Wednesday, August 4, 2010

Where will new primary care docs come from? (Part 2)

In a previous post, I described a study that found that U.S. medical graduates from 1997 to 2006 who became primary care doctors were "more likely to be female, planned to practice in medically underserved communities, and had strong altruistic beliefs about health care and the medical profession's social responsibility." Another research group recently used the percentage of gradutes who practice primary care as one of their "social mission" criteria for ranking medical schools. But using retrospective profiles as the basis for recruiting new students, and promoting schools that have historically graduated higher proportions of primary care physicians, will not be enough to meet the basic health needs of 32 million newly insured patients by 2014, much less those of patients whose family doctors are now nearing retirement.

As if we need another example of how hard it is to prime the primary care pipeline, The Commonwealth Medical College (TCMC), a school in northeastern Pennsylvania that opened its doors in August 2009 with a stated emphasis on training primary care physicians to address the state's widespread workforce shortages, reported in the July/August issue of Family Medicine that the career preferences of its inaugural class changed dramatically between medical school acceptance and matriculation:

In contrast to our students' often-stated primary care proclivity before matriculation, results of the orientation survey just 3–6 months after medical school acceptance and before their first class disclosed that seven (12.5%) students cited general surgery and orthopedic surgery, respectively, as their first career choice, and four (6.2%) students listed emergency medicine. Only 15 (23%) students indicated a preference for general internal medicine (eight students), obstetrics-gynecology (four), family medicine (two), or pediatrics (one). Graduating medical students who are focused on a career in primary care is difficult, and our experience indicates that even accurately identifying medical school candidates with this interest can be fraught with error.

Students change their minds about specialty choice multiple times during medical school, and there is obviously plenty of time left to persuade members of this class of the benefits of a career in primary care. I also hope that TCMC's innovative community-based training curriculum provides students with a more balanced perspective on population health problems than does the average tertiary care-focused academic medical center. A great deal is riding on the outcome of this program, not only for the residents of Pennsylvania, but the entire nation. If it succeeds, perhaps medical schools around the country will follow suit. But if it fails ... what then?


  1. Goes to show how much stated intent at time of applicaton is worth. Students will say whatever they need to to get in.
    Nothing is 100% predictive, but increased probability comes from demographic characteristics (rural origin, older age, under-represented minority status, lower socioeconomic status of family of origin). For students not fitting that demographic profile, only past activities are worth using (Peace corps, VISTA, Teach for America, extensive volunteer work, etc.) not stated intent on an essay.

  2. With only 30% of 25,000 annual primary care graduates entering primary care and even fewer remaining, changes are required.

    We must have permanent primary care training and this involves selection with an obligation, 7 years of training to prepare for an obligation, and a 10 year instate obligation for primary care. At least 5 of these years should be assigned by the state to a most needed location. Family medicine will complain the most but needs the primary care obligation the least with 80% remaining in primary care, but sadly family medicine numbers are too low in the schools that supply primary care to 30 states in most need of primary care.

    It does not matter if the students admitted and trained for permanent primary care tell stories as the obligation, training, admission, and cohort effect align.

    Jichi in Japan has 95% that complete a 9 year in prefecture obligation (graduate training and most needed rural location - Matsumoto, Inoue).

    Jichi graduates in the first year of their obligation pass grads with the least health access contributions (top 20 MCAT schools), pass 75% of allopathic and osteopathic schools by year 3 of obligation, and deliver more than any US school graduate at year 5. Jichi grads deliver 12 - 15 years of most needed health access in their careers.

    The best in the US pipeline programs do not even come close as so few are admitted from origins that will distribute (from the 65% of the US pop left out), so few choose family medicine, and so few have health access medical school training. Each of these 3 factors double or triple primary care and most needed health access when included together in logistic regression equations, but the numbers are so low as to make the end result minimal.

    I can understand why the students deceive to gain admission. But those "admitted" to US Team Primary Care are deceiving the nation by claiming to be primary care programs (physician and non-physician clinician) despite failing to produce primary care delivery.

    Robert C. Bowman, M.D.