Are medical students responsible for the primary care shortage?

There is a lot of speculation about why there are fewer and fewer primary care physicians joining the workforce every year. Some have focused on the choices that medical students are making when choosing residencies. Whether due to laziness, desire to make money or the drive to be perceived as “successful” in choosing a more prestigious specialty, the new generation of physicians are being blamed for not following in their parents’ and predecessors’ footsteps. Some claim that “blame” might be a bad word to use for this situation, since these choices are rational when medical school is so expensive and we have so many other more high-paying specialties to choose from.

On behalf of medical students everywhere, I would like to say that we are acutely aware of the problems that primary care is facing and the role that our choices in applying to residencies has on those problems. Every year, my professors say, more and more medical students say that they see the value of primary care and are strongly considering it as a career choice. We all know about the extraordinary amount of debt that we are facing, but realize that primary care specialties are able to apply for a wide variety of loan forgiveness programs that defray the cost of choosing primary care. This increased awareness of the importance of primary care are being reflected in this year’s match, where more and more students are matching into family medicine and other primary care specialties.

Nevertheless, I cannot help wondering whether the medical student’s role in the decline in primary care is a bit overstated. For one thing, the attrition in primary care isn’t just from the side of medical students entering residencies, but due to many people entering potential primary care specialties, like internal medicine and pediatrics, and leaving general practice for a subspecialty either immediately after residency or within the next five years of practice. Furthermore, since the shortfall in primary care physicians is already quite significant and only expected to get worse in the coming years. It seems unlikely that even a 10% increase in the number of students entering primary care every year would make that much of a difference, and I have serious doubts that such a thing is possible given the way that medical schools work.

The fact is: medical schools are becoming more competitive to enter than ever before. For every person that actually gets into a medical school, there are about 30 people who applied for the same spot. Therefore, medical students have increasingly been defined by those that were able to withstand the grueling pre-medical curriculum and the incredibly competitive admissions process. Anyone who chooses to apply to medical school knows this. They know that they could have chosen an easier path that could have provided a subsidized education (e.g., biology graduate school) or had a more immediate impact on patients and society (e.g., the nonprofit world or a social work school).

So what does this mean for primary care? It means that admissions offices and people concerned about the primary care workforce should be wondering whether the students that they actually admit are really more civic-minded and primary care focused than the many people that apply every year and don’t get in – not to mention many health advocates that could have applied but decided not to due to the costliness and competitiveness of the process. Shifts in admissions policy, such as Mt. Sinai’s program to admit more humanities majors, have been shown to also lead to shifts in specialty choices with the humanities majors tending to choose psychiatry and primary care fields at higher rates than their classmates.

While most schools do not typically have a program as distinctive as Mt. Sinai, most schools recognize the need to strive for a balance of bright and community-minded students. The result is that the medical students that make it through the admissions process embody a wide distribution of interests. Do some socially-minded medical students overcome all of the obstacles and make it to the top medical schools to continue their community work? Absolutely. Are there many medical students that would like nothing better than to do the most cutting-edge research or perform complex high-tech surgeries? Yes, and given the great need for more physician-scientists I am grateful for them. Are there also medical students that after all the sacrifices they have made to come to medical school really just want the job security of doing radiology or dermatology? Of course. Therefore, despite the obvious public health implications, I cannot help but feel that the 6% of students that go into family medicine every year – while it could stand to increase a little – is more or less an accurate reflection of the wide variety of interests and personal motivations found in a typical medical student class.

In short, the admissions decisions that schools are making to admit more community-minded providers are not enough. We need more programs, like the Sophie Davis School’s BS/MD program for training primary care physicians, which are specifically focused on training more primary care providers. However, without the a substantial governmental funding incentive to encourage such programs, there will be little impetus for institutions to break out of the mold of striving to be the best of the best academic center, admitting students with strong research portfolios and high MCAT scores.

Furthermore, we simply need to be training more doctors and medical students. The latest projections from the AAMC on the physician’s shortages indicate that we will face a shortage of 91,000 doctors by 2020. Half of this shortage will be due to the shortfall in primary care but the other half will be due to a shortfall in other specialties. The AAMC has recognized this need for more physicians and has called for an increase in the number of medical schools and the number of students they accept. However, their current plans are only projected to see a 20% increase in the number of students by 2014, falling short of their original goal. The number of physicians that are able to be trained every year is also limited by the number of residency spots that are available, which is capped by Medicare. With all of the other funding debates that are going on, much of this has fallen by the wayside, but it is important that we continue to see the primary care shortage as a workforce supply issue that deserves its rightful place in the discussion of healthcare reform.

