Primary Care: No 'Match' for Higher-Income Specialties

Kenneth W. Lin, MD, MPH


March 21, 2016

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I'm Dr Kenny Lin, a family physician at Georgetown University School of Medicine, and I blog at Common Sense Family Doctor.

The residency program where I teach recently held its match night, that annual ritual where current faculty and residents gather to come up with their rank list of incoming interns based on their applications and interviews. By the time you view this commentary, Match Day will have happened. And unfortunately, if this year is similar to last year's match, too few medical students will enter family medicine or other primary care programs.

An analysis of the 2015 match published in Family Medicine[1] found that even though the number of US senior medical students who filled family medicine positions rose 31% since 2009, last year's total of 1422 was still far lower than the peak of 2340 in 1997. Including primary care pediatrics and internal medicine, 10% fewer primary care residency were positions available in the 2015 match than in the 1997 match. These positions represented only 15% of all PGY-1 [postgraduate year 1] positions offered, which means that the overall proportion of family physicians will continue to fall as older physicians leave practice.

What explains the continuing low student interest in primary care careers? From one point of view, the answer is simple: Although family medicine is a highly recruited specialty and average salaries are rising, there is still an enormous income gulf between primary care and procedural subspecialists. Because 58% of graduating family medicine residents reported more than $150,000 in educational debt, and 26% more than $250,000, in a recent survey,[2] it is perhaps unsurprising that students are likely to go where the money is.

But that's hardly the whole story. The Council of Academic Family Medicine has pointed out that payment reform is only one of four "pillars" for primary care workforce reform.[3] Addressing the other three—the pipeline of medical school applicants, the process of medical education, and practice transformation—are just as important in attracting more students to family medicine.

Let's face it: The financial incentive structure of most academic medical centers tends to devalue primary care training, meaning that family medicine educators like me need to work harder than others to "sell" our specialty. A 2015 paper[4] by three teachers of general internal medicine offered several proven strategies to increase student interest in primary care. Early primary care exposure and required clerkships are necessary but not sufficient, they argued; medical schools also need to "create a school culture that values primary care." That means advocating for excellence and innovation in primary care must be an explicit school goal, along with seizing every opportunity to discuss the foundational role of primary care in courses on health systems, and offering primary care tracks for selected students.

Similarly, the Family Medicine for America's Health leadership team recommended creating longitudinal, integrated curricula in family medicine that allow students to make meaningful contributions to patient-centered care teams and have plenty of opportunities for faculty mentorship.[5]

Although there is hardly one dominant personality type for family physicians, it is safe to say that most of us aren't natural self-promoters. Obviously, our professional organizations should continue to advocate with private and public payers for closing the income gap with subspecialists, but in the meantime, we need to do everything we can to show undecided students just how rewarding a primary care career can be.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.


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