Medical schools in North Carolina are touting the high numbers of students they graduate who go on to primary care specialties. But those numbers aren’t the whole story.
By Rose Hoban
As usual, the scene a couple weeks ago at medical schools across the state was one of nervous anticipation, happiness and some disappointment: in short, a typical “Match Day.”
Match Day, every March 15, is when fourth-year medical students around the country learn where they will be “matched” for the post-graduate residencies that turn them from newly graduated medical students into experienced doctors.
And with the nation facing health care reform that will supposedly favor primary care specialties – pediatrics, family medicine, obstetrics/gynecology and internal medicine – medical schools everywhere are touting how many of their students are headed into primary care.
But the numbers aren’t what they seem, said Andrew Morris-Singer, a primary care doctor and the founder of Primary Care Progress, an organization that’s working to increase the number of physicians and others practicing primary care medicine.
“We are literally hemorrhaging people from the primary care pipeline,” Morris-Singer said. “In the past, 40 percent of students went into primary care, but that number has dropped precipitously.”
In North Carolina, numbers released by the state’s four medical schools claim that from each, upwards of 42 percent of students will be headed into primary care. But Morris-Singer said matching for primary care doesn’t mean those doctors will practice in primary care. He said that by the end of their residencies, at least half of those people will have moved into a specialty.
“Medical school deans are quoting a number that’s not actually the number that will end up in primary care,” Morris-Singer said. “It’s an over-exaggeration we call the ‘dean’s lie.’”
Research published in the Journal of the American Medical Association in December showed that upwards 80 percent of graduates who choose the “primary care” track of internal medicine end up specializing within three years of leaving medical school.
The UNC-Chapel Hill School of Medicine’s Robert Gwyther, M.D. admits UNC’s primary care numbers are more aspirational than actual.
“About 10 years ago, our legislature passed a bill saying medical schools have to put 50 percent of people into primary care,” said Gwyther, who advises students. “They count internal medicine and pediatrics and obstetrics as primary care, and it’s still a challenge for UNC to get the 50 percent.”
“And we know that 95 percent of the interns will end up practicing in a specialty,” he said.
The American Academy of Family Practitioners has stated that the U.S. needs to put at least 25 percent of students into family medicine in order to avoid a primary care shortage.
“Across the country, we’ve never come close,” Gwyther said.
Even though overall enrollment in medical schools is up around the country, the number of students matching to primary care residencies has stayed about flat.
“This year’s Match numbers are proof that increasing enrollment in our medical schools did not translate into an increase in the percentage of U.S. seniors entering family medicine,” wrote AAFP president Jeff Cain, M.D. in a press release.
Reasons for the exodus
Morris-Singer and others point to several factors that compel medical students to abandon primary care, even if it was the reason they entered medical school. The first, and most obvious, is money.
“When a student decides to go into primary care, he or she is walking away from $3.5 million of lifetime revenue while carrying $160,000 to $200,000 in debt,” Morris-Singer said.
Recent changes to reimbursement due to the Affordable Care Act are intended to increase reimbursement to primary care physicians.
“For family docs practicing independently, like they did in the old days, it’s 75 percent overhead to stay in business these days; only about 25 percent stays in your pocket,” said UNC’s Gwyther. “The rest is going to rent and staff and insurance billing people. Whereas if you work in the hospital as a doctor, 90-plus percent stays in your pocket. The rest is picked up by the hospital.
“Frankly, a lot of it is about money. The Brits have found if they paid a little more for family medicine and less for specialties, then people flocked to family medicine.”
Too much training is skewed to emphasize students learning about specialties, said Morris-Singer. Students spend four years in medical school being taught what he called a “hidden curriculum.”
“There’s a culture that programs students,” Morris-Singer said. “It all is pushing students toward hospital-based, technical, procedure-based medicine, not primary care.”
“Primary care isn’t sexy,” UNC’s Gwyther said bluntly. “People don’t like the outpatient environment. They don’t want to sit and talk to Granny about her sore shoulder. They want to be in the hospital where the action is.”
“There’s lots of medicine that’s set up to just rake money off the table by doing volume,” he said. “I hate to say it’s about the money, but it is.”
And aside from more money, specialists have more control over their lives.
“Choosing some of these subspecialties … they’re considered by students to be a lifestyle specialty – no emergencies, no weekends,” Gwyther said. “I mean, being a dermatologist is the ultimate lifestyle specialty. There are almost no emergencies and you do almost no work in the hospital; it’s all in your office, where you have complete control.”
