A few weeks ago, I met up with two of my medical school classmates for a drink. I’ve known them for the past three years, but I never had a heart-to-heart with them before the other night. But it’s the time of year when fourth-year students, like us, have to decide which medical specialty we want to pursue, and our conversations these days are full of gossip about who is choosing what. News travels fast through the medical student grapevine, and we discovered we had something in common.
The three of us sought each other out that night because we all want to go into family medicine. In our medical school class, at the University of Pennsylvania, that makes us anomalies. We were an unofficial support group for a rare condition: becoming a primary-care doctor.
One friend described feeling ashamed at a recent class party, where all the chatter was all about specialty choice. Another classmate who wants to become a neurosurgeon — an extremely competitive specialty—grilled my friend on why he would waste his medical education by becoming a family doctor. My friend loved the breadth of family medicine, but he told me he couldn’t help wondering: “Am I being all that I can be?”
At medical schools, general medicine is often considered unchallenging and quaint, even though primary-care doctors are what our nation needs most from its medical schools. Millions of Americans are newly insured under the Affordable Care Act; the U.S. Department of Health and Human Services predicts a dearth of primary-care doctors in coming years, a shortage as great as 20,000 doctors by the year 2020. The recent Veterans Health Administration scandal came to light, in part, because there aren’t enough general internists working within the system to meet the primary care needs of American veterans. Primary care is where there are the greatest gaps in public health and the most job opportunities for recent graduates. But medical students, at least the ones I know, still shun it.
I am planning on applying in family medicine in the 2015 Match, the national system that pairs medical school graduates with slots in residency-training programs. As I prepare my application, I’ve been doing a lot of thinking about why my career choice seems so unimaginable to so many of my classmates. Why do students at elite medical schools think primary care is boring?
Many of my classmates started medical school with the goal of becoming a primary-care doctor. But somewhere between orientation and Match Day, the high-pressure moment when med school seniors find out where they will be training, the idealism wears off.
At my medical school, 12 out of 162 students in this past year’s graduating class have started primary-care residency programs. Nationwide, about 12 percent of graduates in the 2014 Match entered residencies dedicated specifically to primary care (though graduates who do general internal medicine or pediatrics programs may still end up in primary care).
In the academic hospitals where American medical students complete most of their training, specialty care is the norm rather than the exception. Teams of specialist consultants visit hospitalized patients, asking lots of pointed questions about whatever organ they know best. We students follow along, as part of a whirlwind 12 months known as the “core clerkships.” If a patient has a problem that doesn’t fall within the bounds of whatever specialty we happen to be rotating through, it’s not our responsibility—our advice to the patient is to follow up with his primary-care doctor.
At my medical school, we spend 7 out of 48 weeks of our core clerkships in dedicated primary care settings. But more than half of doctors’ visits are made to primary-care offices, according to the Centers for Disease Control and Prevention’s National Ambulatory Medical Care Survey. The majority of medical care is taking place in outpatient settings, away from the type of care centers where we students learn the basics.
The lack of exposure to primary care sets the stage for my medical school’s hyper-specialized Match list. The role models we work with every day are specialists, and we start to imagine our future careers looking like theirs. As a classmate who is also going into family medicine said, “We don’t get to see the primary-care rockstars.”
But there’s something deeper at play, a widespread and nagging perception that primary care doctors just aren’t as smart as their specialist counterparts. A 2013 essay in the Annals of Internal Medicine asked the question most of my colleagues are too polite to verbalize: If you’re smart enough to do well in medical school, why would you go into primary care?
It’s true that certain specialties, such as plastic surgery and ophthalmology, have few positions available in residency training programs, so competition for those spots becomes fierce. Average test scores and grade-point averages are higher for students who successfully match into those programs. Primary care programs have more positions available, so fewer students vie for each one.
Some of my classmates have asked me why I would want to do work that they think nurses or physician assistants should do. A friend who is thinking of becoming a trauma surgeon put it this way: “On my family medicine rotation, I just felt like the intellectual rigor wasn’t there.” Every time I tell someone I plan to go into primary care, I wonder if they think I just wasn’t smart enough to do something else.
