This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.

The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine.

Monday, November 18, 2013

Why do students not choose primary care?

This is a re-post of a great article written last month by Dr. Joshua Freeman and posted on his blog Medicine and Social Justice.  It is re-posted with his permission here on Education in Medicine. 


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.

Tuesday, November 5, 2013

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 (4th 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.


(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.