Medical students wary of the future - concern over Bill Clinton's health care reform proposals that may limit number of specialists

Insight on the News, Dec 27, 1993 by Gayle Hanson

Summary: The administration's health care plan seeks to increase the ranks of primary care physician by limiting the number of new specialists. That has many aspiring doctors - who are spending huge sums on their educations - worried.

The dark circles under Laurie Bertanyi's eyes are as much an indicator of what she does as the stethoscope around her neck. The fifth-year medical student at Stanford University has work shifts that can last 40 hours; her sleep is often interrupted by "code blue" emergencies. Bertanyi's medical training is an arduous journey that requires stamina and commitment.

But when she talks about becoming a pediatric cardiologist, her eyes light up. She knows she has the right stuff and she's determined to make the most of it.

"I've known that I wanted to be a doctor since I was 5 years old and had an accident and a woman plastic surgeon took care of me," she says. "I know that there is a need for primary care physicians. But pediatric cardiology is what I want to do. Most of my role models have been specialists and I really like doing procedures."

Bertanyi is holding fast to her dream, but she may never get the chance to help children with damaged hearts. If the Clinton administration's health care plan achieves one of its goals - increasing the ranks of primary care doctors - aspiring specialists many have to settle for work outside their chosen field.

Never mind that by the time Bertanyi finishes medical school she will have invested $275,000 in her education. Under the Clinton plan, her future would be determined by a panel of a administrators who would, in essence, fix the number of pediatric cardiologists and other specialists at levels deemed appropriate.

"I'll be coming out of Stanford, which is a respected institution," says Bertanyi, "but the possibility remains that even if I get a residency in pediatric cardiology, I could finish my fellowship and not find a job."

Thousands of students in medical schools, teaching hospitals and research centers across the country are in the same predicament. But as advocates of health care reform focus on the high salaries of specialists and the dearth of general practitioners, analysts less enamored of the Clinton plan are questioning the wisdom of completely overhauling a health care system that has placed this country at the apogee of medical research worldwide. Even as they acknowledge the sea change in the health care delivery system, many wonder whether the proposed cure may be at least as bad as the disease.

The state of medical education and its relationship to research and care giving has been much discussed within the medical community. Most recently, a number of doctors and medical school administrators addressed these issues in the Journal of the American Medical Association, along with related topics such as the low number of doctors in rural areas and the difficulty of attracting minorities (with the exception of Asian-Americans) to careers in medicine. But even though doctors, residents and medical students are finding themselves, as one cancer specialist put it, "in the Vietnam of health care," many believe the Clinton plan is too heavy-handed.

Under the plan, after a five-year transition about 50 percent of physicians in training would be involved in primary care. Those such as Bertanyi who want to specialize could do so only on the recommendation of a national council on medical education. Academic merit would play a part in the selection process, but the council also would consider the quality of the schools' specialty programs, the needs of local communities and minority representation.

Under the plan's system for regulating the number of people going into a specialty, medical schools and teaching hospitals exceeding their limits could find their government funding rescinded.

Not surprisingly, the American Medical Association, which has worked with the Clinton administration to shape the plan, whole-heartedly opposes specialist quotas. "One of our biggest concerns is the notion of a rigid quota system for identifying who will go into primary care," says Dr. William Jacott, a member of the AMA's board of trustees and a family physician. "Clearly many of our academic institutions have very good research programs and very good educational programs. To suddenly put a quota on the numbers of students they can train could have a damaging effect on research."

Critics have long claimed that doctors specialize to make more money; whether or not this is true, the trend continues. According to the 1992 Graduating Student Survey of the Association of American Medical Colleges, only 14.6 percent of the 15,365 graduates that year indicated they intended to become general practitioners.

"You can exhort all you want, until you are red or blue in the face, but if students want to go into high-technology specialities, they will," says Dr. David Korn, dean of Stanford's School of Medicine.

But some medical school administrators note that, given that right incentives and role models, students can be attracted to primary care. The University of Minnesota at Duluth, for instance, established a medical school in 1972 designed to produce primary care physicians. Fifty-two percent of the school's graduates have gone into family practice, and 40 percent have established their careers in a rural setting.