Primary care disrespect starts early in medical school

In medical schools, primary care continues to be among the least respected fields a student can choose.

No where is that more starkly illustrated than in Pauline Chen’s recent New York Times piece, where she tells a story of a bright medical student who had the audacity to choose primary care as a career:

Kerry wanted to become a primary care physician.

Some of my classmates were incredulous. In their minds, primary care was a backup, something to do if one failed to get into subspecialty training. “Kerry is too smart for primary care,” a friend said to me one evening. “She’ll spend her days seeing the same boring chronic problems, doing all that boring paperwork and just coordinating care with other doctors when she could be out there herself actually doing something.”

This lack of peer respect is one reason why only 2 percent of medical students choose primary care internal medicine as a career.

Regular blog readers will know that the generalist-specialist salary disparity, combined with the paperwork and high professional dissatisfaction rate, are major reasons why future doctors are avoiding primary care medicine.

But there remains an implicit bias among medical educators favoring procedure-based medicine, mostly due to the disproportionate amount of dollars specialists bring to an academic institution. Hospitals and medical schools give specialists unspoken, preferential treatment, and that sentiment trickles down to medical students.

There’s no doubt that influencing future doctors away from primary care starts from the earliest stage of medical training.

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  • Tyler

    I couldn’t agree more. Med school needs to focus on educating doctors to care for people — not just strive for high salaries and prestige.

    I found this helpful in that regard:

    Letter to Future Doctors
    http://hopeandhealing.org/contentPage.aspx?resource_id=355

  • jsmith

    Disrespect is merely a headline-grabbing proximate cause. The real cause is the money/lifestyle trade-off. When I started years ago dermatology was not prestigious. Superficiology and all that. Now hot shots want to do derm. You can guess why. It’s not the prestige.
    Fix the money in primary care, and the respect will come.

  • Doc in debt

    medical schools need to stop charging so much money to attend…that way students don’t have to strive for high salaries and prestige.

  • ninguem

    Problem is, the medical students who disrespect primary care are behaving rationally. To the extent that they disrespect primary care, it’s because everone around them is disrespecting primary care.

  • family practitioner

    I was in med school in the early nineties, during the first primary care push. We were told that, at the time, the country needed “gatekeepers.” What a stupid term, the public simply viewed primary care as “keeping them out”, away from their cherished desire for specialists and big ticket testing.

    Anyway, I took the bait.

    12 years in private practice.
    Everyday is a struggle.
    Income level despite seeing more patients, who are less satisfied, for many reasons, one of which is because I am busier.

    Colleagues from med school, went into GI or cardio or ortho, making 400,000 (they complain anyway, it’s never enough).

    Of course med schools are biased but the problem is a lot more complicated than that.

    As it stands now, only a fool would go into primary care.

  • Steven Wynn

    “Med school needs to focus on educating doctors to care for people”

    Who’s to say that they don’t teach us to care for people? As a second year medical student that has considered (maybe still is) primary care the images of primary care I get come from the older docs, blogs like this, and the media. Here’s what I hear about primary care:

    High level of work.
    A lot of hassle from insurance companies.
    Low pay (relatively)
    Low level of job satisfaction

    Who really wants that? Money is not just money. To compare oneself to their neighbor is to be human. So, if I put 60 hours a week into my job and I make $150k and the specialist puts in 60 hours a week and they make $300k am I going to gripe about it? I shouldn’t, but I will.

    And it’s not like if we choose to be a specialist we’re not going to help people. In some respects a specialist helps people more. If i’m an allergist and a patient comes to my office with some strange allergic reaction, I’m going to do something about it. When they get better I feel happy. If I’m a family practice doctor and I send my patient off to the allergist and they get better, will I be happy for them? Yes, of course. But would it provide more satisfaction to me if I was the one that intervened and my clinical plan worked? Arguably yes.

    I guess what I’m trying to say is that no matter how you try to paint the picture, the state of primary care stays the same. Unless things are changed in a way that makes primary care more attractive, medical students will avoid primary care like the plague.

  • http://alchemipedia.blogspot.com/ Alchemipedia

    If this post is meant only for a US readership then perhaps it may be correct.

    In the UK the discrepancy is the other way with Primary Care doctors earning higher salaries and having more professional autonomy.

    IMHO the brightest and the best should be encouraged to take a career in Primary Care is this is the hardest specialty to practice at a consistently high level.

    Promoting and delivering quality Primary Care is almost certainly the best way to help deal with the spiralling costs of modern health care and also still deliver good medical and pastoral care.

