Primary Care in the Shadows: Lack of Medical School Role Models

"Big Doctoring in America demonstrates that primary care works: it provides continuous, personalized care, and minimizes unnecessary referrals and interventions. Yet its role at the center of health care delivery is uncertain. General practitioners are paid less than specialists. Promising medical students are they are “too smart” to go into primary care."

Jacket blurb, Big Doctoring in America, 2002, by Fitzhugh Mullan, MD

Many medical students perceive primary care as a default path, characterized by the absence of differentiation into anything else. Perhaps as a result, general medicine doesn’t inspire the same urgency to “invest early”, it’s rare , for example, to see a classmate skip lecture to shadow an internist.

Rena Xu, A.B, Harvard Medical Student, “ A Differerentiation Diagnosis – Specialization and the Medical Student, New England Journal of Medicine,
August 4, 2011

August 4, 2011- When I was a medical student, most of us didn’t know what we wanted to become. At graduation, most of us still didn’t know so we took rotating or general medicine internships. Even then I didn’t know, so I decided to take a year of pathology, the speciality that studies disease.

Those days are gone. Now, according to Rena Xu, a Harvard medical students, medical students shorten the decision process by students “shadow” various specialists through their daily routines. The idea, she says, is for students to “experience the pace of the work, see how tams function in action, and develop a sense of the different medical challenges faced y different specialties.”

The other idea is to prepare to qualify yourself for a specialty residency, to become competitive, to be chosen for entry into popular subspecialties. Recommendation letters from specialty physicians are a highly prized selection criterion, perhaps even more so than scores on the U.S. Medical Licensure Examination. The pressure to gain a competitive edge drives students to decide early what specific specialty to enter.

So students begin to skip lectures to shadow physicians, to carry a pager to notify themselves of opportunities to scrub into surgery, to rush to learn what specialists do, to ingratiate themselves and to talk to those who have been there and done that. Medical students are hungry for clinical exposure outside the medical school curriculum.

Is this early “differentiation” healthy for the health system? Probably not. It skews students toward specialties. It ignores the reality that specialists dominate medical school faculties. It creates conflicts with medical school schedules. And it often leaves a career in primary care out in the cold. And it seems to be characteristic of the elite medical schools, where “shadowing” is the order of the day.

But it is reality. Students are already looking forward to how they can pay back their medical school debts, how they can live an ordered life style, how they can achieve prestige in a specialty-dominated society.

Some medical schools have sought to circumvent this early specialty selection process with weekly specialty rounds taught by practicing physicians, by bringing community physicians into the teaching process, by sending out students early in their medical school experiences to clinical preceptorships, and in the case of the University of Kansas, by opening a new medical school campus in a small town where students will receive all of their clinical training.