The Road Less Traveled — Attracting Students to Primary Care
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《新英格兰医药杂志》
At the turn of the 20th century, most physicians in the United States were general practitioners; by the turn of the 21st century, most were subspecialists. Yet primary care continues to play a vital role in health care, and patients want a primary doctor who will provide them with continuous care over the course of their lives. As members of the baby-boom generation age, their need for primary care will increase. They will need comprehensive care for chronic illnesses and will want their primary care physician to provide it, supplemented as necessary by subspecialty care and technology. If the prevailing models of practice and trends in students' choices of specialties persist, however, these needs will not be met.
From the 1970s to the 1990s, the consensus was that the United States faced an overall surplus of physicians but would not have enough generalists.1 Now some believe that we will soon have an overall shortage of physicians. In addition, the aging population will need comprehensive hospital, ambulatory, home-based, and nursing home care for chronic medical problems. Thus, we continue to need students who choose careers in primary care. How do students make career choices, and what should we do to help them make the "right" decisions?
Several factors have contributed to the decreased interest in primary care: remuneration is lower than that for subspecialties and fields that involve frequent use of diagnostic procedures and technical interventions, educational debt has increased, the demands of practice are often incompatible with the lifestyles that students desire, and physicians are frustrated by the hassles of medical practice. In a Sounding Board article in this issue of the Journal (pages 710–712), Whitcomb and Cohen argue that students' positive experiences in the offices of primary care physicians during their first two years of medical school are overshadowed by negative experiences during their third-year clerkships in primary care, in which they primarily see inpatients. I think the authors' call to redesign residency programs so that they emphasize interdisciplinary ambulatory, home-based, and inpatient care for an aging population of patients with complex, chronic problems is a valuable recommendation.
In recent years, third-year clerkships in many medical schools have, in fact, included a substantial proportion of experience in ambulatory care. At the Medical College of Georgia, students rate highly our carefully selected community-based faculty physicians and practice sites. However, high ratings have not translated into more students choosing careers as generalists. Although they are increasingly knowledgeable about primary care practice, students are not attracted by what they see in community and academic practices.
Many students enter medical school with the desire to become primary care doctors and to care for the whole patient, not just an individual organ system. And many primary care physicians are indeed gratified by their relationships with patients, but they are increasingly dissatisfied with the regulatory headaches associated with practice, the decreased remuneration for their non–procedure-based services, and the fragmentation of care. They used to provide long-term, continuous care. Now hospitalists provide inpatient care, and patients in a managed-care system may see a different physician each time they seek outpatient care. These forces have eroded the traditional bond between physician and patient, which was what attracted many doctors to primary care in the first place. Although these changes relieve physicians of the responsibility for continuous patient care, they disrupt the continuity of care and the once-cherished physician–patient relationship.
Students also express concern about the way that residents run from wards to clinics to rounds. They get new patients every morning and never catch up. They are harried and unhappy. Clearly, residents and their satisfaction or dissatisfaction play a crucial role in students' career choices. Faculty physicians also have a powerful influence: students are more likely to follow in the footsteps of faculty members who seem satisfied with their specialty than to wish to emulate those who are frustrated and unhappy.
The current marketplace and workforce projections influence some students' decisions, although these projections may not reflect the actual need when students enter the workforce four to eight years after selecting their specialty. In the mid-1990s, for example, the United States had a plethora of anesthesiologists, which inspired cartoons of anesthesiologists standing on street corners, holding "will work" signs. In 1996, only 172 senior medical students (from a total of 13,392 students in the National Residency Matching Program) were matched in residency programs in anesthesiology.2 Eight years later, we are facing a dearth of anesthesiologists, and remuneration for these specialists has increased markedly. In 2004, 897 students (from a total of 13,572 students) were matched in anesthesiology.3
The need to pay off massive educational debt makes primary care and other non–procedure-oriented specialties unaffordable for some students who aspire to primary care practice. Unless we correct the inequities in the payment system, this problem is likely to persist. Increasing debt levels have prompted students to present resolutions to major physicians' organizations, challenging them to support changes in the financing of medical education that would diminish the burden on students.