Primary care in N.C.
Several years ago, Duke University School of Medicine started experimenting with what the school calls a “primary care leadership track” that puts students into more outpatient settings starting early in medical school. The school even offers sizable scholarships for students who follow the program.
But only three students out of Duke’s 102 graduates chose family-medicine residencies.
East Carolina University’s Brody School of Medicine puts students into rural clinics in hopes they’ll like working in those settings and choose to practice there.
The program has had some success: In 2012, more than half of the ECU graduates who chose primary care residencies were still working in primary care five years post-graduation (see chart). Duke students were the least likely of medical students from North Carolina schools to still be in primary care five years after graduation.
A study done for the journal Family Medicine found ECU graduates had the highest retention in primary care of any medical school in the country – 21.4 percent.
“Future professionals need to have clinical skills and they need the science,” said Andy Ellner, co-director of the Harvard Center for Primary Care. “But they also need to understand organizations, how to work in teams, be leaders, manage people. They need to think about complex systems and make them work more effectively.
Medical residency programs at Harvard, the University of New Mexico and elsewhere are experimenting with putting young doctors-in-training into more collaborative settings that are not built around the old model of a single primary care doctor trying to do it all.
The University of Utah is training medical students to be ambulance technicians and medical assistants in order to expose them to other parts of the health care system and to other kinds of health care workers.
But many schools simply create primary care clinics where patient throughput is streamlined, and interactions between doctors and patients are limited, said Gwyther. He said that subverts the idea of getting people more interested in the field, and frustrates patients.
“If you cut the face time with the doctor from 15 to 10 minutes a visit, you’re shooting yourself in the foot, because there’s not time for the patients,” he said. “What patients want is for doctors to listen to them.”
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So why aren’t medical students going into primary care? It’s really very simple. They didn’t go into medicine to practice the healing arts: They went into medicine to make big bucks, buy a Mercedes and house at the lake, etc. Seems like that pretty much tells the story with the largest percentage of our current doctors anymore… Kind of sad – and actually a bit frightening that we have to put our lives and health into the hands of people like this…
Why should you care? Just go find the cheapest doctor around and have them take care of you.
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They aren’t going into primary care because of Obamacare and other government controls.
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Throw in people like you who believe government should control how much a person makes exascerbates the problem.
But how is that different from any other field? If you are a generalist in most fields, you’ll earn less than someone who is an expert in a subset of that field. Not saying it’s right, but that’s the way it is.
I don’t think anyone wants to pay their primary care doctor more to help out the imbalance!
Have you ever talked to a primary care physician? They love their patients. They hate the government control/overhead and all-day paperwork!! They actually spend more time following all the imposed government rules and regulations than they do actually taking care of patients. I have tried to make an appointment with a primary care doctor – I had to wait over six months to get into an office!! And I have good insurance!!
Obamacare!! I cannot believe the country fell for this mess!!
If you had to wait SIX months to see you doc then you have the wrong doc: as few as good ones are, they are out there – blaming your lack of engagement on the AHCA is both disengenuous and rather naive.
AHCA is an oxymoron, forced upon us by a moron.
That wasn’t very nice.
Kid celebrating is my fraternity president Robert Hoover of “Delta House”: http://3.bp.blogspot.com/-thSZ_jKov8g/TnaBwqdH4II/AAAAAAAAFVg/1lUkZkk1ZcE/s1600/AnimalHouse4_001Pyxurz.jpg
On Sunday, June 2, the dean of the University of Utah School of Medicine
had a cozy sit-down with our local “spokesmodel” news anchor and made
several remarks that she knew to be false. Dean Lee recently seduced the Utah
Legislature into giving the medical school yet another $10 million (on
top of the hundreds of millions it already receives) in order, she said,
to train more primary care doctors. She
implied that the U. is dedicated to resolving the shortage — which is
rapidly becoming a crisis — especially since Utah is fourth from the
bottom nationally in primary care doctors per
capita. She ardently made her case for what seemed like a moral as well
as a practical cause.
She referred to this victory during her interview on KUTV Channel 2 in Salt Lake City.
What she failed to disclose is that the U. is 75th nationally in recruiting students who
express a desire to practice primary care.
Last year, there was NOT ONE TAKER for a scholarship that offered a $5,000
reward to any medical student willing to practice primary care medicine for
just three years. That is a shocking indicator of how little interest the U.
has inspired in this vital field of medicine.
Although the need for more primary care doctors has been a critical
issue nationally for years, the U. has blithely ignored it.
