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Primary care physicians include family medicine doctors, internists, pediatricians, and in some instances, obstetrician–gynecologists; of course, not all such physicians practice primary care. Currently, primary care accounts for about one third of the physician workforce, but far fewer U.S. medical students are interested in careers in adult primary care than were a decade ago.1 The percentages of U.S. medical students entering residencies in family medicine and internal medicine have declined substantially (see graph). In 2009, only 247 residency positions were offered in primary care internal medicine, a decrease of 328 from 1999. Although the percentages of U.S. students entering residencies in obstetrics–gynecology and pediatrics have also declined, those decreases have been more modest. The overall number of pediatricians has increased substantially, and the proportion of pediatrics residents entering primary care pediatrics has remained relatively constant.2
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The diminished interest in primary care among U.S. medical students has led to an increased dependence on international medical graduates (IMGs). In 2005 and 2006, about one quarter of all visits to office-based physicians in the United States were to IMGs.3 Some 57.0% of IMGs were in primary care specialties, as compared with 46.2% of U.S. medical graduates; outside metropolitan areas, 67.8% of IMGs — and only 39.8% of U.S. graduates — practiced in areas with primary care shortages.3 In 2009, IMGs filled about two fifths of first-year residency positions that could produce primary care physicians.
What can be done to alleviate the adult primary care shortage and increase the percentage of such doctors who are trained in the United States? The way in which primary care practices are organized and collaborations among doctors, nurse practitioners, and physicians' assistants will be key determinants of the number of physicians needed, their professional experiences, and their job satisfaction. However, merely increasing the numbers of medical schools, medical students, or residency positions that could produce primary care physicians will have limited effects if U.S. medical students continue to shun such careers.
In the near term, with or without health care reform, the United States will continue to rely disproportionately on IMGs to provide primary care. In the long term, augmenting the incomes of primary care physicians, increasing the proportion who accept patients regardless of their type of insurance, implementing new payment models, and reducing or eliminating income disparities between specialists and generalists will probably be essential, as will expanded government support for primary care training through Medicare, Title VII of the Public Health Service Act, and related programs. Revitalizing and expanding the National Health Service Corps (NHSC) is also important. Physicians in the NHSC loan-repayment program are about 7 times as likely as others to choose a primary care career, and students who avoid debt by receiving NHSC scholarships are about 4.5 times as likely as others to enter primary care.1 All physicians in the corps practice primary care; patients who need specialists are referred to the nearest qualified hospital or clinic. Although the NHSC requires a commitment to practice in an underserved area for a limited number of years, participation may lead to a sustained commitment to primary care.1 Unfortunately, the program shrank under the Bush administration: in fiscal year 2008, there were sufficient funds for only 76 new scholarship awards (49 to medical students) and 867 new loan-repayment awards (223 to physicians).
The relationship between medical student debt and career choice is complex, and studies have had conflicting results. Whereas some students have sufficient means to graduate without debt, the risk of accumulating a large debt probably deters some undergraduates, particularly students from low-income families, from even applying to medical school. Although avoiding or promptly repaying debt is more important for some than for others, tuition decreases, scholarships, and loan-repayment programs can promote primary care careers.
Money is not the only consideration, however. Medical career choice involves many factors.1 For example, students who grew up in rural areas and those with a demonstrated interest in caring for underserved groups are more likely than others to practice primary care. And students at public medical schools are more likely to choose primary care careers than those at private schools, as are students in rural as opposed to urban schools. Training in rural locations is an important factor in students' choice to practice in such locations. Women are more likely than men to choose primary care but less likely to practice in rural areas. Positive experiences with primary care during medical school, such as in clerkships, encourage students to pursue primary care: those with favorable impressions of internists' patients, practice environment, and lifestyle are more likely to become internists.4 Such findings can inform policy — for example, by focusing attention on which students are admitted to medical school (and expanding opportunities for applicants from less-affluent families) and on the quality of experiences with primary care during training (including opportunities to work in locations with physician shortages).5
Of course, students notice when teaching hospitals invest in facilities for lucrative specialties but not for primary care. During specialty rotations, students may observe well-managed offices with spacious modern facilities, in contrast to crowded older primary care clinics with harried physicians.1 Such discrepancies make it more difficult for faculty to facilitate primary care careers through teaching and mentoring. The national trends notwithstanding, at some (mostly public) medical schools, high percentages of students still enter residencies in family medicine, internal medicine, or pediatrics (see table). These schools' experiences could inform approaches elsewhere.
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Congress could adopt additional measures that might have an early impact, either as part of a health care reform bill or in separate legislation (see the Perspective article in this issue of the Journal by Bodenheimer et al., pages 2693–2696). Although the shortage of primary care physicians for adults will require the training of additional physicians and other long-term solutions, health care reform may be judged by how well it works from day 1.
Source Information
Dr. Steinbrook (rsteinbrook{at}attglobal.net) is a national correspondent for the Journal.
References
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Related Letters:
Primary Care — Lifelines and Shortages
Rickert J., LeBlanc T. W., Edelman N. H., Bodenheimer T., Grumbach K., Berenson R. A.
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N Engl J Med 2009;
361:1413-1415, Oct 1, 2009.
Correspondence
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