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Only a fifth of US medical students choose primary care

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2684 (Published 27 April 2011) Cite this as: BMJ 2011;342:d2684
  1. Jeanne Lenzer
  1. 1New York

Far fewer US medical students plan to go into primary care than two decades ago, a recent analysis shows.

The United States faces a “troubling shortage in its primary care medical workforce,” say the authors of the analysis, published this week in the Archives of Internal Medicine (2011;171:744, doi:10.1001/archinternmed.2011.139). Surveys of graduating students in 1990 and 2007 show that although roughly a quarter of graduating medical students in both years planned to go into internal medicine, the proportion planning to go into general internal medicine fell from 9% to 2%.

General internal medicine, along with paediatrics and family medicine, comprise what is referred to as “primary care” in the US.

Primary care doctors are becoming rarer overall in the US as many paediatricians and internists elect to go into subspecialties or to become hospital doctors. The authors report that only 16% to 18% of medical students will go into primary care.

A “pending crisis,” say the authors, is being caused by “a convergence of increased demand (aging, chronically ill baby boomers, and an obesity epidemic) with decreasing supply (retiring physicians, fewer clinical work hours among younger physicians, fewer clinical work hours among younger physicians, and fewer students choosing primary care careers).”

Medical students are increasingly likely to be female (52% versus 37%) and to graduate with greater debt: 86% of 2009 graduates owed an average educational debt of $158 000 (£95 000; €107 000), and the overall average debt was $132 000.

Money figures prominently in the choices made by graduating students. Mark Schwartz, lead author of the analysis and associate professor of medicine at New York University, said that the income gap between generalist and specialist doctors has widened over the years. Over a 40 year career a specialist can expect to make $3.5m more than a primary care physician.

Dr Schwartz told the BMJ that money “is a proxy for prestige and status”—two considerations that affect the choices of graduating medical students.

A report by the Association of American Medical Colleges says that the overall shortage of doctors was already acute before the recent health reforms. Under the Affordable Care Act, passed in March 2010, increased demand from newly insured patients will mean even greater stress on the system. The association projects a shortage of 63 000 doctors by 2015 and 130 600 by 2025.

Dr Schwartz said that it is not clear whether the total number of doctors needs to be raised. Instead, he says, it may be more important to increase the proportion of the physician workforce providing primary care. He cites a 2010 report by the Council on Graduate Medical Education that found that only 32% of US doctors are in primary care (www.cogme.gov/20thReport/cogme20threport.pdf ). Dr Schwartz said, “In high performing nations around the world 50:50 is a better mix—and we’re nowhere near that.”

To encourage medical students to enter primary care, policy makers must “rebalance income distribution between generalists and specialists,” said Dr Schwartz. He said that rebalancing is a “zero sum game” and that some specialist groups have opposed efforts to increase generalist pay while decreasing reimbursements for “procedure based medicine.”

“The primary care workforce shortage is a bottleneck to implementation of [health care reform],” said Dr Schwartz. “We expect 32 million newly covered Americans who need access, and we don’t have enough primary care physicians to serve them.”

Notes

Cite this as: BMJ 2011;342:d2684

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