Emily Lu is a medical student who blogs at Medicine for Change.

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  • Anonymous

    Medical students are making completely logical, predictable choices about their futures careers. No one with an ounce of sense can blame them for not going into a dying branch of medicine.

    • Robert Bowman

      Not a dying branch, just one being throttled by decades of MedPAC, Congress, and insurance abuses. And revived by 1965 – 1980 with a doubling of primary care numbers and a brief span 1990  1995 with a brief redesign for more for primary care and less for others. And NP and PA are no help as they decrease to lower proportions remaining in primary care with each passing year and each year after graduation – also because of too little for primary care and too much elsewhere.

      • Anonymous

        20 years of RUC throttling most likely results in death!

  • Michael Heck

    As a medical student, I can tell you that money is only part of the problem.  Job satisfaction is a huge issue.  The bottom line is that Primary Care is HARD and is only made harder by the current low reimbursement.  

    Look at it from our point of view:  I go to do a primary care rotation.  The doctor spends 15 minutes per patient.  He knows the patients, I don’t.  I have only a few short minutes to meet the patient for the first time, establish a rapport, and figure out what’s wrong, then present it to my doctor and come up with a plan.  It is stressful, fast paced, and very, very HARD.  You have to know multiple subjects very well, unless you plan on referring everything.  It is not an enjoyable experience for a student.  

    By comparison, on my radiology rotation, my doctor was well paid, un-rushed (mostly), and happy.  He went home at 5 (or earlier) and didn’t take work with him.  It was easy for a med student to figure out the basics.  In a week, I was reading a chest x-ray pretty well, I think.  After all, it’s just anatomy (mostly) and pattern recognition.  Piece of cake, compared to primary care.  

    So, why don’t I do primary care?  Lower pay.  Paperwork.  Huge Debt.  Insurance Headaches.  High Overhead.  Huge Staff Required (more management headaches), Hours, Demanding Patients, on and on and on and on.  

    Fix all of this, and we’ll talk.  (Disclaimer:  I am actually doing psychiatry, which some consider primary care, because I love it.  That being said, psychiatry is also immune to many of the issues I’ve detailed.  We have more time to spend with patients, less staff requirements, shorter hours, lower over head, and fairly good pay per hour actually.  Most importantly, I loved it.  Students simply aren’t “loving” the primary care, PCP experience.  

    • Anonymous

      Wonderfully well said. I would love for your post to be read by every officer and board member of the AAFP. They really don’t get it.

    • Anonymous

      5 stars Dr. Heck, you nailed it.

      I am a primary care doc, I went into it for all the right reasons, I love the continuity of seeing multiple generations of the same family, and really being a part of peoples lives  I am not the primary breadwinner in our family so I knew I would be making less and didn’t care.  I chose this field knowing it would be a labor of love, but I was not prepared for the amount of emotional energy that is spent day in and out, as it turns out to the detriment of my own health and family life.  

      For these reasons coupled with an increasingly intolerable atmosphere of decreasing reimbursement and increasing demands (see more patients, do more per visit – I want a physical + pap and oh by the way let’s handle every other medical problem I have accumulated in the last year in this one visit, including my chest pain and previously undiagnosed major depressive disorder, more via phone/email/24/7/365 access). 

      I didn’t go into this for the money, but some pay would make some of the daily indignities I endure on the front lines of primary care tolerable (prior autos, referrals, FMLA and other forms).

      But the real deal breaker for me is ending up being this: to do this right you have to really put yourself out there, to invest and give of yourself, emotionally, physically – you have to put yourself out there and invest in the relationship and the person.  I have cried and laughed with my patients along the way but emotionally I am at the edge – it is too much giving in so many ways and I find myself an empty short tempered shell of the person I regularly am once I am home, having given it all at work.  

      So I am pretty close to walking away for all of the above.  At some point when your profession is sucking the life out of you it is time to make a change.  The sad part is how many wonderful caring docs are in my same situation.

      Not sure what the solution is, I suspect we will all be outsourced and internal medicine will be staffed with NPs and PAs.  Sad.

