The question “How much of a monetary bonus [before internship and after residency] would it have taken for you to apply for primary care?” was answered by 272 (93%) of the students who did not apply for primary care. Of these, 82 (30%) would have accepted such a bonus to apply for primary care, ranging from $6,000 to $100,000, with a median of $27,500 (interquartile range [IQR] $15,000–$50,000). An additional 11 students who suggested amounts ranging from $150,000 to $1,000,000 were reclassified as not accepting a bonus to apply for primary care, as the amount suggested was unreasonably high. The question “For what annual salary as an attending physician in internal medicine, pediatrics, and family medicine would you have considered applying for primary care?” was also answered by 272 (93%) of the students who did not apply for primary care. Of these, 112 (41%) listed an annual salary for which they would have considered applying for primary care, ranging from $10,000 to $250,000, with a median of $175,000 (IQR $150,000–$200,000). An additional 15 students who suggested amounts ranging from $280,000 to $750,000 were reclassified as not accepting a higher salary to consider applying for primary care, as the amount suggested was unreasonably high. Students were also asked which type of bonus they preferred. Of those indicating a preference (n = 153), the residency bonus alone was the least popular choice (n = 17; 11%), followed by an increase in attending pay (n = 61; 40%) and finally a mixture of both (n = 75; 49%).
Students were asked at the end of the survey to estimate (1) the annual salary of civilian primary care physicians (general internal medicine, family medicine, and pediatrics) two to three years after residency and (2) the annual salary of their chosen field if it was not a primary care specialty. The median estimated civilian annual salary for general internal medicine was $25,000 less than the participants' median requested military annual salary ($150,000 versus $175,000). For family medicine and pediatrics, the difference was $50,000 ($125,000 versus $175,000). The median civilian expected annual salary for students who did not choose primary care was $230,000 (IQR $200,000–$290,000). Thus, some students were willing to consider primary care for a median income that was $55,000 less or 76% of expected income for their chosen specialty ($175,000 requested salary versus $230,000 anticipated civilian salary).
These financial considerations were also explored in other ways. Equal wages (same pay for every hour worked per week) for all attending physicians regardless of specialty did not seem to entice students to apply for primary care (mean rating 3.1 [SD 2.3] on a nine-point Likert scale, where 1 = still would not have applied and 5 = possibly would have applied). However, students who listed an annual salary that would influence their decision to apply for primary care were more likely to support this concept (mean 4.3 versus 2.2, P < .0001, Student's t test). The typical higher salaries of civilian physicians compared with military physicians also had a minimal effect on students' decisions to apply for primary care (mean 3.1 [SD 2.7] on a nine-point Likert scale, where 1 = no effect and 5 = some effect), but students who listed a salary for which they would have considered applying for primary care endorsed the concept more than those who did not list a salary (mean 4.2 versus 2.2, P < .0001, Student's t test).
The question “What is the most important reason you didn't apply for a primary care residency?” was answered by 261 (89%) of the 293 students who didn't apply for primary care residency (Figure 1). Ten themes (in italics in the following sentences) emerged from the responses (listed in Figure 1). The most common reason was that they preferred another specialty (n = 94; 36%), with students stating factors such as “I love OB-GYN” or “never wanted to do anything except surgery.” This was closely followed by the not interested theme (n = 77; 30%), which was illustrated in students' comments by terms like “not interested,” “monotony,” “bored,” and “hate clinic.” The next group included practice aspects (n = 36; 14%; e.g., “workload,” “appointment length,” “not enough time with each patient,” “conveyor belt feel,” “health care factory”), patient characteristics (n = 33; 13%; e.g., “don't like bread-and-butter cases,” “social issues of primary care,” “not managing disease processes” “noncompliant patients,” “preventative medicine”), and financial reasons (n = 32; 12%; e.g., “pay,” “pay after the military,” “increase pay in the civilian sector,” “reimbursement equivalent to the other specialties”). Ten percent (n = 26) of students cited lifestyle issues, stating “flexibility to put family first,” “longer work hours,” “did not want to be on call,” “time off,” “time with family,” “control of hours,” and “quality of life.” Another 10% (n = 26) of students referred to preferring procedures (e.g., “lack of procedures,” “I want to operate,” “not enough hands-on, procedure-based stuff”). The remaining three themes were cited by less than 7% of students: expert status (n = 15; 6%; e.g., “having to consult too much,” “enjoy specialty work,” “prestige,” “too broad”), military specific (n = 6; 2%; e.g., “deployments,” “lack of combined programs [family medicine–psychiatry] in military”), and poor educational experience (n = 3; 1%).
