Where are we losing America’s future primary care physicians?

I know where America’s future primary care physicians are, and more importantly, where we are losing them. I am one of them, and I almost got lost.

Maybe I was naïve. I’d had no math or science classes as an undergraduate, and I’d never really thought about the mechanics of medical education. Even while jumping through all the prerequisite hoops before applying, it never occurred to me how inadequate my non-traditional background was for sitting still long enough to memorize what seemed like every enzyme in the human body. Fueled more by the art of medicine than the science of it, I told myself I was ready, that I was to be a doctor, and the process could not deter me.

So began two years of sitting in a windowless dungeon of an auditorium watching PhD after PhD lecture on the various “basic sciences of medicine.” It was a collision of what I perceived to be two very different types of creatures: I seemed to have absolutely nothing in common with the quite intelligent, distinguished individuals charged with preparing me to become a physician. For starters, most of those individuals did not want to be physicians. Even the few MDs sprinkled into the curriculum seemed to spend more time with microscopes and cadavers than with patients. Neither ambition is wrong or less noble. They are just completely different. So I adapted, each day moving closer to equating medicine with basic science, memorizing as much as possible and trying to survive and trust the process.

Somewhere in those days in the dungeon, the skills that I had originally thought would make me a competent physician — compassion, observation, critical thinking, communication — were replaced by ideals like competition, memorization, and a realization that medical school rewards those who can regurgitate the most details for the next exam. Even now in my clinical years, those who put the most time into doing question banks and memorizing review books are rewarded on standardized shelf exams over those who would prefer to spend a little extra time in a hospital learning the bedside art of being a physician.

Each year, the more I focused on memorizing and building the endurance for four-hour examinations, the less I focused on cultivating skills like critical thinking, reason, logic or the use of the scientific method. There is one correct bubble for each disease, no discussion. No time to think or reason. Much smarter people have already done that for me. Slowly, the art of medicine was swallowed by science and by an educational system that has failed to change over the last one hundred years as administrator after administrator has misinterpreted the Flexner report, which reads, “Scientific inquiry and discovery, not past traditions and practices, should point the way to the future in both medicine and medical education.”

How can we expect and hope to change the demographics of the physicians produced or the problems inherent in our health care system when we’ve followed the same process for over 100 years? Why would physicians today think any differently than they did 20 years ago if we are still selecting and training them in the same way?

I am not naïve to the importance of research nor the importance of each branch of medicine. I appreciate the advances in science and medicine over the last 100 years. I merely write to tell you that I was drawn to medicine because I know there are competent artists still among us. I met some of those individuals — many of them rural family docs practicing in Tennessee where I’m now in school — before I decided to apply to med school. Some of them — some of you — not only know the mechanism of each pathology you discover in a patient, but you also have the tact, skill, and compassion to explain it to a rural patient with a third-grade reading level and select an adequate medication that the patient can afford. Those physicians are out there. The problem is, you aren’t in here, in medical schools, where all the future primary care physicians are.

The future of primary care is in that dungeon, waiting for one of you to come walking through that door. The future of primary care is here with me, stuck in a 100-year-old process that doesn’t allow us a moment to hone the skills that make a truly competent primary care physician. The skill set we acquire doesn’t lend itself to a primary care career where answers are not black and white or as simple as filling in the right bubble on an exam.  But we have to survive, so we develop the skills that are presented to us, and in the “process,” many of us fall off the path to primary care, feeling uncomfortable in a profession that requires a skill set that we do not get to cultivate in medical school.

Don’t assume there is someone at each school casting the net to encourage primary care during the basic science years, even at “primary-care friendly” institutions like mine. Admissions standards are not changing, LCME requirements are not changing, and I don’t think medical school leaders have the gumption or grace to deviate from the model enforced by the more prestigious institutions.

Take responsibility. Come find us. Recruit one student and you’ve replaced yourself, recruit two and you are part of the solution. We need primary care doctors, not academics, to infiltrate our system and show us what you do. Force your way into my curriculum. Show me that primary care is a viable choice. Future primary care physicians are out there. Please come find us.

Michael Bradfield is a medical student who blogs at Primary Care Progress.

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