  • David Melling

    As a third year medical student, I would also like to say that I think there is simply a lot of uncertainty about the future of primary care which makes med students shy away from it altogether. I think a good number of students are under the impression that mid-level providers will eventually just take over primary care and doctors won’t even be needed in this role anymore. The truth is however, primary care doctors are absolutely needed as the foundation of a quality health care system. What we need now is quality, concrete legislation dedicated to promoting a bright future of primary care doctors in this country. That legislation should start with changing the entire reimbursement system so that it is at least fair for primary care doctors. Like the author of this article stated, we as students are very acutely aware of the problems facing primary care and until something is done to change that, students will continue to shy away from it.

  • ninguem

    How on Earth could you possibly be blamed for the primary care shortage?

    You are making decisions you consider to be in your best interests. If you avoid primary care, that reflects problems with primary care, not with you. Michael Heck’s post is spot-on, I couldn’t say it any better. To the extent that students avoid primary care, I suspect they are making an intelligent choice.

  • JenniferL

    “Are medical students responsible for the primary care shortage?”

    Well… yeah,…. to the extent that medical students are not rushing into the enslavement planned for them by the Washington Bureaucracy.

  • Gthang007

    Interesting that you mention the sophie davis bs/md program. I know a few physicians who have graduated from the program, and the majority say very few graduates go into primary care medicine despite its ‘mission’ to graduate primary care physicians.

    • ninguem

      I didn’t know what the “Sophie Davis BS/MD” was about, so I looked it up.

      They call themselves “innovative”. Gag me. BFD. Those programs have been around since Nixon was President, probably before that. I know I applied to them. in the 1970′s.

      Theyr’e nice, but if they were going to solve anything, they’d be standard now.

      Actually, if people really were serious about producing primary physicians……….and I doubt they are…….how about the osteopathic programs that really pull it off?

      Or at least they used to, I haven’t paid attention for a long time.

      • Robert Bowman

        The FM residency grad delivers about 20 – 25 Standard Primary Care years in a 33 – 35 year career. Duluth at 14 Standard Primary Care Years per graduate leads due to 45 – 50% FM, top osteopathic at 10 – 12 SPCYrs, Osteopathic and Caribbean at about 8 – 9 SPCYr per grad. US MD average is about 4 – 5 or about the same as IM or PA. NP is about 4 but decreasing. In each case it is the family practice component, those remaining in family practice, that makes the difference in primary care, rural, and underserved delivery. Osteopathic was 70% family practice in 1960, 35% in 1990s, and 17% now. Osteopathic is double the primary care delivery per graduate compared to MD, NP, or PA but it takes 4 times more grads now than in the 1960s for the same primary care delivery. NP grads are down to 25% remaining in family practice employ and PA down to 20% entering FP (down from 44% in the 1980s). FM residency graduates remain 90% in family practice for a career – lasting and permanent primary care where needed – but also hostage to the US design that sends the least to primary care and to practice locations where family practice MD, DO, NP, and PA are most likely to be found. The US now has twice the primary care graduates as 1980 (28,000) but has decreased from 280,000 SPCYrs per class year to 230,000 SPCYrs due to only 30% primary care retention. In other words, primary care graduates under the US design have become 70% non-primary care workforce. Serious and SMART in primary care is permanent primary care, not flexible NP, PA, and IM that follow policy designs away from primary care and away from where most needed.

  • Gthang007

    Interesting that you mention the sophie davis bs/md program. I know a few physicians who have graduated from the program, and the majority say very few graduates go into primary care medicine despite its ‘mission’ to graduate primary care physicians.

  • Eric Lu

    Interesting read. Primary care shortage is a complex issue, as you highlighted and also as pointed out by the readers below. But it’s always good to see a fellow med student advocating for a better primary care system!

    • Anonymous

      “Should you find yourself in a chronically-leaking boat, energy devoted to changing vessels is likely to be more productive than energy devoted to patching leaks.”–Warren Buffett

      Should you see a chronically-leaking boat on the shore, don’t get in.–buzzkillersmith

