Reform primary care first, and health care will follow

I mentioned in an earlier posting that fewer medical students each year are choosing to pursue careers in the primary care specialties (family medicine, general pediatrics, and general internal medicine). The reasons for the decline have been documented in other health-oriented blogs such as KevinMD, and are due to a number of factors, including an increasing income disparity between primary care and specialist incomes, the staggering array of conditions that primary care physicians encounter in a typical day at the office, insufficient funding for primary care residency training programs, and a basic research-centered medical education system that limits students' exposure to real-world community practices.

Most industrialized nations with efficient health care systems have roughly a 1:1 ratio of primary care to specialty physicians. In contrast, in the U.S., specialists outnumber generalists by more than 2 to 1, and with less than 15 percent of U.S. medical students choosing primary care careers in recent years, this imbalance continues to worsen.

As is probably obvious if you've been reading earlier posts in this blog, I very much support some form of health care reform that makes primary care available to all Americans. The current reform bills have all incorporated some variation of proposals advocated by groups such as the American Medical Student Association, including expanding the size of the National Health Service Corps (a program that rewards doctors who practice in rural and underserved areas of the U.S. by subsidizing their tuition or forgiving student loan debt), opening new independent, community-oriented medical schools, and preferentially recruiting college students with an interest in primary care during the medical school application process. All good ideas, but they won't be nearly enough to get us to the goal of 50% primary care physicians that will be needed in a transformed health care system.

Bigger, bolder steps are needed to attract medical students to primary care careers. Kevin Grumbach's post earlier this year in the Health Affairs blog summarizes what these steps - largely financial incentives - need to be. To this list, I add one more. For the past 5 years, I have taught medical students and primary care and preventive medicine residents at two universities where these disciplines are often underemphasized, and where my specialty - the essential cog in the wheel of any high-achieving health system - is openly degraded as not being prestigious enough for the best and brightest students. This perception can and must change before American health care can truly be considered to be "reformed."