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Medical Students Still Favor Specialties Over Primary Care



March 23rd, 2009

Given the strong emphasis on medical specialization and the beleaguered state of primary care, Democratic and Republican policymakers and a host of private-sector interests are promoting the resurrection of the generalist doctor in the physician workforce. But most graduating medical students who matched to residency positions this year have not yet gotten the message. And who could blame them, when their incomes pale in comparison to most specialists, their student debt is often more than $100,000, and their working hours are long and uncertain?

The National Resident Matching Program (NRMP) announced its 2009 results on March 19 in which some 30,000 applicants (the largest number in match history) learned where they will spend the next three to seven years of residency training. The NRMP attributed the record turnout to the increased number of positions that a sizable number of medical schools (both allopathic and osteopathic) have added in anticipation of a future shortage of physicians — particularly if Congress is successful in expanding coverage to some or many of the nation’s uninsured population of some 45 million people.

Since 1952, every third Thursday of March has been known as Match Day, a day when graduating medical students open the envelopes that essentially determine the rest of their careers. Of the 29,890 applicants, more than one-third (10,874) were graduates of foreign medical schools, and 2,015 had completed their undergraduate training at schools of osteopathic medicine.

In the orbit of health policy, the results of match day signal how many new doctors are attracted to which medical specialties and whether that complement of physicians will adequately serve the U.S. population. Increasingly, concerns have been expressed that the number of medical students who pursue careers in primary care is waning and that this decline would reduce access to health care for even more Americans.

Family medicine is the specialty that produces the largest number of doctors who devote their practices to primary care. The number of residency training positions in family medicine that have been filled by all applicants, including graduates of U.S. allopathic and osteopathic schools plus international medical graduates, has been decreasing for a decade and has decreased precipitously among graduates of U.S. schools.

In 1997, of 3,262 training positions offered in family medicine, 2,905 (89.1%) were filled — 71.7% by graduates of U.S. medical schools. In 2009, of the 2,535 positions offered in family medicine, 2,311 were filled, but only 1,071 (42%) of these students were graduates of U.S. schools. Overall, the latest match results underscored the increasing popularity of specialties that offer a more controllable lifestyle and higher incomes. Specialties that fall into this category include anesthesiology, dermatology, emergency medicine, neurology, otolaryngology, pathology, plastic surgery, and radiology.

Recognition Of Primary Care’s Importance Is Increasing

Increasingly, a variety of public and private interests have spoken out on the decline of interest in primary care and the inclination of more medical students to pursue these specialties. The political concern is most pronounced in relation to the Medicare population because of the medical needs of its disabled and elderly beneficiaries and because the program supports graduate medical education to the tune of about $9 billion a year (or an estimated $100,000 per resident).

Senators Max Baucus (D-MT) and Chuck Grassley (R-IA), the chairman and ranking member of the Senate Finance Committee, have both expressed concerns about the diminishing number of young physicians who are pursuing careers in primary care, as have key House Democrats Pete Stark and Henry Waxman, who hail from California. So, too, has a coalition of large employers, consumer groups, professional associations, and others, spearheaded by IBM and organized as the “patient-centered primary care collaborative.” Another powerful stakeholder — AARP — also has weighed in on the subject. One of its top executives, John Rother, told me in an interview: “Primary care is key to more effective and efficient delivery of services, especially for individuals with multiple chronic conditions. We support changes in physician reimbursement that will generate a more appropriate mix of physicians going forward.”

While these expressions are welcomed by the primary care community, the president of the American Academy of Family Physicians, Dr. Ted Epperly, emphasized what must happen: “If America is to right the ship of health care and turn it toward a system of higher quality, improved efficiency, better outcomes, less cost, and decreased geographic and ethnic disparity, it must increase the number of primary care physicians. We cannot meet that goal without dramatically changing the policies that affect our medical education system, graduate medical education, and the incentives that draw students to careers in primary care.”

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3 Trackbacks for “Medical Students Still Favor Specialties Over Primary Care”

  1. MedCity morning read, Tuesday, March 23 : MedCity News
    March 24th, 2009 at 9:27 am
  2. Topics about Medical » Archive » Health Affairs Blog
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6 Responses to “Medical Students Still Favor Specialties Over Primary Care”

  1. KatrinaHarrisRN Says:

    As a nurse on a Post Op Surgical unit at a large metropolitan teaching hospital, I have encountered many interns and residents over the course of a year. I have found it discouraging that almost none of them are interested in Internal Medicine. As noted, many specialties offer greater flexibility and higher compensation. It is important for the government, local and national branches, to consider a total revamp of the current system in hopes of attracting medical students. Possibly more offers for loan forgiveness, more incentives for those who chose internal medicine versus specialty areas, and increasing compensation by offering sign on bonueses of some sort would attract more to this area.

  2. Bohdan A. Oryshkevich, MD, MPH Says:

    I think that there is a fundamental profound blind spot about primary care and about medical education in general in this country. There has been remarkably little insight into what needs to be done. It is a decades long problem. That will take a generation of doctors to correct. At this time there is nothing on the horizon.

    This is the legacy of our fragmented 50 state system, private, public, and semi-public medical schools, allopathic and osteopathic medical schools, rich and poor private medical schools, etc. etc.

    Second, there is policy oriented fragmentation of the medical profession. There is a perception that primary care doctors are good and other doctors are bad. Medical students are bad until the commit to primary care. Then they can be forgiven. The unforgiven can be rewarded with high fees. In short, there is no vision of a rational workforce policy of any kind. We want the primary care and specialty MDs to be conscientious and frugal. After all they work in the same system.

