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Show known medical knowledge, a decline in the scope and content of primary care activities, and the attractiveness of lifestyle and status found in specialty medicine (Houser, 1971). Thus, at the same time that recommendations are being made to increase the number of primary care providers, fewer doctors were choosing to go into primary care. The reasons for this are complex, involving both public policy and private perceptions. Reimbursement by both government and private payers emphasizes hospital care and procedures, thus shortchanging outpatient care and preventive services. For example, a Blue Cross/Blue Shield policy does not reimburse for immunizations or well-child care. It will pay 80% of outpatient charges for office visits and laboratory use. However, it will reimburse 100% of charges for surgery and in-patient care. This is typical of the insurance industry in the United States, and has led to a skewing of services in favor of more expensive care and high-tech procedures, preferably done on an in-patient basis. This is, of course, diametrically opposed to primary care practices, which emphasize prevention and low-tech interventions. Countries with national health insurance are often cited as exemplars of this preventive, low-tech focus. They typically have far more physicians practicing primary care medicine, and use these providers to serve as gatekeepers to decide when patients should be referred into the high-tech specialty fields. However, there is controversy about whether this truly works in practice. Seller and Lobley (1991) examined the practice styles of primary care physicians in England and in the U.S., comparing the process of getting to specific final diagnoses. They found that while British physicians order fewer tests per visit, thereby presumably saving more money than American physicians, the British patients had a larger number of visits prior to diagnosis, and the total number of tests ordered were essentially identical to the U.S. practice. Thus, the American patients were actually diagnosed more quickly and cheaply, since they had fewer total visits and the same number of tests. Those going through medical school hear many stereotypes about primary care which have a strong impact on their decision-making about future practice. Students choosing primary care residencies are perceived as being incapable of "succeeding" in the prestigious specialties. Currently, the most difficult residencies to obtain are dermatology, neurosurgery, and orthopedic surgery, and thus these are perceived as the most attractive fields. On the other hand, primary care residencies have chronic shortages of applicants, and anyone who graduates from an accredited school can count on admission to a primary care program, thus making it less prestigious. Most medical students with whom I spoke indicated they perceive that primary care involves working more hours for fewer rewards than any other field. These factors continue to influence primary care today. The rewards of primary care are often not communicated effectively during the decision-making process. For example, continuity of care and the opportunity to see the same patient many times over a period of years is rarely cited as an advantage of primary care. But as Blankfield, Kelly, Alamagno, and King (1990) showed, continuity of care is often a very satisfying portion of such a practice. At the point of entry to medical school, most students have been so focused on the admission process that they haven't thought extensively about what they want to do once they are admitted. The broad range of possibilities is presented for the first time. Many entering students aren't even aware that radiation oncology or pathology are available specialties. Most pre-med or early year medical students say they plan to go into primary care fields, but this is often because it is the only field they know about But as their horizons widen, they begin to consider other alternatives. They see that the faculty members defer to specialists and denigrate primary care physicians, and 96 PHYSICIAN SOCIALIZATION |