Primary Care Medicine in the United States: Where Are We Headed?

Whitcomb, Michael E. MD

Academic Medicine:
From the Editor
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During the early 1990s, the academic medicine community was put on notice that it was expected to take steps to increase the supply of primary care physicians entering practice in this country. This challenge emanated from the strongly held views of some health policymakers, and various analysts and observers of the country's health care system, that the country had a serious shortage of primary care physicians and that the shortage would grow more severe with each passing year. To a very great extent, these views were based on a normative formulation of how medical care services should be organized, financed, and delivered, and on the belief that managed care was going to move the country in the desired direction.

Despite the lack of data unequivocally supporting these views, the academic medicine community, spurred on by several foundation and federal government grant programs, sprang into action. Many medical schools that offered elective rotations in family practice converted those to required clerkships, and some that had resisted establishing departments of family medicine began to do so. The majority of schools also implemented preceptorship experiences that placed students in the offices of primary care practitioners during the first two years of the curriculum, and some established interdisciplinary primary care clerkships in year three. At the same time, teaching hospitals offered more family practice— and primary care—oriented internal medicine residency programs. All of this activity had the intended effect—the number of U.S. medical school graduates choosing residencies leading to careers in primary care medicine increased.

But lo and behold, the increase has proven to be short-lived! In the past few years, an increasing number of U.S. medical school graduates have opted for residencies in specialties that will not lead to primary care practice. To put the impact of this shift away from primary care in perspective, it is useful to examine how family medicine—the specialty most identified with primary care practice—has fared in the Match during the past decade. In 1992, 1,398 U.S. medical school graduates matched to family practice residencies. In 1998, the number of graduating seniors who matched to family practice residencies increased by almost 80%, to 2,340. In this past spring's match, only 1,413 graduates matched to family practice residencies, almost the same number that matched in 1992 before many of the changes noted above were put into place.

It is probably too soon to understand fully why fewer graduating students are committing to careers in primary care medicine. Despite claims to the contrary, I do not believe that this recent trend in medical students' career choices can be attributed to any actions taken by medical schools or teaching hospitals to dissuade students from careers in primary care medicine. In fact, medical schools have continued to implement programs that acknowledge the importance of primary care medicine, and to support students interested in pursuing primary care practice. So what has happened?

The obvious explanation is that in making career decisions, medical students take into consideration their sense of where the practice of medicine is headed, and an increasing number do not believe that the future of primary care is all that bright. I am pretty sure that they realize that managed care is not going to transform the role of primary care physicians in the country's health care system, or create more opportunities for those interested in primary care practice. Indeed, they may even be aware that some market indicators suggest that the demand for primary care physicians is declining. Finally, they probably sense the uncertainty that exists about the future role of physicians in providing primary care services. Given theses forces, it should not be surprising that an increasing number of graduates would decide to choose residencies that will lead to specialty practice.

In this month's issue of the journal, six papers provide important perspectives on these issues. In the lead piece, Cooper argues, based on the results of his own analytic work and a growing number of anecdotal reports, that the country is likely to experience a serious shortage of specialty physicians in the coming years. His viewpoint is in direct conflict with the prevailing view of the mid-1990s that the country was on the verge of a large excess of specialists. He goes on to note that the claims of the early 1990s that the country had a shortage of primary care physicians had the effect of fueling a dramatic increase in the number of primary care physicians and non-physician health professionals who can provide primary care services. As a result, he believes that the country already has an overabundance of primary care providers.

Cooper's view, if correct, suggests that in the future fewer U.S. medical school graduates will choose careers in primary care. This raises several important questions about the future of primary care medicine in this country. Will the number of U.S. medical school graduates choosing careers in primary care be adequate to meet the primary care needs of those who wish to have their care provided by a physician? What roles will physicians trained in family medicine, internal medicine, and pediatrics—and advanced practice nurses and other health care professionals—play in providing primary care services in the country's health care delivery system? Who will provide medical care to persons living in rural communities, who are particularly dependent on family physicians who are willing to practice in those communities? The papers by Schroeder, Green and Fryer, Mundinger, Brooks and colleagues, and Senf and colleagues provide important insights into some of these issues.

Schroeder, in his paper (originally presented as the Alan Gregg Memorial Lecture at the 2001 AAMC Annual Meeting), takes a critical look at the state of primary care medicine in this country. He focuses his attention primarily on the future of general internal medicine and general pediatrics. He envisions a bleak future for the role of physicians in primary care unless there are fundamental changes in the country's health care delivery system, and in the medical profession's view about the role of physicians in providing primary care services. Green and Fryer follow with their assessment of the state of family practice in this country. They also note that the future of family practice is somewhat dependent on changes occurring in the organization, financing, and delivery of medical care services. Importantly, however, they identify a number of challenges that the family practice community must meet if it is to define a meaningful role for family medicine in the future. Mundinger describes the expanded role that advanced practice nurses can and, in her view, will play in providing primary care services in the future. Brooks and colleagues provide a systematic review of factors associated with the recruitment and retention of primary care physicians in rural areas. Finally, Senf and colleagues offer a long-overdue hard look at the limits and dangers involved in lumping together the primary care specialties for research purposes, and how findings of such flawed research can lead to faulty conclusions about such crucial issues as the factors influencing the choice of primary care as a career.

Taken together, these papers contribute a great deal to our understanding of the state of primary care medicine in this country, and provide insights into what, if anything, the academic medicine community and health policymakers should do to influence the career choices of medical students. No doubt, much will be written about these issues in the days ahead—stay tuned!

© 2002 Association of American Medical Colleges