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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