Norman Rockwell Doctor and Doll 1942

Norman Rockwell Doctor and Doll 1942

One of the reasons I have a vested interest in the reform effort is that without it, I fear that we in America will head into the uncharted waters of a healthcare system without primary care as outlined in a recent USA Today article as well as other venues. The roots of the shortage are in a 20 year deselection of primary care by US Medical Students. Of the 16,300 US Medical School graduates in 2007, only 1351 (8.2%) went into Family Medicine. In 2009, this number was 1040. Of the residents who entered Internal Medicine (2726) only 2% (50) stated they had an interest in primary care.

Josiah Macey Foundation in conjunction with the Robert Graham Center looked into “What influences Student Choice of Specialty” earlier this year.They found that students’ choices of primary care or specialty careers are influenced by student related factors, curriculum factors, income differences, and institutional factors. 

Student Related Factors

Students who grow up in rural areas, plan to choose family medicine at matriculation to medical school, and are male, have historically been more likely to practice rural primary care. The majority role that women now play in the Pediatrician workforce may be one of the explanations for why Pediatricians have nearly stopped going to rural and small towns.Similarly, students who grow up in urban underserved areas are more likely to practice in inner cities.Being born in a rural county increases the odds of practice in a rural area by 2.4 times and nearly doubles the odds of choosing Family Medicine. It is therefore not surprising that the significant declines of acceptance of rural-born students to medical school overlaps so well with the declines in student interest in choosing primary care, rural practice, and care for underserved populations. Under-represented minority physicians and women are more likely to care for underserved populations. Personal values, spirituality, and mentoring also increase students’ likelihood of choosing service careers. Intention to serve underserved (rural) populations more than tripled the liklihood that a graduate would practice in a rural or underserved area. Students with no or low debt (less than $50,000) and those with high debt (more than $150,000) had higher odds of not choosing primary care, while those educated in public institutions with debt between $100,000 and $150,000 had the highest odds of choosing primary care. National Health Service Corps (NHSC) alumni provide vital health care in their sponsoring communities and have a high likelihood of continuing to care for underserved populations even after their commitments have ended, although they are less likely to remain in underserved practice than physicians who initially care for underserved populations without NHSC financial support. Pathman also demonstrated that state-sponsored scholarship and loan repayment programs support a substantial work force of physicians in underserved communities throughout the country and that physicians who benefit from statebased financial incentives are more likely than other generalist physicians to practice in needy areas and care for uninsured and Medicaid.

Curriculum Factors

Longitudinal, comprehensive medical school and residency educational programs with the explicit goals of preparation of students and physicians for underserved practice have demonstrated clear success. Training in primary care, community health electives, and highly rating one’s primary care elective all significantly increased the relative risk of working in a geographic Health Professions Shortage Area. Rural community medicine electives and experiencing a family medicine clerkship both significantly increased the relative risk of practicing in a Medically Underserved Area. Family medicine residents who train in Community Health Centers are also more likely to later care for underserved populations. implementation of a required clinical clerkship in family medicine increases the proportion of medical students who choose Family Medicine careers. Longer clerkships in Family Medicine appear to be more effective. Students report that mentors and training experiences are also important in their specialty intentions.Mentoring and training experiences are very important. Medical students often receive negative messages from mentors about primary care and these messages may be influenced by the academic culture and income disparities.

Income Difference

Ebell demonstrated a tight correlation between specialty income at graduation and choice of residency specialty.They found that the income gap is a significant and substantial factor in students’ eventual practice location and specialty Institutional Influences

Instuitutional Culture

Medical schools’ institutional culture seems to correlate with career choice. For example, medical schools located in rural areas graduate substantially more rural physicians,and training away from urban centers is believed to be a core component of preparation for eventual rural practice. Schools that graduate a greater proportion of primary care physicians are more likely to: 1) have community hospital teaching sites, rather than academic medical centers have explicit primary care missions; 3) have been founded since 1960; and, 4) have Family Medicine departments.There seems to be an inverse relationship between the amount of institutional NIH funding and the proportion of primary care graduates, Unfortunately, the culture of academic medicine, as a whole, has a negative disposition toward primary care.

Unfortunately, the problems are often easier to identify than the solutions. Over the next several weeks I hope to share some things that are working to increase the number of primary care doctors in our country.