    Encourage the least talented doctors to take up highly specialist medical careers. Some of these specialties don’t even require you to be able to talk to people.

    Effective Primary Care practice requires a much broader palette of skills such as interpersonal intelligence, intrapersonal intelligence, verbal-linguistic intelligence, as well as the recognized professional standard of logical-mathematical intelligence.

    The quote by Robert A. Heinlein comes to mind:

    “A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly. Specialization is for insects.”

    Replace “human being” in the above quote with “primary care doctor” or any other medical specialty and “primary care doctor” fits best.

    Conflict of interest declaration – the author is not a Primary Care doctor.

  • Jenga

    If it was truly the hardest to practice the residency wouldn’t be the shortest and easiest.

  • alex

    Actually, the real reason the smartest med students don’t want to do FP doesn’t just have to do with money and time. I know of a freaking 5 year BA/PA program. There are 24 year olds in my area practicing primary care with essentially no supervision. It is the erosion of FP territory by unsupervised NPs and PAs that makes us feel like we would be total fools to go into FP. Can they do the job as well as we might? No, but so what? The government doesn’t care and in fact would prefer whoever follows guidelines more. The future is not bright.

  • http://alchemipedia.blogspot.com/ Alchemipedia

    Reply to Jenga.
    Please don’t selectively interpret my comment which said “… this is the hardest specialty to practice at a consistently high level.”

    Regarding your comment – “If it was truly the hardest to practice the residency wouldn’t be the shortest and easiest.”
    The length of a residency or how easy a residency seems does not necessarily reflect the difficulty of the discipline. It simply reflects the standards that have been set for successful completion of the training.

    Primary care is probably easy to practice at a mediocre level, hard to practice at a competent level, and very difficult to practice at consistently high level in all domains (ie pediatrics, psychiatry, minor surgery, sports injuries, etc etc) as clearly the remit is so broad.

    Robust critical thinking skills, the ability to reflect objectively about your own practice, and the desire to do things better, are much more important than the residency program a doctor enters.

  • jsmith

    family practitioner, I feel your pain. Your vision of primary care is dark, cynical and completely accurate. My wife is an FP who finished residency in 1995. She was snookered too. She’s not happy about it. I finished in 1989 when things were still pretty good. In the early 90s things were OK, but by the mid to late 90s things started to deteriorate badly and done so ever since. And we have yet to find a bottom. It will be interesting to see what the med students think of all this–what the Match will bring in March.
    Steven Wynn, You don’t have to justify yourself to us. Specialists are good people too.

  • Blake

    Alex– That’s a good word. I am a medical student and can tell you that there are two factors deterring me from primary care and he nailed one of them spot on the head. I hear physicians rave about their PAs and NPs, and then hear the PAs and NPs say that they can do the same job as the doc… but cheaper. It seems to me, at this point in my education, that being a physician going into primary care might be like a small business taking on Wal-Mart. Sure, maybe we can offer a better product, but people don’t necessarily want better… the success of wal-mart shows that people want average, affordable, available products. Of course there will always be a place for docs in primary care… small businesses succeed too. I just don’t feel like personally picking a fight with wal-mart.

    The other deterrent is that, in the current state of health care, primary care docs don’t diagnose; they manage. For anything interesting that walks in the door, say, a person presenting with a chief complain of chest pain–it seems all the PCP does is determine if it is cardiac, pulmonary, neurological, or muscular in origin and then send them to the appropriate specialist. Then the specialists makes the diagnosis and starts appropriate therapy. The PCP might switch meds if there are side effects and makes sure that all these specialists aren’t writing orders that are contraindicated, and that’s about it.

  • jenga

    All of those domains however are easily referred out and most often are. In my opinion the physicians and, I am not one by the way, that have it the hardest are the small town general surgeon. They are often at it every day, tons of call with no apparent backup. They are often making life and death decisions on trauma patients, managing other critical care patients in the ICU and often have to ride in on the white horse for any mishaps by other members of the medical staff.

  • jimmyz

    Jenga,

    And for that reason they (general surgeons) probably made a bigger mistake going into general surgery than FP’s.

  • http://alchemipedia.blogspot.com/ Alchemipedia

    Yes Jenga tough jobs are tough.

    The more general and unselected a clinicians’s casemix, whatever the specialty, the harder the job is likely to be.

    I will reiterate my point made earlier. The brightest and best should be encouraged to work in these more general fields. Leave the less talented to be the “superspecialists” with their highly selected patient casemix. Healthcare costs will fall when it is realised that you don’t need as many of the superspecialists with their often very inflated fees.