When I spoke to Andrew Morris-Singer, a primary-care physician at Harvard Medical School and the founder of Primary Care Progress, an advocacy organization that promotes training in primary care, he recounted a story a medical student once told him. The student told a colleague about his plans to practice general medicine, and the doctor apparently responded: “A monkey could do this.
General practitioners don’t exactly have a great reputation in popular media, either. A recent Washington Post article painted a disturbing portrait of what my future career might look like: Primary-care docs are burned out, bitter, and leaving their practices behind for more lucrative endeavors, it said. They forgo, on average, about $175,000 a year in salary compared to their specialist counterparts.
Bias against primary care influences the way medical students think about their careers. A 2013 paper in the journal Academic Medicine interviewed more than 1,500 students, and authors found that students who attended schools where there was frequent badmouthing of primary care were, unsurprisingly, less likely to pursue a career in that field.
This stigma has certainly affected me and my classmates who are bound for primary care. Most of us have strongly considered other paths. When a hand surgeon told me I had excellent surgical technique, I had a 24-hour fantasy of going into orthopedics. I thought seriously about obstetrics and gynecology, a field with strong public-health implications, but more surgery than I really wanted to do. It’s been hard at times not to envision myself in a medical specialty, given that’s most of what I’ve seen in medical school.
I remember one sub-specialty gynecology rotation I did, where one of the tasks that fell to me was to explain to the patients that the doctor I was working with wasn’t a “normal” gynecologist, so she could only be of help with a few specific conditions, not with their annual exams.
For those specific conditions, she is one of the country’s foremost experts. I learned a lot from her, and she’s a kind and talented physician. But I could sense how frustrated the patients were, bouncing from specialist to specialist, seeing doctors in disjointed fits and spurts. Specialized care doesn’t always mean better care. For rare and complicated ailments, it is. But not for keeping people healthy, or for preventing disease in the first place.
Doctors love data, and there’s good data that more primary-care mentorship can encourage medical students to go into this field.
Clese Erickson, the director of the American Association of Medical Colleges’ Center for Workforce Statistics and the lead author of the 2013 Academic Medicine study that examined primary-care stigma in medical schools, says strong role models—those “primary-care rockstars” my classmate lamented not meeting—can really change the trajectory of students’ careers.
“Their eyes would just light up,” she said, describing her interviews with students around the country who described these kinds of formative experiences. Students at schools with a positive “primary-care culture,” she said, “are connected with primary-care physicians, and practices, and can see something that they would want to wake up every day and do.”
Sitting in a classroom and listening to a lecture on why primary care is cool won’t convince anyone. It’s seeing it in action that might.
When I spoke to Morris-Singer, he asked me where I saw myself in five years. For a moment, I forgot I was the one who had come with questions for him, and I felt like what I will become this fall: a medical student on a job interview.
I told him some of the things that make me excited about working in primary care. I’m eager to work across disciplines to help keep patients healthy, rather than reacting when they get sick; I want to get to know my patients over time. There will be painfully rushed office visits in my future. There will be red tape and frustrations. But like many of my smart peers headed into this field, I also feel motivated by the challenges of designing new systems that meet the needs of patients, not the needs of insurance companies.
As part of an advanced family-medicine elective this past spring, I worked in a free North Philadelphia clinic with a harm-reduction philosophy, trading heroin users packs of clean needles for their dirty ones in an effort to curb the spread of HIV and Hepatitis C. These patients did not always have complicated medical problems. But the ways the legal and healthcare systems had let them down were certainly complicated. It was thrilling to work with other doctors who saw this inequality as a call to action, not a problem outside of the scope of our medical practice. This kind of challenge is the reason I went to medical school.
Harnessing this sense of activism and opportunity, Morris-Singer said, is the key to more primary-care doctors, and not just primary-care doctors who feel subservient to an antiquated bureaucracy.
“The next generation is hungry,” he told me. “They see the problems in the system.” He went on to imitate a typical shocked medical student response to some of the absurd processes we find ourselves shackled to in American healthcare: “‘He’s faxing! Why is he faxing something?’ There’s something screwed up here.” Instead, Morris-Singer wants medical students to think: “I can help fix this.”