Posted February 27, 2012
By John Corker
The Association of American Medical Colleges’ Office of Workforce Studies projects by 2015 — the year after the Patient Protection and 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 to address this critical shortage, then that number is projected to reach an astounding 130,600 by 2025. Unfortunately, as of this time one year ago, these “projections” had already become reality for 22 states and 17 medical societies across the country.
It’s true these current shortages and their projected exacerbation span all medical specialties in most areas of the country. But it’s also no secret their day-to-day strain is felt most heavily amongst primary care specialties and in the under-served areas of our urban and rural communities.
Already, foundational efforts are underway to begin to address our growing physician shortage. Existing medical schools across the country are increasing class sizes. And, since 2007, 18 new medical schools have opened and 10 more are in the planning stages. Many of these new medical schools have been 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 specialties after graduation. And it’s precisely this challenge in recruiting medical students to primary care that will serve as arguably the biggest obstacle (adequate Graduate Medical Education funding for residency slots being the other) 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, it’s important to first understand why medical students are avoiding these all-important primary care specialties.
The two-ton albatross sitting conspicuously in the middle of the room on this one is money. The average primary care physician earns between $175,000 – 200,000 per year, depending on the area of the country in which they live. At face value, that’s 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 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 these students will be more likely to pursue specialties allowing 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 sheer 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 hopes to support a family and be able to afford an actual mortgage someday.
But money is certainly not the only disincentive for today’s medical students in pursuing careers 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, five 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 very real financial differences between primary care and medical specialties, this perception of the mundane primary care practice seems to depend more on the eye of the beholder. Of course, certain specialties are going to appeal differently to the myriad personalities and career goals of medical graduates across the country. But even from my limited clinical experience as a third-year medical student, I can confidently assert that the perception of some is far from an inherent reality.
Every Family Practitioner whom I’ve met on faculty at Wright State would tell you they love their job (and, by the way, none of them are going broke). I can say the same for my OB/GYN attending physicians, and they enjoy the added bonus of facilitating the miracle of new life each and every day. Additionally, on my outpatient (non-hospital) pediatrics month alone, I saw patients with interesting, rare diseases such as 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 do more to overcome these obstacles (both real and perceived) 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 in their medical training. In this manner, students will be provided with a personal, first-hand window into the realities of primary care medicine.
Then, and only then, will they be able to definitively determine whether the unique aspects of a particular primary care specialty comprise a desirable match for the students’ unique personalities and career goals. In addition, more resources need to be devoted to primary care-specific post-graduate loan repayment programs, as well as to support efforts to replace the current government reimbursement formulas that value technology-heavy procedures needed to fix problems more than the preventative measures necessary to keep them from occurring.
Effectively incentivising medical students to pursue careers in primary care continually grows harder, especially as medical graduates’ financial burdens continue to escalate while popular perception of preventative care continues to decline. If properly prioritized, however, the resources are available to tackle this significant challenge. And as the American population continues to both grow and grow older, doing so will be essential to adequately addressing the nation’s ever-growing health care needs.