    Alot of the so-called “specialist” work that is undertaken could easily be dealt with by more generalist clinicians. It should also be remembered that generalists tend to be more holistic in their approach to patient care with the benefits that that produces.

    I agree with your point about the small town general surgeons. The problem here is more about inequitable allocation of healthcare resources, which unfortunately comes down mostly to politics

  • Jenga

    Your first statement would be true, if the cases were followed to completion. That rarely happens today. Most primary care physicians now don’t even follow their own patients in the hospital.
    Your argument ultimately fails when you factor in how specialists are trained. I can’t think of a vocation where more training equals less money and prestige, otherwise no one would do it. High school teachers probably have a harder job than someone teaching at a university, longer hours and less-motivated students but no one believes they deserve more money and prestige than those at a university.

  • Paul MD

    All of these comments are valid. Something that I shared with the chief of medicine at my school in the early 90s when he told me that internal medicine was my forte is the following. I declined his offer (but accepted his unsolicited letter of recommendation) and the following was part of my justification. Sounds simple, but for me it is still relevant today.

    I feel at my best, am most content and challenged in a field where I know an awful lot about a very concentrated area rather than knowing a lot about many areas. Global management and a lack of definitiveness made me feel like the floor was always moving. Frankly, I’m pretty sure that I would be a lousy primary care physician. I think sometimes we choose specialties because some of us are hardwired to do so.

  • hawk

    Alchem

    I take it you are a brit by your comments. I trained in australia,a nd have worked with a lot of highly competent british docs, mostly specialists, who left because they saw the prim cares making more than they did. Maybe the reason the non-superstars dominate the specialty field where you are is that the best and brightest left for ‘greener’ pastures

  • http://alchemipedia.blogspot.com/ Alchemipedia

    jenga:
    I refer back to my previous comment – “The length of a residency or how easy a residency seems does not necessarily reflect the difficulty of the discipline. It simply reflects the standards that have been set for successful completion of the training.”

    If you make specialist training very easy and generalist training very hard. Perceptions would change. Anyway it is the personal qualities of the doctor that are more important than the specialty they practice. I am certain there are many very fine primary care doctors nearby you, just look a little harder Jenja.

    Re: “I can’t think of a vocation where more training equals less money and prestige …”. Well how about all the very talented highly trained scientists out there who struggle to get postdoc positions, longterm tenure, or even a paying job that utilizes even a portion of their skills?

    The example of teachers is also not a good one. Universities don’t tend to employ teachers. They primarily want researchers who attract their own research funds (essentially paying their own and their team’s salaries as well as research costs), with teaching mostly taking second place.

    I also believe there are many teachers out there who deserve more prestige and money. Some of these apparent lowly teachers do get some recognition for the important work they do i.e. “Efren Peñaflorida, who started a “pushcart classroom” in the Philippines to bring education to poor children as an alternative to gang membership, has been named the 2009 CNN Hero of the Year.” (from CNN Heroes)

    Paul MD – I liked your comment. Very balanced perspective.

    hawk – interesting points. My impression is that most docs that go to Australia seem to go for the lifestyle benefits, not so much for academic reasons. I doubt that either UK or Australian speciialists would say that “non-superstars dominate the specialty field” (in UK). It was nice to see Elizabeth Blackburn, one of the recipients of the 2009 Nobel Prize in Medicine & Physiology was born in Australia, though her formative PhD training was from Cambridge University (1975). She did however “brain drain” to the University of California, San Francisco.

    Regarding primary care in the UK. Standards are definitely increasing in this specialty. The training is now harder and more rigorous. Some of the brightest and best medical graduates ARE choosing Primary Care over hospital specialties. Also, some of the regional training programs are extremely competitive, with high quality trainees and rigorous selection criteria. Remuneration seems to have something to do with this change. The same could happen in the US with support and the political will.

  • Jenga

    Research is only a portion of the work force and typically only a small portion of the.science department in your larger central state schools. You have business, mathematics, education, athletics, humanities and so on and so forth that are all salaried and outnumber research positions. The current talk is to LENGTHEN current specialty residencies due to the 80 hour work week restriction. Which was put into effect because some surgical specialties are already extremely difficult, not for onerous family practice residencies. Now if you want to bring all primary care physicians back to residency for two to three extra years of rigorous training, you might have a discussion.

  • http://DigitalNeurosurgeon.com Pieter Kubben

    I do not really recognize this for the Netherlands, at least not for Maastricht. Yes, they do have lots of administration, but so do we in the hospital. But you are not considered as a loser if you want to go into primary care, it’s more like “one of the alternatives” but among students not really a last resort. It may become so later, maybe.

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