Lifestyle is another important factor for today's students,4 who may be more concerned about discretionary time than about money. As compared with students of 20 or 30 years ago, contemporary students are more concerned about the balance between their personal and professional lives. They want more time for themselves and their families, and they are less willing to enter a specialty with long, unpredictable working hours. Physicians who are seeking partners for their practice recognize this change in priorities, as residents negotiating for jobs become more candid about their desire to limit their on-call responsibilities and work hours. It is not only a women's issue, even though soon more than half the physicians entering the workforce will be women, a sizable proportion of whom will be married to other physicians.
What can we do to help the next generation of physicians meet the health care needs of our aging population while choosing the specialty that is right for them? On a national level, we need to revamp clerkships and residencies so that high-quality, efficient, interdisciplinary patient care becomes the centerpiece of clinical education. In terms of financial issues, we need to reduce the inequities in reimbursement that favor procedure-related skills over patient-focused skills, reform the federal financing of residency education that favors hospital-based education over ambulatory-care–based education, reduce the escalating burden of student debt, and deal with the crisis in the cost of malpractice insurance. We must identify or create models of efficient, interdisciplinary, patient-friendly care in academic medical centers and exemplary community-based practices. These models should serve as templates for providing comprehensive care to patients with complex, chronic illnesses in a variety of settings. When students learn from physicians who enjoy their professional experience and provide high-quality care, they are likely to be attracted to the discipline that best suits their personal and professional goals.
Ideally, students should choose a specialty independently of concern about educational debt and inequities in remuneration, on the basis of the knowledge they have gained from clinical experiences with comprehensive care. A dedicated core of students will continue to choose primary care, but to attract more students to such generalist careers, our systems of health care delivery and education must change.
Source Information
From the Medical College of Georgia School of Medicine, Augusta.
References
Council on Graduate Medical Education sixth report: managed health care: implications for the physician workforce and medical education. Rockville, Md.: U.S. Department of Health and Human Services, September 1995.
Randlett RR, Creighton KP. Results of the National Residency Matching Program for 1996. Acad Med 1996;71:697-699.
National Residency Matching Program 2004 match data. (Accessed July 22, 2004, at http://www.nrmp.org/2004advdata.)
Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173-1178.
Related Letters:
Attracting Students to Primary Care
Saver B. G., Poplin C. M., Cykert S., Fleming M., Johnson M. S., South-Paul J., Rustin T. A., Whitcomb M. E., Cohen J. J., Fincher R.-M. E.(Ruth-Marie E. Fincher, M.)
From the 1970s to the 1990s, the consensus was that the United States faced an overall surplus of physicians but would not have enough generalists.1 Now some believe that we will soon have an overall shortage of physicians. In addition, the aging population will need comprehensive hospital, ambulatory, home-based, and nursing home care for chronic medical problems. Thus, we continue to need students who choose careers in primary care. How do students make career choices, and what should we do to help them make the "right" decisions?
Several factors have contributed to the decreased interest in primary care: remuneration is lower than that for subspecialties and fields that involve frequent use of diagnostic procedures and technical interventions, educational debt has increased, the demands of practice are often incompatible with the lifestyles that students desire, and physicians are frustrated by the hassles of medical practice. In a Sounding Board article in this issue of the Journal (pages 710–712), Whitcomb and Cohen argue that students' positive experiences in the offices of primary care physicians during their first two years of medical school are overshadowed by negative experiences during their third-year clerkships in primary care, in which they primarily see inpatients. I think the authors' call to redesign residency programs so that they emphasize interdisciplinary ambulatory, home-based, and inpatient care for an aging population of patients with complex, chronic problems is a valuable recommendation.
In recent years, third-year clerkships in many medical schools have, in fact, included a substantial proportion of experience in ambulatory care. At the Medical College of Georgia, students rate highly our carefully selected community-based faculty physicians and practice sites. However, high ratings have not translated into more students choosing careers as generalists. Although they are increasingly knowledgeable about primary care practice, students are not attracted by what they see in community and academic practices.
