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Primary care still isn't an attractive choice for new doctors

March 19, 2010 |  6:00 am

Match Thursday was Match Day, the annual rite of passage when medical school graduates at the nation's 130 medical schools are assigned to a hospital for their post-graduate training. The students request the type of specialty they want to practice as well as their top preferences for where they'd like to train.

Overall, the news Thursday wasn't great for consumers. The nation is in dire need of more primary-care doctors, but the number of medical students choosing internal medicine residencies (where they learn primary care) increased only 3.4% from 2009, according to the 2010 National Resident Matching Program report. The number of students choosing internal medicine was 2,722 this year compared with 3,884 in 1985. Moreover, only about one-quarter of internal medicine residents eventually go on to specialize in internal medicine.

Some students may avoid primary care because they won't make as much money as their colleagues in cardiology or dermatology. Meanwhile the cost of medical school keeps rising.

It's interesting that, with all of the debate over healthcare reform, the question of having enough primary-care doctors still hasn't been addressed.

"As America's aging population increases and more people gain access to affordable coverage, the demand for general internists and other primary care doctors will drastically outpace the primary care physician supply," said Dr. Steven Weinberger, an official with the American College of Physicians, in a news release bemoaning the lack of primary-care doctors.

For those students who chose internal medicine residencies -- thanks. We need you.

-- Shari Roan

Photo: Medical students cheer the news at a 2001 Match Day. Photo credit: Al Schaben  /  Los Angeles Times

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Comments (12)

Internal medicine is not the only primary care specialty. In fact, family medicine, which is exclusively primary care, saw a 9% increase: http://www.aamc.org/newsroom/pressrel/2010/100318.htm

The results are true about internal medicine. However, you left out very promising stats that occurred yesterday, where family medicine matched at its highest percentage of filled slots ever and an overall 9% increase from last year, the most out of all "primary care" specialties. There are other primary care specialties, which I am sure was just a simple oversight from the blogger.

Internal medicine does produce more specialists than general internists - which I believe is even lower than 25%. However, family medicine is exclusively primary care - a better gauge for where primary care is going. Other specialties considered primary care are pediatrics and OB/GYN - these are listed in the house bill as the qualified primary care specialties which I am sure you have read.

Primary care consists of family medicine, pediatrics, ob/gyn, AND internal medecine. Additionally, many more students chose family medicine as a specialty, resulting in the highest number of family medicine residency spots being filled this year.

You neglected to cite that the major press release out from the Match program headlines, "MORE U.S. MEDICAL SCHOOL SENIORS TO TRAIN AS FAMILY MEDICINE RESIDENTS Record 16,000 Participate in Annual “Match”" (http://www.nrmp.org/data/2010pressrelease.pdf). Family Physicians are the backbone of primary care in this country. Few internal medicine residents are going into primary care, while virtually all family medicine residents are.

Primary care encompasses MUCH more than internal medicine. Have you looked at the Family Medicine fill rates for this year? Highest ever!!! And what about Pediatrics and OB/GYN? Articles like this one just mislead the public into thinking they don't have a choice other than to see an Internist, when that just isn't true.

I appreciate that you are highlighting our need for more primary care doctors in the U.S., but why not mention the match rates for family medicine and pediatrics? Both of these specialties are just as liklely to be underpaid and overwhelmed serving the American public "in the trenches." Limiting family doctors and pediatricians to "other primary care," three words in your entire article, really doesn't help the general public see that there are potentially more options than a general internist for primary care.

What about our thanks?

Please note that internists are not the only primary care doctors, there are those who choose family practice and pediatric residencies who will eventually settle into primary care roles, but likewise there is a downward trend in those pursuing these specialties.

The entire match system is seriously flawed. The truth is, hardly any med school graduate gets to choose his or her specialty, in the end, it´s all down to sheer luck. See, in any profession you choose what you think you are best at, at the place you feel most comfortable with. In medicine, you are assigned to a specialty that an intransparent and buggy computer system selects for you - without even knowing what city you´ll end up in. Try putting the blame on new doctors now - were it not for the flawed, outdated, grossly ineffective and discriminatory match as it stands today, new doctors could choose freely what specialty to match to, rather than viewing an internal medicine position as the reject tray of match day. Unless the current match gets replaced by a transparent and more applicant-centered approach, we will continue to end up getting the doctors that we deserve: Too few, too late and, after all, too expensive.

Physician assistants will pick up some of the slack in the primary care arena, but even PAs are leaving primary care. Why take a low paying job ($20 to spend an half hour teaching an uncontrolled hypertensive, morbidly obese diabetic that they won't survive beyond their 20s if they don't get their blood sugars under 500) when you can first assist in orthopaedics or cardiothoracic surgery? The only place primary care pays the bills is in the prison system.

And who do you think is going to be hurt the most by an outcomes based healthcare system? "Wait, I only get my bonus if this lard@$$ gets his HgbA1C under 6 this quarter?, but if I were an orthopaedist and replace a hip, I get my bonus if my patient can walk 50% more than before the surgery?"

Out of thousands and thousands of patients, I have only had one patient lose weight despite, education, referrals, and pleading. And he went off the deep end and became obsessed with spreadsheets, calories, and whether 3.5 grams of carrot was better for him or 4.2 grams of celery for his next snack. And this is how I'm to be compensated?

Primary care doctors also include family medicine and pediatrics ... we need and heartily thank them too!

Dear Ms. Roan,
I agree, it is interesting that enhancing incentives for primary care medicine hasn't come up much in the healthcare debates. The problem of a shrinking primary care work force will not go away on its own. In fact, it will likely get worse as baby boomer primary care physicians retire and the remaining PCPs are increasingly overburdened by the sheer volume of patients. Your thanks is very nice, but sadly not enough. Specialists like dermatologists, radiologists, anesthesiologists, and orthopedists will make 3-4x what primary care physicians will make upon completion of residency. More importantly specialists will see 1/2 to 1/4 of the patients and deal with 1/4 to 1/8 of the medical issues at one time. They are also in a much better position to cherry pick patients with higher reimbursing insurance plans. The general rule in primary care is to treat all comers without exception. When taken together you can see that it is not logical to choose primary care. Thus, I imagine it will get worse before it gets better.
Sincerely,
Ashley Gallagher, MD
Family Medicine Resident, PGY 3
(Family Medicine residency trains only primary care physicians, unlike Internal Medicine residency which is a stepping stone to specialties like cardiology, gastroenterology, rheumatology, etc.)

Point of information--primary care in the U.S is defined as the specialties of internal medicine, family medicine, pediatrics and obstetrics/gynecology. Internists are able to only care for those above 18 years of age, so if they were the entire primary care workforce, children would be in trouble, as would pregnant women, since only Family Medicine doctors and OB/Gyns are trained to give prenatal care and perform deliveries.
It is correct that about 80% of all internists eventually specialize, and internists provide less than 20% of all primary care. It is Family Doctors who provide the lions share of primary care, and fortunately, Family Medicine just experienced its best match year ever, filling 91.4% of all spots.
So for those who will eventually practice primary care and not specialize, thanks. We need you.



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