Thursday, September 11, 2008

Primary Care- The Primary Care Shortage and the Coming Reform Crisis

"All I know is what I read in the papers."

Will Rogers

I read in the papers - USA Today and Reuters - and in Netscape, Yahoo, and countless blogs that only 23% of medical students have any interest in Internal Medicine as a career, and only 2% plan to become general practitioners.

This information has been gleaned from a September 10 article in the Journal of the American Medical Association "Factors Associated with Medical Student's Career Choices Regarding Internal Medicine." The article, based on interviews of 1777 medical students completing an Internal Medicine clerkship, concludes; “Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career."

Small wonder.

Medical students aren’t stupid.

They know:

• The average medical student finishes school $140,000 in debt.
• Medical students typically spend 8 years going through college and medical school.
• Specialists – in fields like radiology, orthopedic surgery, cardiology, and other tech fields – take home 2 to 3 times the income of primary care physicians, and have more time off.
• Primary care doctors work longer hours, deal with more complicated diseases, more often treat the elderly, and need a more extensive knowledge base than specialists.
• Specialists in general work shorter hours and have more balanced life styles and more time with family.
• Most of their classmates, with equivalent educations, are choosing to enter specialty training.
• Many of the graduating seniors have married to classmates or are women – both factors contributing to the desire for a sensible balanced life.
• The current coding system is biased against primary care.
• It is simpler, often more gratifying, and more lucrative to perform curative procedures than to offer cognitive services to the elderly..
• The American population is aging, the number of adults over 65 will double in the next 20 years, and many will be afflicted with Alzheimers, Parkinson’s disease, incurable malignancies, and irreversible degenerative diseases.

Small wonder, then, that the JAMA article, concludes, after interviewing 1777 medical students who had just completed an internal medicine stint, ”Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career.”

A serious primary care shortage is upon us, and I question the tardiness, indeed, even the intelligence, of policy makers in addressing the problem. Instead, it seems to me, they are talking about cosmetic adjustments. You can make all the surface reform changes you want – more EMRs, more preventive and wellness measures, more coordinated and comprehensive care, more insurance coverage - but these measures will fall short or fail if there are not more primary care physicians engaged in direct patient care. And patients will become more and more dissatisfied with the system, if we don’t have personal physicians to care for them and who care about them.


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