Many students enter medical school with the desire to become primary care doctors and to care for the whole patient, not just an individual organ system. And many primary care physicians are indeed gratified by their relationships with patients, but they are increasingly dissatisfied with the regulatory headaches associated with practice, the decreased remuneration for their non–procedure-based services, and the fragmentation of care. They used to provide long-term, continuous care. Now hospitalists provide inpatient care, and patients in a managed-care system may see a different physician each time they seek outpatient care. These forces have eroded the traditional bond between physician and patient, which was what attracted many doctors to primary care in the first place. Although these changes relieve physicians of the responsibility for continuous patient care, they disrupt the continuity of care and the once-cherished physician–patient relationship.
Students also express concern about the way that residents run from wards to clinics to rounds. They get new patients every morning and never catch up. They are harried and unhappy. Clearly, residents and their satisfaction or dissatisfaction play a crucial role in students' career choices. Faculty physicians also have a powerful influence: students are more likely to follow in the footsteps of faculty members who seem satisfied with their specialty than to wish to emulate those who are frustrated and unhappy.
The current marketplace and workforce projections influence some students' decisions, although these projections may not reflect the actual need when students enter the workforce four to eight years after selecting their specialty. In the mid-1990s, for example, the United States had a plethora of anesthesiologists, which inspired cartoons of anesthesiologists standing on street corners, holding "will work" signs. In 1996, only 172 senior medical students (from a total of 13,392 students in the National Residency Matching Program) were matched in residency programs in anesthesiology.2 Eight years later, we are facing a dearth of anesthesiologists, and remuneration for these specialists has increased markedly. In 2004, 897 students (from a total of 13,572 students) were matched in anesthesiology.3
The need to pay off massive educational debt makes primary care and other non–procedure-oriented specialties unaffordable for some students who aspire to primary care practice. Unless we correct the inequities in the payment system, this problem is likely to persist. Increasing debt levels have prompted students to present resolutions to major physicians' organizations, challenging them to support changes in the financing of medical education that would diminish the burden on students.
Lifestyle is another important factor for today's students,4 who may be more concerned about discretionary time than about money. As compared with students of 20 or 30 years ago, contemporary students are more concerned about the balance between their personal and professional lives. They want more time for themselves and their families, and they are less willing to enter a specialty with long, unpredictable working hours. Physicians who are seeking partners for their practice recognize this change in priorities, as residents negotiating for jobs become more candid about their desire to limit their on-call responsibilities and work hours. It is not only a women's issue, even though soon more than half the physicians entering the workforce will be women, a sizable proportion of whom will be married to other physicians.
What can we do to help the next generation of physicians meet the health care needs of our aging population while choosing the specialty that is right for them? On a national level, we need to revamp clerkships and residencies so that high-quality, efficient, interdisciplinary patient care becomes the centerpiece of clinical education. In terms of financial issues, we need to reduce the inequities in reimbursement that favor procedure-related skills over patient-focused skills, reform the federal financing of residency education that favors hospital-based education over ambulatory-care–based education, reduce the escalating burden of student debt, and deal with the crisis in the cost of malpractice insurance. We must identify or create models of efficient, interdisciplinary, patient-friendly care in academic medical centers and exemplary community-based practices. These models should serve as templates for providing comprehensive care to patients with complex, chronic illnesses in a variety of settings. When students learn from physicians who enjoy their professional experience and provide high-quality care, they are likely to be attracted to the discipline that best suits their personal and professional goals.
Ideally, students should choose a specialty independently of concern about educational debt and inequities in remuneration, on the basis of the knowledge they have gained from clinical experiences with comprehensive care. A dedicated core of students will continue to choose primary care, but to attract more students to such generalist careers, our systems of health care delivery and education must change.
Source Information
From the Medical College of Georgia School of Medicine, Augusta.
References
Council on Graduate Medical Education sixth report: managed health care: implications for the physician workforce and medical education. Rockville, Md.: U.S. Department of Health and Human Services, September 1995.
Randlett RR, Creighton KP. Results of the National Residency Matching Program for 1996. Acad Med 1996;71:697-699.
National Residency Matching Program 2004 match data. (Accessed July 22, 2004, at http://www.nrmp.org/2004advdata.)
Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173-1178.
Related Letters:
Attracting Students to Primary Care
Saver B. G., Poplin C. M., Cykert S., Fleming M., Johnson M. S., South-Paul J., Rustin T. A., Whitcomb M. E., Cohen J. J., Fincher R.-M. E.(Ruth-Marie E. Fincher, M.)