The question “What is the most important thing(s) that could be changed that would have changed your mind to apply for a primary care residency (if nothing, please state so)?” was answered by 257 (88%) of the 293 students who didn't apply for primary care. The most common answer was nothing, cited by more than half (n = 147; 57%) of the students (Figure 2). The next most common answer was financial reasons (n = 57; 22%), with students answering “pay,” “reimbursement equivalent to the other specialties,” “increased annual pay,” “more money,” “financial compensation,” and “increased pay in the civilian sector.” Lifestyle issues was next (n = 30; 12%), illustrated by terms such as “quality of life,” “decreased work hours,” “half-time work,” “less call,” “change of work schedule,” and “easier scheduling.” Practice aspects, which centered on appointment length and workload, was cited by 9% (n = 23) of students, who gave such reasons as “decrease patient load so able to devote more time to each patient,” “longer appointment times,” “less patients seen per day,” and “more of a teamwork approach.” No other theme was listed by more than 5% of students. These remaining themes included patient characteristics (n = 13; 5%; e.g., “different patient population,” “less having to see unnecessary visits from nonsick to hardly ill patients”), procedures (n = 8; 3%; e.g., the field would have to be much more procedure based,” “more procedures,” “start doing surgery”), less interest (n = 8; 3%; e.g., “if I were more passionate about [pediatrics] than OB-GYN,” “found desire to do so,” “didn't find general surgery so appealing”), military specific (n = 6; 2% “deployments,” “option for combined residencies”), additional training (n = 4; 2%; e.g., “true generalist training,” “surgery, ENT, urology mini-fellowships,” “more fellowship opportunities”), and better educational experiences (n = 3; 1%).
Students were then asked to rate on a nine-point Likert scale their answers to the question, “If the most important thing you just listed were changed, how would this have affected your applying for primary care?” Students who answered something other than “nothing” to the previous question (n = 109) had a mean rating of 5.6 (SD 1.9), which was between “somewhat” (an answer of 5) and a “great deal” (an answer of 7) on the scale.
Multivariate analysis for financial questions
Using logistic regression, we assessed responses to financial questions about the residency bonus and the attending salary to determine underlying factors that were associated with accepting a financial remuneration. For the residency bonus question, four factors were associated with indicating any amount: citing a lifestyle reason for not selecting primary care (OR 3.5; 95% CI 1.4–9.0; P = .01), considering primary care in one of the top four residency choices (OR 3.3; 95% CI 1.8–6.0; P < .001), indicating that a flexible work schedule would have resulted in at least some consideration toward applying for primary care (OR 2.5; 95% CI 1.1–5.8; P = .03), and restriction of deployment to combat zones to a maximum of six months at time for all physicians, not just specialist physicians (OR 2.0; 95% CI 1.0–4.1; P = .05). For the attending salary question, four factors were associated with listing any amount: indicating that a flexible work schedule would have resulted in at least some effect toward applying for primary care (OR 6.4; 95% CI 3.2–13.2; P < .001), citing a lifestyle reason for not selecting primary care (OR 3.2; 95% CI 1.1–9.6; P = .04), desiring a residency with time for outside interests (OR 2.7; 95% CI 0.9–7.7; P = .07; retained in the final model due to confounding with lifestyle), and considering primary care in one of the top four residency choices (OR 2.6; 95% CI 1.4–2.8; P = .003). For both analyses, no demographic factor was significant, nor was the amount of educational debt or type of medical school (MD granting versus DO granting).
Lifestyle sensitivity analysis
As the factors associated with accepting a financial incentive centered around interest in primary care and lifestyle issues, additional logistic regression analyses were performed using only two variables: consideration of primary care and type of specialty selected in the Match (controllable versus noncontrollable). Both consideration of primary care and selecting a controllable lifestyle specialty were associated with listing an annual salary to consider applying for primary care (considered primary care: OR 2.9; 95% CI 1.7–5.0; P < .001; controllable lifestyle: OR 3.4; 95% CI 2.0–5.9; P < .001). However, for listing a residency bonus, only consideration of primary care was significant (considered primary care: OR 3.5; 95% CI 2.0–6.1; P < .001; controllable lifestyle: OR 1.5; 95% CI 0.9–2.7; P = .15). In other words, students who considered primary care but chose a controllable lifestyle specialty were nearly four times more likely to list a salary to consider applying for primary care than were students who did not consider primary care and selected a noncontrollable lifestyle specialty (38/57 or 67% versus 16/93 or 17%).
We found that most students who did not apply for primary care (internal medicine, family medicine, and pediatrics) did so simply because of lack of interest in those specialties. Students indicated financial and lifestyle aspects were the primary factors that could have been changed to convince them to apply for primary care. Many (41%) who did not apply for primary care appeared as though they would have considered applying if the annual salary were higher, at a median military annual salary of 76% of the expected civilian median salary from their chosen specialty. Students who considered primary care but chose a controllable lifestyle specialty were particularly likely to accept a salary to consider applying for primary care, implying a willingness to make trade-offs between lifestyle and financial remuneration. Almost one-third of students appeared as though they would have applied for primary care if a bonus payment were made at the beginning of internship and end of residency. The only modifiable nonfinancial and lifestyle factors that would entice more fourth-year students into primary care were practice aspects, particularly “appointment length.”
