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.”