By John Corker
The misconception that primary care is dull is just as damaging as the salary discrepancy, says John Corker. By his third year in medical school, Corker saw that primary care is anything but boring and that the misconceptions of many are far from reality.
The AAMC projects that by 2015 - the year after the Affordable Care Act is scheduled to add approximately 32 million patients to the ranks of the insured - we will have 63,000 fewer physicians than we need in the United States. If nothing is done, that number is then projected to surpass 130,000 by 2025. Unfortunately, as of this time one year ago, these "projections" had already become reality for 22 U.S. states and 17 medical societies across the country.
While these shortages span all medical specialties in most of the country, the day-to-day strain is felt most in primary care and in the under-served areas of our urban and rural communities. Already, foundational efforts are underway to address this growing shortage. Medical schools are increasing class sizes. And, since 2007, 18 new medical schools have opened and 10 more are in the works – many created with the express purpose of training more primary care physicians.
Despite these new schools' best intentions, however, they cannot force students to choose primary care after graduation. This challenge in recruiting students to primary care will arguably be the biggest obstacle (adequate Graduate Medical Education funding for residency slots being the other) that we face in our ongoing attempts to train enough doctors to meet our growing population's needs. Before we can adequately tackle this daunting challenge, however, we must first understand why medical students are avoiding primary care to begin with.
The two-ton albatross sitting conspicuously in the middle of the room is money. The average primary care physician earns $175,000 to $200,000 per year, depending on geographic region. At face value, that is a very impressive sum of money. But consider that this amount is approximately half of the average earnings of a medical specialist. In addition, consider that the average educational debt carried by a medical student at graduation is approximately $160,000. Digging even deeper, this average debt figure is the product of a bimodal distribution. In other words, there are very few medical students who actually graduate with debt approximating $160,000. In reality, there is a very large group that graduates with approximately $80,000 in debt (those who receive familial assistance) and another very large group who graduates with approximately $240,000 in debt (those who are on their own).
Thus, we are left with very few students carrying "average" debt and two very large groups who are both more likely to gravitate toward higher-paying specialties. Since the $80,000 group is ostensibly comprised of students from more affluent backgrounds, it stands to reason that these students will be more likely to pursue specialties that will allow them to maintain the lifestyle to which they've become accustomed. Additionally, the $250,000 group is more likely to pursue higher-paying specialties out of shear economic necessity. Paying off a quarter-million dollar educational debt at an average of 6.8% interest (almost twice that of the average home mortgage interest rate) over 15-30 years (same pay-off period as a mortgage) can seem quite daunting to a young person who is hoping to support a family and be able to afford an actual
But money is not the only disincentive for pursuing a career in primary care. Just as damaging is the perception that primary care specialties are inherently more mundane than their higher-tech, procedure-heavy counterparts; often requiring longer hours for less exciting work. As Dr. John Donnelly, a family practitioner on faculty at the Wright State University Boonshoft School of Medicine says, "A lot of people think that all I see every day are sore throats and runny noses." It’s hard to get a medical student excited about spending 10-12 hours per day, 5 days per week wading through rapid-fire, 15-minute appointments, prescribing and re-prescribing medications in an attempt to manage the chronic conditions of patients who are often unwilling or unable to play an equal role in that management.
But unlike the real financial differences between primary care and medical specialties, the perception that primary care practice is mundane seems to lie in the eye of the beholder. Of course, certain specialties are going to appeal differently to the myriad personalities and career goals of medical graduates. But even from my limited clinical experience as a medical student, I confidently assert that the perception of some is far from reality. Every family practitioner whom I've met on faculty at Wright State would tell you that they love their job (and, by the way, none of them are going broke). I can say the same of my OB/GYN attendings. And on my outpatient pediatrics month alone, I saw patients with not-so-mundane diseases like DiGeorge Syndrome, severe Polymicrogyria, Neonatal Lupus, brothers with Neurofibromatosis Type 1, and a vibrant, athletic 11-year old who had survived multiple open-heart surgeries after being born with Hypoplastic Left Heart Syndrome.
So how can we overcome both real and perceived obstacles to recruiting medical students into primary care? It stands to reason that the first step would be to systematically and longitudinally expose more medical students to the primary care setting from day one of their medical training. In this manner, students will be provided with a personal, first-hand view of primary care. Then, and only then, will they be able to definitively determine whether primary care is a match for them. In addition, more resources need to be devoted to primary-care-specific post-graduate loan repayment programs and to replacing the current government reimbursement formulas that value technology-heavy procedures over prevention.
Effectively incentivizing medical students to pursue careers in primary care continually grows harder, especially as medical graduates' financial burdens escalate while popular perception of preventive care continues to decline. If prioritized, however, the resources are available to tackle this significant challenge. And as the American population continues to both grow and age, doing so will be essential to adequately addressing the nation’s health care needs.
John Corker is a third-year medical student at the Wright State University Boonshoft School of Medicine. He serves as Host and Executive Board Member of Radio Rounds, as well as the Health Care Correspondent for the Next Generation Journal. He will be moving to Washington, D.C., for the coming year in order to serve as the American Medical Association's Government Relations Advocacy Fellow. Upon completion of medical school, he hopes to pursue a career in Emergency Medicine and Public Health Policy.