    Now I am a former WK Kellogg Fellow at Harvard (81-83) who came back from Canada and was shocked by emerging student indebtedness and the commercialism of American medicine. I found the people at the HSPH to be oriented against doctors in general and the people at HMS very protective of their prerogative to charge tuition.

    Workforce policy is very easy for other societies. It seems impossible for us. Outsiders immediately see what is wrong here and propose what is at home: inexpensive or free medical education, stipends for living, and sustainable mix of primary care and specialty residency slots determined by broad policy. A culture of service and respect for the primary care physician along with a simple payment mechanism.

    They understand the connection to medical student debt, specialty oriented preferences of physicians, and high health care costs.

    The AAMC claims that medical school tuition and student debt have no clear relationship to the decline in primary care in this country and to the high costs of our system. But the reality is that every country in the developed world has less expensive medical education and lower health care costs. They also have an emphasis on primary care. Now either, one is the cause of the other, or both are caused by the same thing.

    In reality, medical tuition income for our medical schools comes to less than 4 billion dollars a year. That comes to less than 0.2 percent of the 2.1 trillion dollars we spend on health care per year. This is a political problem and not an economic one. But as one dean at Johns Hopkins told me many years ago: “We want our medical students to be hungry.” He meant they want them to be entrepreneurial and business like and loans are the prod for that. That is what we have chosen.

    Unless, we find some way of mildly nationalizing our medical students and developing primary care, we will not get anywhere in health care reform. Now we have to move them some way closer to being West Point Cadets or Annapolis Midshipmen. I do not mean putting uniforms on them. I mean making medical education free without nationalizing medical schools.

    For the four mechanisms of dealing with medical student debt and jump starting primary care, you can write to me. The four approaches are institutional, professional, policy based, and reform based. All can be budget neutral.

    Bohdan A. Oryshkevich, MD, MPH
    bohdan_oryshkevich@verizon.net

  3. Christopher Hughes Says:

    It is interesting to watch this “concern” play out.

    We have had much talk about the medical home, valuing primary care, paying for value and on and on. But if the available pool of money allocated for these new models of payment for primary care is the same pool as it was before we reconfigure things, do we really expect an influx of medical students into primary care? Of course not.

    We may actually have to finally have a little class warfare, if you will, and get at least a modest chunk of the pile currently going to the very highly paid procedure based specialties and reallocating it to primary care.

    Do we really hope to move people to primary care when the economics of making that decision are so egregious?

    Cheers,

  4. acavale Says:

    Being a non-procedural sub specialist in solo practice in successful collaboration with an experienced CRNP/CDE for 5 years, I agree with both Micheal and Richard. However, one should never equate medical care rendered by a Primary Care physician to that by a PA or NP. They offer different levels of care and hence have different levels of compensation.

    Eventually society has to make this choice – what is it willing to pay for its medical care. If cost is the only consideration, then Micheal’s observation is true. Interestingly, it is often forgotten that university and higher education has one of the highest inflation rates. Unless this is addressed appropriately, college costs cannot decline or stabilize.

    Besides the monetary issues, the lack of professional satisfaction in primary care has a lot to do with medical students’ choices. Therefore, policymakers must address the overall issue of removing the barriers (regulatory, legal, etc.) that make the practice of medicine in general, and primary care in particular, extremely unrewarding as a career. Incidentally, simply training enough PAs and NPs to substitute doctors will only lead to a similar situation that hospitals with accelerated nursing programs face – substandard care with a potentially high price to pay in the long term.

  5. Michael Halasy, PA-C, MPAS Says:

    This is why I think we need to review the actual delivery system regarding primary care. I think with some minimal supervision, that PA’s and NP’s can adequately and safely fill these positions. We would need to encourage this through financial incentives, perhaps loan forgiveness, and as PA’s and NP’s make substantially less than MD’s, cost savings could occur. In smaller, more rural areas, and in some inner city areas, this is already how primary care is delivered, but expanding this to a more national base should be in the discussion. PA’s and NP’s can be trained MUCH faster then MD’s, and on my blog (http://physasst.blogspot.com) I am discussing the utilization of PA residencies (there are already 49 in existence that I am aware of) to help train PA’s to more optimally fill roles with less supervision. This I think, is an idea whose time has come. The problem with using MD’s in ths role is not only the cost of residency, and then lower salaries (the other alternative is to dramatically increase reimbursements which won’t work in a system that is already financially strained), but that to really lower costs you need to dramatically reduce medical school tuition. I think your number above regarding 100k is wrong, as I remember recently reading that med school graduates are now graduating with about 260k in student loan debt on the average.

  6. Richard E. Sacks-Wilner, MD Says:

    Yep, just shows that Medical Students aren’t stupid, our politicians are.

    As an EX-INTERNIST/PCP, now Hospitalist let me say that it’s not enough to make I.M. Primary Care “viable” (which it’s simply NOT currently), when specialties like Derm & Ophth are clean, easy and make 4-5 TIMES as much. Not to mention that there are VERY few times either of these get called to the E.D.

    They can “recognize” Primary Care all they want…No, they have to make I.M. PROFITABLE (so you can pay back the huge debts AND have something to show for all those years of delayed gratification & wage earning – & on a par – if not better – than most sub-specialties.

    Without that, as these numbers already bear out, Primary Care is DEAD. RIP.

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