Our finding that financial incentives can influence students' career choice is consistent with other findings from the last 15 years.3–6,8,9,11,12 However, only one previous study (in 1994) attempted to quantify the amount of financial compensation necessary to change students' minds.11 In this study, 17% of students not choosing primary care would have chosen primary care for an annual salary of $180,000, which was 18% higher than their expected specialty income of $152,000.11 In contrast, our study found that more non-primary-care students (41%) would have considered switching to primary care for a median salary of $175,000, which was 76% of their expected specialty income of $230,000. The reasons for these differences are not clear, but might be explained by a lower percentage of students entering primary care in the 1994 study (27% versus 34% in our study), differences in survey technique (a pick list of incomes in the 1994 study compared with open-ended questions in our study), our students' expectation of a military salary, and changes in students' motivation over time.
The other major determinant of what could be changed was lifestyle, which again is consistent with the previous literature.4,8,11,13–16 Our finding that 67% of students who considered primary care but chose a controllable lifestyle specialty would have considered applying for primary care for a higher salary suggests that some students can be given financial enticements to offset the perceived lifestyle disadvantages of primary care. Exactly which of these lifestyle concerns would be most attractive to students is not clear, though our respondents seemed to favor a flexible work schedule and perhaps time for outside interests. Further research is needed to better describe the relative impacts of these lifestyle concerns.
In addition to financial rewards and lifestyle changes, we found a variety of other factors that, if changed, might have enticed students to apply for primary care. Most of these, such as changing the patient population or including opportunities to perform surgery, would change the dynamic of the practice to be something other than primary care. Many potentially modifiable factors within primary care practice are contained within the domain of “practice aspects,” as shown in Figure 1. Several quotes from the students are particularly enlightening about this factor:
Primary care physicians, I felt, are overworked, underpaid, and underappreciated. They are supposed to take care of all of there [sic] patients [sic] basic medical problems, give advice, council on preventative med, etc., all within 15 minutes.
Too many patients to see with not enough time to devote to each patient.
The expectations for the amount of patients seen per day in most primary care practices [are] too high. Seeing that many patients every day is exhausting.
It seems that some students perceived the workload of primary care to be too high, both in the number of patients seen and the expectations for what should be accomplished during visits. Perhaps students are seeing a “chaotic work pace,” as was seen in nearly half of primary care practices in a recent study.20 Our finding lends support to the recommendation of others that students need a different training paradigm in outpatient medicine.21–23
Our study had several limitations. The response rate was only 56%, leaving the possibility for nonresponse bias. However, this response rate is typical for physician studies.24 We also determined that the specialties of the Army HPSP nonresponders were nearly identical (within 2%) to those of the responders for all but two specialties. The demographic characteristics of students with a military obligation may be different from nonmilitary students (e.g., gender, debt), but unlike lifestyle issues, none of these factors were significantly associated with accepting a financial reward in the regression models. In addition, 85% of the students attended civilian medical schools, indicating that the results can possibly be generalized to all U.S. medical students. However, some students, possibly those with longer service obligations, may have been less aware of or less concerned with civilian physician pay. As with other studies in this area, we did not follow students who selected primary care to determine whether they ultimately pursued subspecialty training, but this is of lesser importance because our study focused on students who did not initially choose primary care. Finally, because the survey took place after the Match, recall bias is a possibility.
Our data suggest that until financial and lifestyle issues are adequately addressed, some students who may have selected primary care will choose a more lucrative and lifestyle-friendly specialty. If the goal is to correct the shortage of primary care providers by increasing the number of primary care trainees, policy makers should consider altering reimbursement such that primary care physicians earn at least 75% of the salary of most other physicians for equivalent practice-related time and advocate for delivery systems that are sensitive to provider satisfaction.
The authors would like to thank Dr. Patrick G. O'Malley for his assistance in revising the manuscript.
The institutional review boards at William Beaumont Army Medical Center in El Paso, Texas, Carl R. Darnall Army Medical Center in Fort Hood, Texas, and the Uniformed Services University in Bethesda, Maryland, reviewed and approved the protocol.
The opinions in this manuscript are those of the authors and do not represent the official policy of the U.S. Government, the Department of Defense, or any unit within the Department of Defense.
This study was presented at the 2009 Army–Air Force regional meeting of the American College of Physicians, San Antonio, Texas, November 19, 2009.
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