions are eventually filled-often by foreign medical students-specialty residencies are clearly the first choice of most new doctors, said Dr. David Altman, associate vice president for education policy at the Association for American Medical Colleges.

Cook County Hospital's 82 primary care positions, the most of any hospital, still represent just 19.2 percent of its 428 residencies.

Residency programs are financed by payments from patients, insurance companies, Medicare and Medicaid. Patients at teaching hospitals pay slightly higher bills to cover the cost of their care.

"Yes, we get paid more money for having more of these people," said Michael Koetting, vice president of program evaluation at the University of Chicago Medical Center. "But the more of them we have, the more cost we incur."

Medicare and Medicaid also reimburse hospitals for the direct costs of medical education, such as teachers' and residents' salaries, and the indirect costs of training young doctors, such as increased testing and repeated procedures.

Medicare reimburses teaching hospitals an average of $70,000 per medical resident, according to the Council on Graduate Medical Education.

But Medicare does not pay for residents who work outside the hospital, even though residents learn primary care better in these settings, said Dr. Mohan L. Garg, a professor at the University of Illinois College of Medicine, who analyzed financing of graduate medical education in a 1993 study for the W.K. Kellogg Foundation.

In a report on graduate medical education published in October, the U.S. General Accounting Office concluded: "There are financial disincentives for teaching hospitals to sponsor primary care training."

Northwestern University's McGaw Medical Center, for example, received $33.2 million in Medicare and Medicaid payments last year. The hospital maintained 132 specialty residencies, but just four primary care positions. The Council defines primary care doctors as family physicians, pediatricians and internists who do not further specialize.

But Northwestern officials insist primary care includes all internal medicine and obstetrics-gynecology residents. They argue that about one-third of Northwestem residents start out as primary care doctors.

"The difficulty is that many of our trainees go on to a subspecialty, and that's something no institution has control over," said Dr. Robert M. Vanecko, the school's associate dean of graduate medical education.

But medical schools also benefit from the emphasis on specialization, since they get a portion of the money the hospitals make from performing specialty procedures and teaching the residents.

"A cardiologist who performs an angioplasty will take half an hour and charge maybe $12,000," Garg said. "A generalist will see someone for the same time and charge $60."

That income now makes up a significant portion of medical schools' budgets. In 1970-71, these revenues accounted for only 6.7 percent of operating revenues for U.S. medical schools, Garg's study showed. By 1991-92, they made up 32.4 percent of revenues.

Better Balance
By the turn of the century, the United States will face a shortage of 35,000 general practitioners and a surplus of 115,000 specialists, according to U.S. Department of Health and Human Services.

And the trend will only worsen as the nation moves toward a system of managed care to control costs, said Dr. Marc Rivo, staff director of the Council on Graduate Medical Education.

More employers are choosing managed care plans, such as health maintenance organizations, to cut costs and promote preventive care. Managed care requires more generalists, fewer specialists and fewer doctors overall, he said.

"If you're a benefits manager for your company and you take a look at how much it costs to take care of a patient with an ulcer in a Rockford (hospital) versus the University of Chicago, it costs a lot more at U. of C. because of the residency program," Hoffmann said.

The glut of specialists is already having an effect. "The real problem facing Chicago, as managed care develops, is what to do with all the specialists that aren't needed," Rivo said.

Some specialists are being retrained to become primary care doctors. Addington, a physician in internal medicine with a specialty in pulmonary care, is spending half a day a week working with family practice doctors to adjust to a different approach to care.

As a specialist, Addington said he would treat a person with lower back pain by immediately ordering X-rays and sending the patient to another specialist.

But a generalist aims for frequent checkups, an earlier diagnosis, and then prescribes simpler measures, like aspirin and rest, before more intensive treatment.

Garg said that managed care will force teaching hospitals to hire more primary care physicians, but that it will still be more profitable to train specialists.

He recommends that more Medicare money go to clinics and other primary care facilities, that states spend more money on medical schools to promote primary care training and tax the medical schools to fund primary care training.

The Council on Graduate Medical Education is urging the federal government to cap the number of residencies and increase the number of primary slots.

Funding for graduate medical education would no longer be tied to in-patient hospital care, but would be extended to care given in private offices and clinics.

The Illinois State Medical Society supports changing the financing formula, but opposes quotas or caps.

"We like to let the free market have its say as opposed to some kind of externally imposed quota systems," Hoffmann said.

And the Illinois Primary Health Care Association wants the state to extend funds for graduate medical education to the community-based health centers that provide primary care.

The state's Medicaid Advisory Committee is setting a course of action on graduate medical education for Illinois and how to encourage primary care training, said committee chairman George O'Neill Jr.

But everyone agrees that nothing will change unless the financial system is restructured.

"Clearly we need to do something about graduate medical education or there will be no quality education and no quality physicians. And in 10 years, the life expectancies and mortality rates are going to start climbing again," Hoffmann said.

Interns Jody Campbell and Michel Schwartz helped research this article.