Medical students want to become primary care doctors, until reality hits

According to the Journal of the American Medical Association, only 2 percent of medical students are entering primary care internal medicine.

A fourth year medical student gives some reasons why in a Baltimore Sun op-ed:

Like many medical students, I proudly wear Obama T-shirts and yearn to reform medicine. While watching the president speak, I envision myself working in primary care, on the vanguard of health care reform.

Then, a little later, reality hits.

That reality involves staggering medical school debt, where numbers show that 40 percent of students graduate with debt in excess of $140,000.

And it’s not all about the money. Combined with the fact that the burnout rate is higher in primary care, along with the onerous paperwork and bureaucracy requirements, it’s no wonder why students are avoiding primary care.

A paltry increase in pay isn’t going to stem the medical student tide towards specialty practice.

And to those who suggest that mid-level providers can help with the shortage of primary care doctors, think again. They are not immune to the same economic incentives, and indeed, we’re seeing physician assistants and nurse practitioners gravitate specialists’ offices as well.

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  • Michael Kirsch, M.D.

    Here’s what Harvard thinks about primary care!

  • ErnieG

    It’s a real problem that those outside medicine have a hard time grasping– that primary care (internal medicine, family medicine, and pediatrics) is being abandoned by medical students, particularly the brightest ones, because it looks no good. Why work your tail off, underappreciated by a system that values procedures rather than diagnostic accumen, and therapeutic advice when being a procedural specialist pays off? It is precisely the brightest ones that should be going into the challenging cognititive specialties that look at the patient as a whole and this current payment system makes the system into one of self-serving partialists with hacked up care. Medicine was about serving the patient, and what we are getting is medicine that serves the doctor when the best students line up for dermatology, ophthalmology, and radiology, and orthopedics.

  • Michael Kirsch, M.D.

    I am one of those procedurists, although you omitted my specialty of GI in your list. I agree with your analysis. I fear that to the extent that Obamacare takes root, that there won’t be too many of “the brightest ones” who will be pursuing a medical career, let alone primary care. At present, I agree that many medical specialists are excessively compensated. Most everyone, however, feels that he or she is worth more than they are paid.

  • Send513

    Any ‘mid-levels’ (got I hate that term) don’t want to do primary care any more than MDs because they do NOT get paid either!

  • Dr. Mary Johnson

    Kevin, a huge part of the problem right now is that the President of the United States (married to an ex high-dollar, “non-profit” hospital executive) does not even know what primary care providers do – or indeed, who they are:

  • Nuclear Fire

    That’s why I chose not to do primary care and chose to sub-specialize. I’m in my first year of fellowship and it’s already so much better even in training.

  • Matt

    I think it is also important to keep in mind the perception that medical students get from the physicians they train with. Obviously, this is often an n of one situation, but I seemed to run into anesthesiologists, radiologists, and cardiologists who raved about their job and tried to convince students to enter their chosen field. While plenty of internists and FPs complained about paperwork, their lack of control and whatnot. My basic point is that perceived job satisfaction is learned primarily during the third year, and I think that makes a big difference for a lot of people.

  • Anonymous

    Guess what Speciality care is not going to make you richer either. More paper work and a lot of nobodys looking over your shoulder and wecond guessing everything you do. Malpractice premiums for speciality care is much higher than Primary care and a whole lot of angst over nothing and certainly not much financial incentive either.

  • Nuclear Fire

    LOL. I hear the bitterness Matt was alluding to in Anon 8:53′s comment. I think Matt’s point is well taken. The specialists seem to really enjoy doing their jobs, while the internists I worked with and the FPs I know seemed to want to enjoy their job and thought they would in some ideal situation, but their daily life seemed like such a grind. Med Students are paying attention and are already tired from all their studying.

  • dennis

    You are spot on. Over the years of being a patient, I’ve noticed great differences in the work hours and earning potentials of different medical professionals.

    It is but practical for people to look after themselves, for if they don’t, no one else will.

  • Dr. Grumpy

    I’ve been in solo neurology practice for 10 years, and am surprised to hear people think I am making a fortune at this. I work 80 hours/week and make enough to cover my office and support my family, but looking at my numbers I’m pretty sure the internists in my building are making about the same.

  • Whitny

    Hey, Kev, in case you aren’t aware, the term “mid-level” isn’t PC anymore.

    Ah, primary care is simply suffering the same fate that other professions like teaching and those in the social services suffer. It’s no surprise. Still, I’m totally excited to begin my career in primary care and I feel grateful to have gotten here. Maybe I’ll be whistling a different tune a few years from now when I’m buried in paperwork and crushed by a broken system.

  • Paul

    Market forces are at work here as are so many other forces. Medicine is the same as so many other jobs, but is also sooo much different. I am a surgical subspecialist. I am fairly well compensated for the moment. The stress of my work is quite taxing to me and others of my ilk.

    My dad’s best friend was the only doctor we knew growing up and he is a very successful orthopedic surgeon. He once told me to follow my interests but to also realize the inalienable truth that people in this country will not pay you for what you know, only what you can do.

    Why do baseball players get paid so much to play a game esp when they don’t seem to be working as much as soccer players or linemen in football? It is because in that split second while at the plate as the pitch arrives something very consequential is about to happen that may have great significance and gravity in the course and results of the game….a powerfully pivotal moment. Those moments of intervention with great pivotal situational value have always been seen as having more value.

    The value of primary care is vast but muddled in the mundane and is often lost to perception. Sad. I don’t know what should be done. I hope the cream rises to the top and they can find their way to professional fulfillment. I plan on getting old and in need of expert medical care provided and orchestrated by a smart motivated internist and hope that they have not gone the way of the Do Do bird.

    Sorry about the spelling.

  • Evinx

    There is a small trend in primary care physicians moving toward concierge style, a la MDVIP. As a concierge dr, they limit the practice to 600 patients and start to practice medicine with a more personal touch. The marketplace will move drs to primary care if we allow them to function as drs and not medical automotons. Of course, more govt involvement will not solve the problem just bcs Obama wants it to. Alignment of incentive is what is required + only a freer medical marketplace will allow for that. That is what prices do – they allow for feedback to the supplier network.

  • Melben

    Hey Michael,

    Great article on Harvard’s point of view, check out this article on Harvard suspending funding for Primary Care:

  • Michael Kirsch, M.D.

    Melben, thanks for the link. Very poor PR for Harvard who should be setting a higher example. I think that the mission of academia is often higher than their actions.

  • Melben

    Agreed Michael, I would have expected Harvard to set a much higher example..

  • ninguem

    If practicing in East Podunk is undesirable for a native-born American physician, it’s just as undesirable for an American midlevel. Even more so, in a way. At the risk of sounding sexist, to the extent that the midlevels might be more female than male, a single woman often does not want to move out to a rural area.

    Even more so, if it’s undesirable to an American, male or female, it’s even more undesirable for someone born outside the USA.

    The practice demographics of USA midlevels, and international medical graduates, reflect this.

    The biggest determining factor of getting a doctor into a rural area is being from the area in the first place.

  • Rob Lai

    For anyone interested, here is a video relevant to this discussion from The Doctor’s Channel.
    It discusses factors contributing to aspiring doctors’ disinterest in primary care, as well as several proposed solutions.

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