Medical Schools Can Play Role in Boosting Student Interest in Primary Care, Says Report

The nation's medical schools could significantly increase the number of students who choose to go into primary care by admitting students from rural and medically underserved areas and providing them with long-term experiences in primary care settings. That's one of the conclusions of a recently released report by the AAFP's Robert Graham Center in Washington.

"Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student and Resident Choices?" (102-page PDF; About PDFs) which was funded by the Josiah Macy Jr. Foundation, provides a detailed analysis of the reasons why medical students choose to become primary care physicians, as well as why they later choose to pursue careers in underserved areas.

The report is based, in part, on the AMA's physician master file database and on Medicare claims data filed by federally qualified community health centers and rural health centers.

According to the report, the "popularity of primary care among U.S. medical school students has been steadily declining for the last decade and is now at historic lows. This is especially true for family medicine, the broadest primary care field and one in which residents are the least likely to eventually subspecialize and most likely to care for underserved populations."

The report also points out that "primary care physicians now make up slightly more than one-third of the physician workforce, yet only slightly more than one-fifth of our current students are interested in a primary care career. This discrepancy gives little hope of resolving a long-standing specialty maldistribution or securing patient-centered medical homes for all Americans."

According to the report, the income gap between primary care physicians and subspecialists is a key factor in discouraging medical students from pursuing careers in primary care. These disparities halve the chances that a medical student will choose to enter a primary care specialty.

For example, during a career span of 35-40 years, the report estimates that the average return on investment for subspecialty careers is $3.5 million more than the return on investment for primary care professionals.

"It is hard for students to look at (those figures) and swallow and say, 'OK, I am going to give up $3.5 million,'" says Robert Phillips, M.D., M.P.H., director of the Robert Graham Center and one of the primary authors of the report. "It is the power of that difference that drives at least half of our students out of primary care."

Income disparities also may have an indirect impact on medical students because they can convey messages about prestige, intellectual rigor, the need to increase productivity and status, says the report.

Although income disparities may play a role in driving medical students away from primary care, such disparities do not "absolve medical schools and residency programs of their role in affecting student choices," according to the report's authors. "We found very clear evidence that the student selection process and curriculum are very important in producing primary care physicians and physicians willing to serve in rural and underserved settings."

For example, students with rural backgrounds are more likely to enter the primary care field and to practice in underserved parts of the country. In addition, the report found that students who expressed an interest in serving minority populations, underserved areas and underserved populations were significantly more likely to practice in underserved areas with underserved and minority populations.

The report suggests that medical schools ask potential students about service to individuals who are underinsured, socioeconomically deprived or minorities or who live in rural or inner-city areas and factor the answers to those questions into acceptance decisions.

Attending a public medical school also significantly increases the likelihood that a student will choose a primary care specialty and practice in a rural shortage or underserved area compared with students from private medical schools. Attending a public medical school increases the odds of choosing family medicine by 77 percent and primary care by 27 percent, according to the study.

Not surprisingly, the report notes that debt plays an important role in shaping career choices for students. But its influence is complex.

For example, the report found that among public schools, students carrying a mid-range debt of $100,000 to $150,000 appeared to have the highest likelihood of going into primary care. However, if students had no debt or no obligatory scholarships, the chance that they would go into primary care decreased. This finding is not completely understood, said Phillips.

"We think there are few explanations," he said. "The students with no debt probably come from higher income households, and so they have higher income expectations, making it less likely for them to go into primary care."

In addition, "debt-averse students may not apply to medical school due to fear of debt, or may choose less expensive public schools," says the report. Because of this, "schools may select students less likely to choose (primary care) careers, or students more likely make these choices are not applying (to medical school)."

In the end, the report recommends several steps to ensure that medical schools produce more primary care physicians: