Don't Blame Medical Students for the Decline in Primary Care

Cross-posted at Doctors for American Progress Notes.

There is a lot of speculation about why there are fewer and fewer primary care physicians joining the workforce every year. Some have focused on the choices that medical students are making when choosing residencies. Whether due to laziness, desire to make money or the drive to be perceived as “successful” in choosing a more prestigious specialty, the new generation of physicians are being blamed for not following in their parents’ and predecessors’ footsteps. Some claim that “blame” might be a bad word to use for this situation, since these choices are rational when medical school is so expensive and we have so many other more high-paying specialties to choose from.

On behalf of medical students everywhere, I would like to say that we are acutely aware of the problems that primary care is facing and the role that our choices in applying to residencies has on those problems. Every year, my professors say, more and more medical students say that they see the value of primary care and are strongly considering it as a career choice. We all know about the extraordinary amount of debt that we are facing, but realize that primary care specialties are able to apply for a wide variety of loan forgiveness programs that defray the cost of choosing primary care. This increased awareness of the importance of primary care are being reflected in this year’s match, where more and more students are matching into family medicine and other primary care specialties.

Nevertheless, I cannot help wondering whether the medical student’s role in the decline in primary care is a bit overstated. For one thing, the attrition in primary care isn’t just from the side of medical students entering residencies, but due to many people entering potential primary care specialties, like internal medicine and pediatrics, and leaving general practice for a subspecialty either immediately after residency or within the next five years of practice. Furthermore, since the shortfall in primary care physicians is already quite significant and only expected to get worse in the coming years. It seems unlikely that even a 10% increase in the number of students entering primary care every year would make that much of a difference, and I have serious doubts that such a thing is possible given the way that medical schools work.

The fact is: medical schools are becoming more competitive to enter than ever before. For every person that actually gets into a medical school, there are about 30 people who applied for the same spot. Therefore, medical students have increasingly been defined by those that were able to withstand the grueling pre-medical curriculum and the incredibly competitive admissions process. Anyone who chooses to apply to medical school knows this. They know that they could have chosen an easier path that could have provided a subsidized education (e.g., biology graduate school) or had a more immediate impact on patients and society (e.g., the nonprofit world or a social work school).

So what does this mean for primary care? It means that admissions offices and people concerned about the primary care workforce should be wondering whether the students that they actually admit are really more civic-minded and primary care focused than the many people that apply every year and don’t get in – not to mention many health advocates that could have applied but decided not to due to the costliness and competitiveness of the process. Shifts in admissions policy, such as Mt. Sinai’s program to admit more humanities majors, have been shown to also lead to shifts in specialty choices with the humanities majors tending to choose psychiatry and primary care fields at higher rates than their classmates.

While most schools do not typically have a program as distinctive as Mt. Sinai, most schools recognize the need to strive for a balance of bright and community-minded students. The result is that the medical students that make it through the admissions process embody a wide distribution of interests. Do some socially-minded medical students overcome all of the obstacles and make it to the top medical schools to continue their community work? Absolutely. Are there many medical students that would like nothing better than to do the most cutting-edge research or perform complex high-tech surgeries? Yes, and given the great need for more physician-scientists I am grateful for them. Are there also medical students that after all the sacrifices they have made to come to medical school really just want the job security of doing radiology or dermatology? Of course. Therefore, despite the obvious public health implications, I cannot help but feel that the 6% of students that go into family medicine every year – while it could stand to increase a little – is more or less an accurate reflection of the wide variety of interests and personal motivations found in a typical medical student class.

In short, the admissions decisions that schools are making to admit more community-minded providers are not enough. We need more programs, like the Sophie Davis School’s BS/MD program for training primary care physicians, which are specifically focused on training more primary care providers. However, without the a substantial governmental funding incentive to encourage such programs, there will be little impetus for institutions to break out of the mold of striving to be the best of the best academic center, admitting students with strong research portfolios and high MCAT scores.

Furthermore, we simply need to be training more doctors and medical students. The latest projections from the AAMC on the physician’s shortages indicate that we will face a shortage of 91,000 doctors by 2020. Half of this shortage will be due to the shortfall in primary care but the other half will be due to a shortfall in other specialties. The AAMC has recognized this need for more physicians and has called for an increase in the number of medical schools and the number of students they accept. However, their current plans are only projected to see a 20% increase in the number of students by 2014, falling short of their original goal. The number of physicians that are able to be trained every year is also limited by the number of residency spots that are available, which is capped by Medicare. With all of the other funding debates that are going on, much of this has fallen by the wayside, but it is important that we continue to see the primary care shortage as a workforce supply issue that deserves its rightful place in the discussion of healthcare reform.