AMA to Study Barriers to Primary Care as Specialty Choice

Thanks in part to language offered by an Academy representative to the AMA House of Delegates during its recent interim meeting here, as well as to testimony from AAFP delegation members and others, the AMA will formally investigate the barriers keeping many medical students from choosing careers in primary care and how those obstacles affect patient access.

Specifically, a substitute resolution AMA delegates adopted Nov. 12 calls for the AMA to "explore the barriers to primary care medicine as a career choice and the impact of these barriers on the profession of medicine as a whole and on access to health care in the United States." The findings from that report, along with a plan of action, are to be presented to the house at the 2008 interim meeting.

The original AMA resolution was introduced by Mississippi's delegation to the AMA and spearheaded by FP Mary Gayle Armstrong, M.D., of Madison, a past president of the Mississippi AFP. That constituent chapter had submitted a similar resolution to the 2007 AAFP Congress of Delegates, which adopted a substitute measure calling for just such an AMA action.

The AMA delegates' decision represents a win for family medicine and the patient-centered medical home, according to Dale Moquist, M.D., of Sugar Land, Texas, chair of the AAFP delegation to the AMA. He views the move as a logical and necessary next step for the AMA, which already has committed to spending $16 million on a three-year campaign promoting health care for America's uninsured. After all, Moquist noted during the meeting, "How's that supposed to happen without this guarantee of primary care coverage in place?"

The AMA resolution, as originally worded, drew fire from some subspecialty delegates during reference committee testimony Nov. 11 because it called for exploration of the "growing inadequacy of primary care reimbursement and its impact on medical student career choice." Other limited specialists, however, spoke in favor of the measure, as did numerous primary care representatives.

AAFP Board Chair Rick Kellerman, M.D., of Wichita, Kan., laid out three points in his testimony supporting the resolution.

First, he said, "Medical students are good at math. They're looking at the numbers and making their specialty choice."

Second, Kellerman added, "The nature of care is changing. We need to emphasize preventive care, chronic care and end-of-life care, in addition to acute care."

Finally, he noted, the resolution is consistent with existing AMA policy, including a commitment made by the AMA house at its 2006 annual meeting. At that meeting, delegates adopted a policy calling for the AMA to "encourage physician reimbursement changes which would make generalist physician practice more attractive," and "support the concept of partnerships between primary care physicians and patients to coordinate access to all needed medical services and consultations (a 'medical home') for all patients."

Still, opponents argued, primary care specialists aren't the only physicians suffering from inadequate reimbursement. Some, like the American College of Surgeons' alternate delegate John Armstrong, M.D., pushed to broaden the measure's scope to include examining reimbursement for all physicians.

In response to the threatened derailment of the resolution's intent, Janet West, M.D., of Pensacola, Fla., the AAFP's alternate delegate to the AMA Resident and Fellow Section, offered a compromise measure on behalf of that section.

"While recognizing the importance of specialty care and the need for adequate reimbursement for all physicians, the decreasing number of primary care physicians is a significant factor in the increasing problem of access to the basic and preventive health care that our patients need to stay healthy, which is one of our American Medical Association's top priorities," West testified.

"The resolution mentions medical students choosing to enter into primary care, but this is also an issue that affects internal medicine and pediatric residents choosing to practice as generalists versus subspecialists," she added. "We also recognize the impact of multiple factors on this decision in addition to reimbursement, including medical liability premiums, the crushing burden of medical education debt, lifestyle considerations and many others."

The amendment West proposed eventually worked its way into the reference committee's recommended substitute, shifting the focus of the study from payment inadequacies alone to all barriers keeping physicians-in-training from entering primary care.

The issue of declining numbers of medical students, particularly of U.S. medical school graduates, choosing to enter family medicine has been on the Academy's radar screen since the numbers started dropping about a decade ago. The AAFP commissioned a study by the University of Arizona in 2000 that identified multiple contributory factors, categorizing them into three areas: student characteristics, institutional characteristics, and medical school experiences and outcomes.

The AAFP's Robert Graham Center in Washington also has examined various aspects of students' specialty and career choices. Most recently, the center announced it had received funding from the Josiah Macy Jr. Foundation to study factors that influence medical students' career choices and whether those factors affect their decisions to work with underserved populations. Student debt will be a key focus of that study, according to Graham Center Director Robert Phillips, M.D., M.P.H.

Similar concerns also spurred the Academy's 2007 Congress of Delegates to adopt a resolution calling for the AAFP to "assist constituent chapters in developing model legislation addressing funding, facilities, training opportunities and incentives for increasing the number of graduates from U.S. medical schools seeking careers in family medicine so that every American may have a medical home."