Medical schools struggle to close primary care gap

Diana Huang entered medical school ready to work hard to realize her ambition of becoming a primary care doctor. What she wasn’t prepared for was the tepid support she has gotten from some classmates and faculty regarding her chosen specialty.

“I definitely got messages along the way where I could tell people had the attitude of, ‘it’s fine if you want to do that, but it’s not anything impressive,” says Huang, a fourth-year student at Temple University’s Lewis Katz School of Medicine in Philadelphia. 

Huang’s feeling that she receives little encouragement for a career in primary care is common among medical students. Changing the attitude that produces it-that specialization is preferable to more general medicine-is but one of the challenges schools face in trying to graduate enough primary care physicians to meet the expected demand-challenges ranging from their admissions policies to the difficulty of finding acceptable sites for primary care rotations. 

“The AAMC [Association of American Medical Colleges] endorses the notion that we need a strong primary care workforce,” says Scott Shipman, MD, MPH, director of primary care initiatives and workforce analysis at the AAMC. He adds that the association’s projections “suggest that we are falling short on creating enough primary care practitioners to meet the projected demand, although there is also a shortage of physicians in many specialties.” 

At the same time, Shipman notes, students base career decisions on many factors, and in the absence of a national allocation structure for graduating students, “much of the output of the medical workforce is dictated by student preferences and the availability of GME [graduate medical education] positions,” rather than anything schools themselves can do. 

While many of these issues lie outside the control of physicians now in practice, those concerned about the future supply of primary care doctors do have opportunities to help, experts say. These can take the forms of mentoring individual students, speaking at medical schools or allowing students into their practices, either to shadow physicians or as part of a clinical rotation program. (See sidebar.) 

Primary care shortage expected to increase

Healthcare policy experts and physicians’ groups have been sounding the alarm about a looming doctor shortage for more than a decade, but the problem shows no signs of abating. A 2016 study of physician supply and demand commissioned by the AAMC forecasts a primary care physician shortfall ranging from about 15,000 to more than 35,000 by 2025-even though the number of graduates matching to residencies in internal and family medicine and pediatrics has been trending up in recent years. 

Confronting debt loads

When looking for reasons for students’ ambivalence towards primary care, the logical place to start is with money: primary care pays less than most other specialties, as shown in the Medical Economics Physician Report.

In the 2015 report, for example, the median income for cardiologists was $363,000, and $312,000 for surgeons. For internists, family physicians and pediatricians, median income was $188,000. (Results of the latest Physician Report will appear in the April 25 issue of Medical Economics.)  

In addition, students are leaving medical school with ever-larger debt loads-an average of nearly $182,000 (combined undergraduate and medical school), according to AAMC data. “I think it’s fair to suggest that significant debt burden does serve as a disincentive to choosing any specialty with a comparatively lower salary, given all else being equal in terms of students’ interest,” says Shipman. 

At Case Western Reserve University (CWRU) School of Medicine in Cleveland, tuition is approaching $60,000 per year, and students graduate owing an average of $180,000 in medical school debt alone.

“It’s no secret that there’s a tremendous variance between primary care specialties and surgical specialties, which are the ones students are often comparing,” says Patricia Thomas, MD, PhD, the school’s vice dean for education. “You start off behind and you’ll have trouble catching up. It doesn’t take students long to realize that.” 

But the links between debt, income and career choice are not always clear-cut, say students and administrators. “I think we know long-term [money] is going to play a role, but I don’t think it’s in the forefront of a lot of people’s minds as they make career decisions,” says Craig Washington, a fourth-year student at Meharry Medical College in Nashville, Tennessee and chair of the American College of
Physicians Council of Student Members. “It’s really more a question of, ‘what do you want to be doing on a day-to-day basis?’”

Washington says he will finish medical school owing about $280,000, including loans from undergraduate school, but feels confident he will be able to pay it off. 

In addition, administrators cite the National Health Service Corps-which offers scholarships and loan repayment in return for two years of work in medically underserved areas-and federally-sponsored programs such as Pay as You Earn  (PAYE) and Revised Pay as You Earn (REPAYE) These latter programs ease debt burdens by tying loan repayment amounts to a borrower’s income and forgiving unpaid balances in as little as 20 years. 

PAYE and REPAYE are “very popular with students because they know there’s an end in sight and they won’t have to keep paying until they’re very old because of the level of debt they’ve taken on,” says Ellen Gomes, director of financial aid at Florida Atlantic University’s Schmidt School of Medicine in Boca Raton, Florida.  

The role of admissions

A second challenge schools face in building interest in primary care stems from their admissions policies. 

Studies show that minority students are more apt to enter primary care (and work in underserved areas) than are students who are white and come from more affluent families and/or families with higher levels of educational attainment.  For example, an AAMC analysis of medical school graduation trends between 1982 and 2007 found that, on average, about 42% of African-American students and 37% of Hispanic students went into primary care, compared with 32% of white and 30% of Asian students-groups who make up far higher proportions of medical school graduates. 

Medical schools have long been aware of the problem, of course, and are continually working to diversify their student bodies. In the AAMC’s 2015 Medical School Enrollment Survey, 83% of responding schools said they have, or plan to have, admissions policies and programs to bolster the number of minority groups now underrepresented in medicine. Seventy-five percent said the same regarding students from disadvantaged backgrounds.  

But medical school administrators acknowledge that diversifying student ranks is a daunting task, especially in light of continually escalating tuitions. “Unless you have a lot of scholarship support for those students, your ability to do that [admit more of them] is somewhat limited,” says CWRU’s Thomas.

Role models

Still another problem schools confront is finding practicing physicians who can provide positive role models for aspiring primary care practitioners. Exposure to, and experiences working with, a particular physician is often an important driver of a student’s career choice, notes Shipman.

The problem where primary care is concerned, he adds, is that “primary care practitioners are, in general, burnt out to a high degree,” thus making them inappropriate role models for students. 

“Many of us are struggling to find the ideal learning environment for primary care,” says Thomas. “Physicians in the outpatient arena are often stressed out, and that might produce negative learning, with students finishing a rotation and saying, ‘I know I don’t want to be someone who’s at the office until nine every night completing electronic health records.’”

First-year students at CWRU spend one afternoon per week in the second half of the year in a preceptorship at a community-based primary care clinic. Thomas says the school is trying to become “more purposeful” in finding places where students can observe, and participate in, high-quality care.

“We look for places where team-based care is happening, with teams that work together and everyone is practicing at the top of their scope,” she says. “We actually get students excited about that mode of practice. They see there are ways of getting physicians back to working with patients and experiencing the joy of practicing primary care medicine.”

At Florida Atlantic, medical school administrators interview candidates for primary care preceptorships. The qualification they look for above all is “a really positive attitude about primary care,” says Stuart Markowitz, MD, senior associate dean for student affairs and admissions. 

“We know there are a lot of docs out there who will say to students, ‘I don’t even know why you’d want to get into this business,’” Markowitz says. “We try to find people who are going to be real cheerleaders for primary care.”

Fighting the ‘hidden curriculum’

Probably the most difficult challenge schools face, however, is overcoming biases against primary care that frequently exist among administrators, faculty and sometimes among students themselves-the so-called hidden curriculum of medical school. 

“The underlying culture of a medical school, in terms of embracing primary care versus considering it sort of an also-ran, is likely to translate into whether it’s an aspirational specialty for students,” says the AAMC’s Shipman. “Too often you hear stories from students about physician faculty telling them they’re too smart to go into primary care, or similar disparaging comments. That sends a message about what is perceived as a valued specialty.”

Shipman’s observation is supported by results of a 2013 study published in the journal Academic Medicine, which found an inverse relationship between the prevalence of “badmouthing” primary care at a school and the likelihood of a student from that school choosing a career in primary care.

The problem stems in part from the way medical schools usually structure their curricula, Thomas notes. Students begin by learning basic scientific and physiological concepts. “Then we bring in the expert to explore subjects in greater depth, and those folks often can say, even unintentionally, disparaging things about primary care.”

Huang recalls a similar experience during her first years as a medical student at Temple, where even basic courses were taught largely by researchers and specialists. She was fortunate to have found faculty with an interest in primary care who encouraged her, she says, but knows others who haven’t been as lucky.

“I have friends who would tell faculty they want to do family medicine, and they’d go, ‘why would you want to do that?’” she says. Huang adds that some faculty show more interest in students who aspire to careers in surgical specialties than those like her whose interests lie in primary care. “They’re like, ‘oh, that’s nice,’ but don’t really consider it something to celebrate. And I think it’s something that should be celebrated,” she says.

Just the fact that medical schools tend to attract motivated, high-achieving students can lead to a bias towards specialization, as students themselves concede.

“Medicine is full of know-it-alls, and there’s always a little one-upmanship that comes with that,” notes Elianna Peak, a third-year student at the University of Cincinnati College of Medicine. That desire to flaunt one’s knowledge often gets channeled into an interest in narrow medical specialties, and “specialty anything is always more valued in our society,” she says.

The importance of faculty encouragement

Schools that attempt to counter the hidden curriculum often do so by ensuring that primary care specialists are well-represented among faculty and administrators. At Florida Atlantic, for example, the director of medical education is a pediatrician, while Markowitz and Assistant Dean of Student Affairs Jennifer Caceres, MD, are internists. 

“Students hear a lot about primary care from us, both in medical education and student affairs,” says Markowitz. The latter department also has responsibility for career planning, “so there’s naturally a bias towards primary care coming from us,” he adds.

Students seem to be getting the message: about 28% of its 2016 graduates are pursuing residencies in internal, family or pediatric medicine, and 39% of the class of 2017 are planning to do so. 

Similarly at Meharry, where more than half the class of 2017 say they plan on careers in primary care, the top two student affairs administrators come from primary care backgrounds. So do a significant number of teaching faculty, says Craig Washington. “I’d say the students here view primary care faculty more favorably than those from other backgrounds,” Washington says.

Like many other students intent on primary care careers, Washington is aware of the challenges he faces, including lower earnings and higher stress levels than many of his classmates. But those will be more than balanced, he says, by the benefits of establishing long-term relationships with patients, and contributing to whatever community he settles in.