Friday, June 4, 2010

Where will new primary care docs come from?

There is widespread consensus that the upcoming increase in the numbers of people who will gain health insurance as a result of the Patient Protection and Affordable Care Act will require a corresponding increase in the numbers of primary care physicians trained to care for them, even if new practice models eventually redistribute physicians' workloads and health insurers' policies change to accomodate these new models (by paying for medical advice dispensed over e-mail, for example). I've previously mentioned in this blog that researchers at the American Academy of Family Physicians' Robert Graham Center have been hard at work for the past several years figuring out what besides salary attracts medical students to careers in family medicine, general internal medicine, and pediatrics.

This month, a study in the journal Academic Medicine provides additional perspective on the steps that policymakers and academic leaders need to take to revitalize the pipeline for primary care training. This analysis of more than 100,000 medical school graduates from 1997 through 2006 who completed a questionnaire administered by the Association of American Medical Colleges (this must have included me, though possibly not - only 65% of all graduates during these years actually completed the survey) studied statistical associations between choice of a primary care specialty and a slew of other factors.

The study's major findings aren't terribly surprising: in terms of percentage of medical school graduates entering their fields, primary care has been losing ground to internal medicine and pediatrics subspecialties for more than a decade. Students who chose primary care 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.

If we believe the findings from this study - and there's no reason not to, given that they are largely consistent with those from previous studies - it makes sense for medical schools to respond by targeting recruitment efforts for women and college graduates who already plan to practice in underserved areas and who see health care as a basic human right, rather than a privilege provided for those who can afford it. It also makes sense for schools to take a more active role in promoting the whole-person (or "holistic," if you prefer) philosophy that underlies the primary care specialities from day one, rather than misleading students that the segmented, organ-system organization of the typical academic medical center is a sensible approach to improving population health.

But will medical schools actually do any of these things, and more importantly, will it really matter if the primary care-speciality income gap persists?


  1. I have not seen much in the way of a discussion of the idea that perhaps medical school should be education provided by the state in some way to avoid the horrible loan situation that follows. Perhaps much expansion of public service for new MDs would be in order as payment for loans. Also, for inculcating some understanding of the practice of medicine as one that has obligations to society.

  2. Esther, that's a good point. Many governments in other countries subsidize medical training and therefore medical students in those countries have much less concern about educational debt. And studies do suggest that U.S. students with the highest debt burdens are less likely to go into family medicine. But the salary disparity between PCPs and subspecialists appears to be an even more important driver of career choice than educational debt. (As an aside, my wife and I are both FPs who are 10 and 9 years out of medical school, respectively, and still have a total of >$100 K in educational debt.)

  3. Being always suspicious of the AAMC, whose members delivered our current specialty maldistribution, I wouldn't tend to align with a direction they recommended. The women who want to serve the underserved should not be the lead category to serve a mostly not-underserved (but maybe soon to be underserved) American middle class.

    The future of American primary care (which now consists of family medicine and a small potential for primary care pediatrics) may also have to be radically redirected from the business-as-usual humble and compliant employees of misguided powers in the Medical Industrial Complex (MIC).

    I wonder about huge numbers of military veterans entering medical school as warriors for their friends and family. Warriors who know the importance of a good story, a friend and a caring God. Warriors who are good at Facebook and Skype, who would love Twitter and comfortably connect to a vast array of professionals on Linkedin. Warriors who hug and cry when indicated because they are wholehearted and comfortable with who they are. Warriors who would easily commit to their patient's safety since they already know how to attend to the safety of their friends in hazardous situations.

    Warriors who understand the stewardship of scarce resources and the importance of citizenship. Warriors who are committed to the freedom of their patients as unique individuals with a singular but connected genome that allows for significant input to become that unique individual.

    A Warrior-student will know how to stand up for what they believe while respecting and listening to the opinions of others. They will understand how to say no to illegal orders from a military commander and the same from elements of the MIC that seek to misdirect them toward maximizing profit with overuse of costly, sometimes harmful (e.g., CT scans) resources.

    In The Four Fold Way, Angeles Arrien wrote of the Warrior role in each historic global tribe, as well as the Healer, Teacher and Visionary. She noted that, while individuals in each tribe had a major part of their identity in one role, each person has all four roles within.

    The role of Healer, Teacher and Visionary is within each physician already. The Warrior role may need an upgrade in the individuals who will ultimately be at the front lines of health care. If they have already been trained to function at the front lines in modern military conflict, they will have an advantage in their service to their patients.

    (You may notice that I don't equate warrior with killer. There is a huge difference that I hope you can appreciate. I hope you also notice that no gender is exclusive to warriors, nor to military or combat veterans).

    I just wonder if we can expand our considerations beyond the narrow perspective of the AAMC to remember the vastness of the populations that we Family Physicians serve.
    Wholehearted Warriors with recent military service may fit nicely in the future primary care team for America.