  • Anonymous

    Very interesting article and comments.  Why should students pursue primary care?  Out of the goodness of their hearts?  Life, and reality, is more than that.  I am a family doc working at an internal medicine clinic.  70% Medicare patients.  Most are over 75 with every associated disease that you can think of.  I enjoy my patients but the hassle to practice is unbelievable.  
    About 5 years ago I decided enough is enough and contacted my local dermatology residency to see if I could apply.  The director told me about a Medicare law that passed in the late 90′s that prohibits Medicare residency funding for primary care docs who try to go back into another specialty.  I was floored–even looked up the law on the internet and sure enough, it was true.  
    So, here I am, doing my best, working 13-14 hour days, making less now than 4 years ago, seeing no benefit from electronic records, finding it hard to believe that my professional academy (American Academy of Family Physicians) even cares about us out in the trenches anymore, and staring a 30% Medicare payment cut in the face this coming new year.
    Maybe, just maybe, when family docs start retiring in droves and it takes longer to get an appointment with your local primary care doc than a specialist, someone will wake up and change this putrid environment, but until then, I don’t expect medical students to be applying to primary care residencies.
    If you can tell I’m depressed by reading this, then maybe you should go into primary care.

  • Terence Ivfmd Lee

    This is just a prime example of what happens when free market forces are sabotaged.

    There is a fundamental inconsistency in all the debates surrounding primary care. From some perspectives, the arguments shout that primary care is the most precious thing in the world and we will be doomed if there is not enough. From other perspectives, the arguments shout that primary care is the most horrendous thing in the world and that anybody would be crazy to want to go into it.

    Where else in the world do we ever have this type of blatant contradiction? Can you think of anything else where people say “We need more X. There is not enough X. Everybody wants X.” while simultaneously saying “X is without hope. Don’t go into X.” It just doesn’t work that way unless someone is artificially interfering. With interference, you must look not only at the direct short-term effects, but also the indirect and long-term consequences. This is why we have the mess that we have today.

    This dilemma we are facing is due to interference with normal healthy market forces. Without this interference, there would be a dynamic balance achieved between how many people choose to devote their time and energy into learning and performing primary care services and how much other people value such services.

  • Anonymous

    Great comments all.  The theme here is “incentives.”  If you want people to do X, you must give them the proper incentives to do X.  Simple really, econ 101 (the microeconomics chapter).  All the rhetoric in the world will be ineffective unless the incentives change.  The search for the mythical altruistic medical student who will come and save us will be ineffective.  New residency slots will be ineffective.  Outreach to elementary schools will be ineffective. President Obama (bless his heart) telling us how important we are will be ineffective.  Upbeat emails from the AAFP (bless their hearts) will be ineffective. 
    Money and working conditions compared with those of other specialties, baby, money and working conditions.

  • Jim Jaffe

    okay, you say we need to be training more doctors, apparently ignoring the case made by some that there’s no shortage.  even the government accountability office reports that the ratio between docs and patients has been improving for decades.  don’t know if you also worry about rising costs beyond physician loan burden, but its worth considering data suggesting that more doctors result in higher medical bills — without necessarily improving health status.  

    • ninguem

      We don’t need to train more doctors. If you could snap your fingers and magically double the med school pipeline flow of docs out of the schools, all you would accomplish is lots of specialists, and those feeling pushed into primary care like the losers in a musical chairs game, will find another line of work. Students seeing unemployment at the end of their training would walk away and the med schools wouldn’t fill.

      Students reacted swiftly when they saw unemployed anesthesiologists in the 1990′s.

    • Robert Bowman

      The US increased primary care delivery capacity per class year only 1965 to 1980 and to a small degree 1990 – 1995. During these periods somewhat coordinated policies involved production, retention, and support of primary care. We essentially have had less primary care (training, workforce, funding) steadily despite increasing population and more elderly. These calculations include MD, DO, NP, and PA.
      Primary care costs are limited by too few RN, MD, DO, NP, and PA in primary care. Doubling of primary care was only 1965 to 1980 – only one time every. Doubling of non-primary care workforce has proceeded each 15 years and will continue until 2025 at least. The design is very clear. The awareness is totally lacking. Without awareness, the same designs and denials will continue.

  • Vikas Desai

    There is absolutely no primary care shortage in southern new york and most of new jersey that’s for sure, and most likely very little shortage in most major(desirable) cities. patients are as demanding as ever and will leave the practice in heartbeat, just saying, it is more a rural issue, but in that case those areas have an absolute physician shortage. As low as medicare pays, in new york the private insurance companies pay around 60-70% of medicare’s already low rates, why would any student want to do primary care with these types of numbers is beyond me when for 1 or 2 years of training extra they can double or quintuple their income as a specialist. There is just as much a shortage with surgical subspecialists. I

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