Doctor Dilemma With Growth Of Managed Care, New Physicians Are Shunning Specialties For Safer Family Practice.

It has not taken long for the economic realities of medicine to smack Scott McLean around.

The fledgling psychiatric resident at Jefferson (Pa.) Medical College recently lost an argument with an insurance-company doctor who didn’t want to pay for a troubled patient to stay in the hospital. “It made me really angry,” McLean said. “I’m not a businessperson. I just want to do my job. I couldn’t sleep at night thinking I had denied hospitalization to someone who is suicidal.”

McLean, 28, doesn’t have to look far for someone who is faring better in the upheaval engulfing health care.

His wife, Regan Wylie, 30, is an emergency-medicine resident at Allegheny (Pa.) University Hospitals. She, too, has had to defend several treatment decisions to insurers, but her judgment so far has been seconded.

While far from conclusive, their experiences suggest some of the reasons new doctors are avoiding specialties such as psychiatry and are entering less-narrow fields like emergency medicine.

Newly minted doctors who work for years at low pay as residents are flocking to be generalists - and medical schools are seeking to smooth their passage by overhauling decades-old curricula.

American-trained MDs are generally avoiding such specialties as anesthesiology, cardiology and psychiatry for wider-ranging fields such as family practice and primary care.

This shift is partly a response to market pressures. The rise of managed care is cutting into specialists’ pay and creating a greater need for primary-care gatekeepers.

Cost-cutters are going farther by seeking to transfer some doctors’ duties to specially-trained nurses and other lower-paid staff members.

Many believe it simply makes good sense for medical schools to produce more generalists. “Managed care is just accelerating what should happen anyway,” said Jonathan E. Gottlieb, associate dean of academic affairs at Jefferson Medical College.

Among the impressive statistics: The number of U.S. medical residents entering family practice through the National Resident Matching Program has climbed by 70 percent since 1991, from 1,374 to 2,340 this year.

The surge is so pronounced some medical administrators privately say the generalist bandwagon may be getting overcrowded and medicine could experience a shortage of specialists in a few years.

The generalist trend seems to be everywhere. Even for doctors who specialize, medical schools are moving to train them more in the mold of generalists who can organize many aspects of care and talk persuasively to their patients.

What’s new is the perception among American-trained residents that specialties are to be avoided.

Nationally, the total number of new American-trained doctors seeking to become specialists through the matching program fell by 40 percent, from 1,165 in 1992 to 694 this year.

Cardiology, once one of the most prestigious specialities, has attracted 31 percent fewer U.S. graduates since 1993 while gastroenterology has seen a 64 percent decline.

In an analysis of these trends, David E. Longnecker, chairman of Penn’s department of anesthesia, noted recently how quickly the changes have come and how suddenly the status of specialists has been altered.

“Specialty care, once considered a strength of the American system, is now maligned as an example of waste and unnecessary expense,” Longnecker wrote in a March 1997 article in the journal Anesthesiology. “Prestige has shifted from highly trained specialists to generalists, leaving medical students … and practitioners confused about career choice or (the) value of their services.”

Longnecker’s own field had been a coveted specialty that assured its practitioners of regular operating-room hours and good pay. Now it has become a microcosm of the changes sweeping the specialties.

Some health economists have suggested nurses could assume the anesthetist’s role. Medical students say they often hear stories about the field’s poor prospects. From 1993 to 1996, the number of U.S. students entering the anesthesia field nationwide through two matching programs sank from 831 to 169 - a drop of 80 percent.

In an interview, Longnecker called the shift “a remarkable overreaction” to a changing medical market. He noted demand probably was not as low as students thought it was and the field was already starting to recover. A total of 253 U.S. graduates chose anesthesiology this year - a substantial rise from the decade’s low point last year.

Longnecker said some of the decline was cyclical. For years, he said, Veterans Administration officials said anesthesiologists were in short supply. The field overexpanded in the 1970s and 1980s, and a necessary contraction has occurred.

Anesthesiologists, he said, have also failed to promote the value of their work.

Still, the decline in residents is forcing Penn’s anesthesia residency program to scale back. The department, long one of the nation’s most renowned, can boast of alumni who head more than 20 other anesthesiology departments nationwide.

But only seven people, the lowest number in memory, began this summer in its residency program, which has had as many as 33.

There is evidence some residents think the worst has passed. Phillip Venable, a Jefferson resident, came to anesthesiology this year after three years in a surgical residency, in part because he wanted a better lifestyle.

“I had heard the nightmare stories of people finishing residencies and not getting a job,” Venable said But “… the specialty is changing with the times. There’s more opportunity, especially as it expands.”

The skittishness of residents isn’t limited to anesthesiology. Radiology has taken a similar downturn. In 1993, 699 U.S. students were matched with radiology residencies; this year, the number dropped 37 percent as 440 U.S. students were matched.