In what seems like an eternity ago, one of the selling points for the expanding role of managed care in our health care system was that the role of the generalist would become more desirable. The primary care physician was to be the most prominent figure in the care of an individual patient, and with this expanded role would come improved financial incentives, which would work towards reducing the discrepancies between the incomes of generalists and specialists.
Obviously, we have fallen well short of these predictions. In fact, generalist physicians are probably more dissatisfied than ever. Students in our medical school—and, we feel sure, at others as well—are savvy to this, and the sentiment toward primary care has become increasingly negative. The fallout confirming this disturbing trend is apparent from the results of the National Residency Matching Program (“the Match”) in 2000 and 2001.
The national data from those years showed a slight decline in those choosing internal medicine after a steady five-year increase in that area. Although the data for 2001 showed that 51% of graduates chose primary care fields (internal medicine, pediatrics, family medicine, and medicine/pediatrics)—the same percentage that chose those fields in 2000—fewer graduates are actually choosing primary care careers. Compared with the 2000 Match results, primary care medicine positions filled by U.S. graduates in 2001 declined 16.7%, and family medicine positions declined by 17.3%.1 This argues that the 51% figure is misleading, since more students are choosing subspecialty careers in medicine.
This trend is especially discouraging because so much effort was expended in the previous decade to foster generalism. Starting in the early 1990s, many schools around the country were increasing their curricular emphasis on primary care, all motivated by the declining number of students selecting generalist careers. In 1980, 32% of medical graduates indicated they were interested in a primary care specialty, but by 1992 that had declined to 14%.2 In 1991, The Robert Wood Foundation announced a $32 million grant program, the Generalist Physician Initiative (GPI), to help medical schools increase their production of generalist physicians.3 Sixteen schools were given support for six years beginning in 1994. At the same time, the Health Resources and Service Administration provided three years of funding for ten medical schools through the Interdisciplinary Generalist Curriculum (IGC) grant program.
While it is difficult to attribute the specific impact of these educational interventions on the production of primary care physicians, it is useful to review the percentages of graduates from the GPI and IGC schools who entered the primary care specialties.4 Schools participating in the GPI program ranked 13th to 115th out of 126 allopathic medical schools, with a scattered distribution, including six schools in the top quartile and four schools in the bottom quartile. Allopathic schools participating in the IGC program ranked 17th to 85th, with three schools in the top quartile, two in the second quartile, and four in the third quartile. Thus, there is no clear evidence that these programs have had a major impact in promoting primary care career choices at the funded schools compared with the promotion of such careers at other U.S. medical schools that were not part of these programs.
Our institution—the University of Colorado School of Medicine—was one of the IGC schools. With the support of our dean, a new three-year longitudinal curriculum was developed in 1994. The goal was to increase the students' exposure to the primary care curriculum and primary care role models, in hopes of increasing their interest in generalist careers. Although there were many facets to the curriculum, the most prominent component was having a one-on-one student-to-preceptor interaction over a three-year period.
We did not truly understand the up-hill battle that was awaiting us. No one could have forecast the economic boom that occurred through the '90s, which offered unprecedented opportunities, particularly in high-technology fields, nor did we fully understand the impact managed care would have on generalist specialties. Although we were told primary care physicians' incomes would increase in the era of managed care, generalists in our community are closing practices, as they cannot survive in the present economic climate. Salary data are revealing: between 1993 and 1997, despite a 5% increase in average salary for all physicians, internists' salaries remained unchanged.5,6 The median physician net income for 1997 was $164,000.6 However, there was a significant disparity between the 1997 incomes of those in primary care specialties (family practice, internal medicine, and pediatrics), who earned $134,000 on average, and the incomes of those in the more procedure-oriented specialties (surgery, obstetrics-gynecology, radiology, anesthesiology), who earned over $224,000.6
Issues of debt also come into play. In the late 1990s, a steep rise began in the amount of debt students have when they graduate from medical school. The average debt for students keeps rising, from $67,022 in 1998 to $70,926 in 1999 to $74,438 in 2000. Over half of graduating seniors (52.4%) had over $75,000 in educational debt upon graduation from medical school in 2000.7 We know from previous studies that debt above $75,000 clearly affects career choice, attracting students to higher-paying subspecialties.8,9
The decreasing financial incentives and increasing debt are not the only factors that are influencing graduates to turn away from generalism. In many ways physicians have lost control of deciding what is right for their patients, and this has led to considerable dissatisfaction, particularly among generalists. Generalists are asked to be the managers of their patients' care, yet are being told when and where they can send their patients, what medications they can prescribe, and what tests can be ordered. So far, repercussions for bad outcomes based on these coerced decisions have been the responsibility of the physician, not the administrators dictating the policies. We think it is fair to say that physicians feel they have lost control of patient care. Our experience indicates that students who now have more contact with generalist physicians perceive this dissatisfaction and will begin to steer even further away from generalist careers.