The school glamorizes the
specialties — paying professors in those disciplines hundreds of thousands of dollars more than
those who teach primary care and family
medicine (a professor of orthopedic surgery, for example, was paid $1.3
million in taxpayer funds last year. A professor of family medicine got
$125,000).
Primary care has always been the “stepchild” of the U’s
medical school, while the glamorous, high-status, high-paid, high-tech
specialties are made ever more alluring.
Apparently it’s not just University of Utah officials who
misrepresent their dedication to mobilizing an infusion of devoted
primary care doctors into the health-care system. A shocking article,
“The Dean’s Lie” (http://www.healthnewsreview.org/2013/04/the-deans-lie-about-new-docs-going-into-primary-care/),
describes how medical-school deans all over the country are making the
same urgent appeals to their legislatures for more money, brazenly
fabricating the percentage of their graduates who are committed to
serving in primary care, and then continuing to relegate primary care to
the sidelines. The “dean’s lie” expression was coined by Dr. Reid
Blackwelder, president-elect of the American Academy of Family
Physicians.
(When I posted “The
Dean’s Lie” on Lee’s University of Utah blog, it was promptly removed.
Freedom of speech is so overrated, don’t you find? It just upsets
people!)
Only
Stanford University, according to one survey, was honest about how many
of its medical school graduates actually established primary-care
practices after their residencies: two percent (http://futureoffamilymedicine.blogspot.com/2011/04/deans-lie-about-medical-school-primary.html).
Dean Lee also asserted in her television interview that the U.’s medical system has consistently ranked in the top
ten nationally. She proudly proclaimed that Utah’s program has prominence and superiority that are broadly acknowledged.
That simply isn’t true — in fact, it’s far from the truth.
Utah’s is not on the U.S. News & World
Report’s “Honor Roll” of top hospitals for 2013, and it never has been, although it does well in several specialties. It
isn’t even the highest-ranked hospital in the state. And quality rankings put
the U.’s medical school at 48th in the nation – 29th in
primary care — according to the magazine’s study — nothing to brag about. (It
coincidentally ranks as 48th in “top medical schools for research”
as well.).
The
U. is not listed among the top 25 teaching hospitals in the nation by
Thompson-Reuters. Truven Analytics does not name the U. in its lists of the top
100 hospitals in the country, the top 50 cardiac facilities, or the top 15
health systems, the three areas which it assesses. The U. does not appear on
the 20 Best Hospitals in America list released by the Master of Health study.
The Medical Resource Group does not place the U. in either of its Top 10
rankings. It is not on the 2011 HealthGrades list of 50 distinguished
hospitals for clinical excellence. It ranks very poorly in some specialties,
getting one out of five stars. University.list.net does not include the U. in
its list of the nation’s top 25 medical schools.
Consumer
Reports
does not include the U. medical center in its Top Ten list of the safest
hospitals.
It’s hard to comprehend why Lee would claim such pre-eminence for the U.
when she can so readily and decisively be contradicted. It makes you
wonder what kind of shenanigans went into her term papers and laboratory
research when she was a student.
I was especially surprised when the dean bragged that the U. was
named the best academic
medical center in the country three years ago by the University
HealthSystems
Consortium — an honor that it touted with great fanfare in an ecstatic
advertising campaign — saying it had outranked the Mayo Clinic and
Johns Hopkins.
I simply did not believe it.
My
investigation (http://kronstantinople.blogspot.com/p/the-consortium.html) revealed that the U. had unethically reverse-engineered the
“top secret” Consortium algorithm so it could tweak its data and skew
the results to conform with the Consortium’s benchmarks. When the
underhanded tactics and subsequent scandal were revealed, the Consortium ceased
its vast and longstanding ranking program. The Consortium now uses U.S. News
and Thompson-Reuters studies in its assessment of academic medical centers.
Even after this massive embarrassment, the U. was at it again — just one month later — claiming that it had been named “first among the region’s health care providers” by U.S. News & World Report.
Actually, it had been named the Number One hospital within the Salt Lake metro area,
which — according to the magazine — encompasses only Salt Lake City and two much smaller municipalities,
Ogden and Clearfield.
That isn’t “the region,” which the University knew very well.
We do seem to have a “truthiness” problem going on here in the Land of Zion.
Virtually every statement the dean made in her aggressively promoted
five-minute interview was demonstrably false (I assume that she really
does have four children and a wonderful husband), but neither the TV
station nor the Salt Lake Tribune would give me the opportunity to refute them.