Enjoy!
Joshua Freeman, MD
We need more primary care physicians. I have written about
this often, and cited extensive references that support this contention, most
recently in The role of Primary Care in improving health: In the US and aroundthe world, October 13, 2013. Yet, although most studies from the US and around
the world suggest that the optimum percent of primary care doctors should be
40-60%, the ratio in the US is under 30% and falling. A clear reason for this
is that relative lack of interest of US medical students in entering primary
care at the rates needed to maintain, not to mention increase, our current
primary care ratio. In addition, the ratio of primary care to other specialty
residency positions is too low. Here we confront the fact that the large
majority of medical students completing Internal Medicine residencies enter
subspecialty fellowships rather than practicing General Internal Medicine. At
the Graduate Medical Education level, a simple way of estimating the future
production of primary care doctors would be to add the number of residency
positions in Internal Medicine (IM), Pediatrics (PD), Family Medicine (FM), and
combined Internal Medicine-Pediatrics (IMPD) and subtract the number of
fellowship positions they might enter. This still overestimates the number of
general internists, however, since it does not account for doctors who practice
as “hospitalists” after completing their residency because such a role does not
currently require a fellowship (as does, say cardiology). Estimates are now
that 50% or more of IM graduates who do not pursue fellowship training become
hospitalists.
Thus, we welcome the research report from the Association of
American Medical Colleges (AAMC) “The role of in medical school culture inprimary care career choice” (1), by Erikson et al. that appears in the December
2013 issue of AAMC’s journal Academic Medicine.
The authors surveyed all 4th-year medical students from a random sample of 20
medical schools to assess both student and school level characteristics that
were associated with greater likelihood of entering primary care. The first,
and arguably most important finding, was that only 13% of these final-year
medical students were planning on primary care careers. This is despite the
fact that 40% were planning to enter the “primary care” residencies of IM, PD,
FM, and IMPD, with most of the fall-off in internal medicine and least in
family medicine. This finding strongly supports my assertions above, and makes
clear that the historically AAMC-encouraged practice of medical schools
reporting “primary care” rates by entry into residencies in those fields is not
valid. It also, even more important, shows the extent of our problem – a 13%
production rate will not get us from 30% to 40% or 50% primary care no matter
how long we wait; obviously it will take us in the other direction.
The primary outcome variable of the study was entry into
primary care, and it specifically looked at two school level (but perceived by
students, as reported in the survey) characteristics: badmouthing primary care
(faculty, residents or other students saying it is a fall back or something
that is a “waste of a mind”) and having greater than the average number of
positive primary care experiences. It turns out that both were associated with
primary care choice (in the case of badmouthing, students from schools with
higher than average reported rates were less likely to be planning primary care
careers, while students who were planning such careers reported higher rates of
badmouthing), but, after controlling for individual student and school
characteristics, accounted for only 8% of the difference in primary care
choice. Characteristics of the student (demographics such as sex, minority
status or rural origin, academic performance defined as the score on Step 1 of
USMLE, as well as expectation of income and feeling of a personal “fit” with
primary care) and of the school (research emphasis, private vs. public, selectivity) accounted for the rest.
Interestingly, debt was not a significant factor in this study.
I would argue that many of these individual and school
characteristics are highly correlated. A school that prides itself on being
selective (taking students with high scores) and producing subspecialists and
research scientists does not have to badmouth primary care; the institutional
culture intrinsically marginalizes it. On the other side, the students selected
at those schools are more likely to have those characteristics (particularly
high socioeconomic status and urban or suburban origin) not associated with
primary care choice. It is worth noting that the measure of academic
performance in this study was USMLE Step 1, usually taken after the first 2
years and focusing more on the basic science material covered in those years,
rather than USMLE Step 2, which covers more clinical material (perhaps because
not all 4th-year students studied have taken Step 2 yet). This biases the
assessment of academic qualification; many studies have demonstrated high
levels of association of pre-medical grades and scores on the Medical College
Admissions Test (MCAT) with pre-clinical medical school course grades and USMLE
Step 1 scores, but not with performance in any clinical activity, not to
mention primary care. Perhaps most students improve their scores from Step 1 to
Step 2, but it is particularly true for FM and primary care. A quick look at
our KU students applying to our family medicine program shows an average
increase of nearly 30 points in these scores.
So the problem is in the overall culture of medical schools,
in their self-perception of their role (creating research scientists vs.
clinicians, creating subspecialists vs. primary care doctors) and in their
belief that taking students with the highest grades is equivalent to taking the
best students. This culture, simply put, is bad, defined as “it has undesirable
outcomes for the production of the doctors America needs”, and must change.
Erikson and colleagues acknowledge that schools could do a better job of taking
rural students, offer more opportunities to engage in public health and
community outreach activities, and have more experiences in primary care, all
of which were somewhat associated with primary care career choice. These are
tepid, but coming from the AAMC, a reasonably significant set of
recommendations. I say we need an immediate change in every single medical
school to recruit at least half of every class with students whose demographic
and personal characteristics are strongly associated with primary care choice,
present a curriculum that has much less emphasis on “basic science” and more on
clinical, especially public health, community health, and primary care. One of
the primary bases for assessing the quality of a medical school should be its
rate of primary care production, and this is going to require a major
qualitative shift in their practices and the beliefs of many of their faculty
and leaders.
I am NOT saying is that we don’t need subspecialists or
research scientists. We do. I AM saying that the emphasis on production of
these doctors compared to primary care doctors is out of whack, not just a
little but tremendously so, and can only be addressed by a major sea change in
attitudes and practices in all of our medical schools. I do not expect that all
schools should produce the same percent of primary care physicians. Some might
be at 70%, while others are “only” at 30%, but ALL need a huge increase, by
whatever means it takes. Even if we produce 50% primary care physicians on average
from all schools it will be a generation before we get to their being 50% of
the workforce. At less than that it will take longer, and at less than 30% we
will not even maintain where we are.
13% is not just “insufficient”, it is a scandalous abrogation
of the responsibility of medical schools to provide for the health care of the
American people. They should be ashamed, should be shamed, and must change.
(1) Erikson CE, Danish S, Jones KC, Sandberg SF, Carle AC,
“The role of in medical school culture in primary care career choice”, Acad Med
December2013;88(12) published online before print.
