The ROAD less traveled or why don’t med students choose primary care?

A recent article in AcademicMedicine by Kimberly Clinite and colleagues (1) is an important addition to the growing body of literature around specialty choice. For those of you who are not familiar with the subject, let me give you a bit of background.

Many countries in the world have better health outcomes than we do here in the United States. There are many reasons for these differences, but one that is often pointed to, is the lack of a strong primary care infrastructure as compared to other developed nations. For instance, our neighbors to the North, the Canadians, have a national health system that is built around having about 40 percent of the physician workforce in primary care and 60 percent in specialty care. (2) The Canadians rank higher than the US in almost every health outcome category, except cost. They spend less per capita than we do, and we get worse health outcomes as our reward!

The problem is that students in the US are choosing primary care specialties less often than they are choosing other specialties. (3) The ROAD in the title refers to a (not-so-funny) joke amongst medical students. The joke goes: if you do well enough in medical school, you can hit the ROAD (Radiology, Ophthalmology, Anesthesiology, Dermatology) when you graduate. Why those four specialties?  Primarily, because they are high-paying specialties that have the “best” lifestyles.

In the most recent residency selection match (4), US seniors (4^th year medical students applying for residency) applying to Internal Medicine, Pediatrics, and Family Medicine filled 6,327 of 26,392 total spots that were offered (23.97%). Now 23.97% is lower than we need (at 40%) but the true picture is even bleaker. Of the 3,135 students that matched into Internal Medicine, about 80 percent will go on to do specialty training (for example Cardiology or Rheumatology) and another 10 percent will practice as hospitalists. This leaves about 314 students in primary care practice. For Pediatrics it is a bit better, only about 45 percent go on to specialty training, leaving about 1,010 in primary care. And for Family Medicine, about 90 percent end up in primary care practice (1,220).

This means that the actual number of US Seniors in the 2013 Match that will end up practicing primary care is 2,544 or 9.6 percent of the total. On the flip side, 2,710 students matched into positions on the ROAD, which accounts for 10.3% of US Seniors. That number should scare all of us in medical education! If the American public knew the implications of that number to the health of our nation, they would be scared as well. Twice as many students will become Radiologists as will become General Internists.

Don’t get me wrong, we need some Radiologists. I have no problems with that. But this “market-driven” system has been skewed to the point that the product of our medical schools is no longer meeting the needs of our country.

So, the survey by Clinite, et al (1) looked at first-year medical students’ views on the importance of lifestyle and specialty characteristics. They surveyed 11 allopathic (MD) schools across the country. The schools including public and private schools and even included the military’s school (the Uniformed Services University). 60 percent of the students that were surveyed responded.

The students rated, “enjoying the type of work that I am doing” highest in importance for lifestyle characteristics. For specialty characteristics, they rated “being satisfied with the job” highest. Students were also asked to declare their interest in practicing in a primary care field after graduation. The groups were split fairly evenly between four groups (primary care first, primary care second, primary care least, and no opinion). And here is where it starts to get interesting…

Financial compensation of the specialty overall was not ranked as that important. But in students who ranked primary care first and those that ranked it as least, the ranking was significantly different (2.8 to 3.7; p ≤ 0.01). Looking at specialty characteristics, “average salary earned by attending physicians in the specialty” ranked 2.7 (SD 0.9) for the primary care first group but was up to 3.6 (SD 0.8) in the primary care least group. The effect size for this difference was large (0.94).

All of this suggests that the number of students who choose primary care specialties will continue to shrink unless something is done. Some students are making a financial, lifestyle, and long-term investment decision to choose specialties with higher pay and “better” lifestyles. The only way to change this is to change the lifestyle, change the pay or bring in a different group of students. I can’t really control the high pay differential with specialists or make a difference in the lifestyle of primary care doctors. But we can definitely bring in students who value different characteristics of the physician lifestyle.

References

(1)   Clinite KL, et al. Primary Care, the ROAD Less Traveled: What First-Year Medical Students Want in a Specialty. Academic Medicine  2013;88(10):1522-1528.

(2)   Association of Faculties of Medicine of Canada. The Future of Medical Education in Canada: a collective vision for MD Education. 2010

(3)   Chen C, et al. Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions. Acad Med  2013; 88(9):1267–1280.

(4)   Results and Data 2013 Main Residency Match. National Residency Matching Program.  http://b83c73bcf0e7ca356c80-e8560f466940e4ec38ed51af32994bc6.r6.cf1.rackcdn.com/wp-content/uploads/2013/08/resultsanddata2013.pdf