But our own students' views are the most discouraging. As part of our longitudinal primary care curriculum, the junior medical students meet in a small-group format every other month to discuss their perceptions of their medical training and their future in medicine. This portion of the curriculum is entitled “The Hidden Curriculum,” and it has given the students a safe environment to discuss what they have encountered in their clinical training. Facilitators are given topics for each session, such as gender bias, cultural sensitivity, exposures to positive and negative role models, professional behavior, etc.
Our most recent session focussed on career goals of our students. We asked them why they had originally chosen careers in medicine and where they saw themselves in five to ten years. Some disturbing trends were clearly evident from these discussions. Although most reflected very altruistic motives, many of the students were unable to articulate their initial goals for careers and medicine, and those that were able to had to give the matter considerable thought. Uniformly, the students spoke of how difficult it was to watch their primary care preceptors struggle in the managed care environment. Many spoke of lifestyle issues, and a disturbing number indicated that they would not consider careers in primary care. “Why should we work in such a frustrating environment when we can work less hours, make more money, and have a much better lifestyle?” asked one student—and his question overwhelmingly reflects the general sentiment. Several spoke of how frustrating it was to see their friends from college obtain jobs right after graduation and soon obtain salaries at levels far ahead of what awaits graduating residents. Some facilitators suggested that physicians traditionally have stated—or at least given lip service to the statement—that money would not influence their career choices. But the students wisely pointed out that “stockholders and executives are making money from our services, why shouldn't we?” The students did recognize that allowing others (e.g., stockholders in managed care companies, etc.) to profit from physicians' services is of far less concern to them than is the fact that those same individuals profit from patients' suffering.
Underlying the reasons given above for the decline in interest in primary care careers is a more fundamental one: Medicine is increasingly becoming a business, eroding the noble qualities that most physicians recognize as inherent and essential to the profession they chose. In no place is that more evident than in the generalist disciplines. Our experience with both Colorado medical students and applicants to our residency program is that there is a marked increase in interest in subspecialty training. It is imperative that we in medical schools and residency programs every-where reexamine what we can do to make generalist careers more desirable to our students. Otherwise, we may be headed toward a shortage of primary care physicians that will likely rival, if not surpass, what we encountered in the early 1990s.
1. Lostumbo EM, Beran RL. Results of the National Resident Matching Program for 2001. Acad Med. 2001;76:665–8.
2. 1992 AAMC Graduation Questionnaire. Washington, DC: Association of American Medical Colleges, 1992.
3. Colwill JM, Perkoff GT, Blake RL, Paden C, Beachler M. Modifying the culture of medical education: the first three years of the RWJ generalist physician initiative. Acad Med. 1997;72:745–53.
4. Fifth Annual Primary Care Scorecard. New Physician. 2000;April:20–1.
5. Table K4: Median physician net income after expenses before taxes. AAMC Data Book. Washington, DC: Association of American Medical Colleges, 1996.
6. Table K4: Median physician net income after expenses before taxes. AAMC Data Book. Washington, DC: Association of American Medical Colleges, 2000.
7. 2000 AAMC Graduate Questionnaire. Washington, DC: Association of American Medical Colleges, 2000. 〈www.aamc.org/meded.gq
〉, accessed 3/31/01.
8. Kassebaum DG, Szenas PL. Relationship between indebtedness and the specialty choices of graduating medical students: 1993 update. Acad Med. 1993;68:934–7.
9. Rosenthal MP, Diamond JJ, Rabinowitz HK, et al. Influence of income, hours worked, and loan repayment on medical students' decisions to pursue a primary care career. JAMA. 1994;271:914–7.