In the United States, an emerging body of evidence argues that a robust supply of primary care physicians (especially family physicians) yields better health, greater equity, and lower costs.1 One study demonstrated that both adults and children with a family physician as their regular source of care generated lower annual costs of care, made fewer emergency visits, and reported less difficulty in accessing care.2 Despite this evidence, our nation’s low primary-care-to-specialty ratio is a key contributing factor to our health care system’s place at the bottom of health rankings of Western European and North American countries. The increasing number of specialists is likely to lead to greater health disparities in the future.3
The Deficit in Primary Care
Internal medicine has seen the most alarming decline in the number of primary care practitioners, with pediatrics following suit; instead, residents in internal medicine and pediatrics are choosing to train as hospitalists or to subspecialize. Family medicine remains the only almost “pure” primary care specialty and the only one with physicians distributed somewhat equally relative to the geographic distribution of the U.S. population.4 Despite the gradual increase in medical students’ interest in family medicine and their match rate to such residencies, this incremental growth is not keeping pace with the growing national demand for primary care services in general and for family physicians in particular, the rising need driven by the growth and aging of the population, and the mounting demands placed on our system by health care reform, triggered by the Affordable Care Act. The expansion of the nurse practitioner and physician assistant workforce is a welcome addition to primary care but can only partially fill the deficit because almost half of these health care professionals also choose to specialize.5
Perceptions of Family Medicine Abroad
The study by Rodríguez and colleagues should serve as a wake-up call for academics and as a sobering reminder to the policy makers and health system employers who expect academic health centers (AHCs) to graduate the types of physicians our nation needs most.6 Too often, many at AHCs assume that student debt, adverse health service incentives, the lifestyle preferences of the younger generation of physicians, or the market forces outside their control are the sole reasons for their failure to train an adequate primary care workforce. While these factors contribute to the problem, the study by Rodríguez et al points to other, more pervasive factors—the social environment and academic discourses at AHCs.
Rodríguez and colleagues found that, in the United Kingdom, family medicine was considered by medical students to be a prestigious academic discipline, offering practitioners clinical variety, professional autonomy, a good income, and the opportunity to be a “true clinician.” In Canada, Spain, and France, however, both students and faculty derided family medicine for a lack of innovative technology, poor pay, and high work demand. While students in the United Kingdom had early and sustained exposure to family medicine role models, this was not the case in Spain or France. To raise the prestige of family medicine, the authors recommend that medical schools increase the presence of family physicians in their power structure, thus hopefully attracting more students to the discipline.
The Hidden Curriculum in Medical Education
Perhaps the most salient and underreported factor negatively affecting medical students’ interest in family medicine in the United States is the hidden curriculum, first described by Hafferty.7 He stated that “a great deal of what is taught—and most of what is learned—in medical school takes place not within formal course offerings but within medicine’s ‘hidden curriculum.’” The hidden curriculum can reinforce the negative elements of existing reward and recognition systems and deter students from pursuing certain career paths, such as family medicine. Consistent with Rodríguez and colleagues’ findings, students interested in family medicine often doubt their career choice, instead being drawn to the inpatient specialty of their current rotation. In addition, students adapt to the social norms and pressures of peers, residents, and professors. For example, Erikson and colleagues8 studied the role of medical school culture in primary care career choice. Of 1,554 senior students from 20 randomly selected medical schools completing a survey on the variables affecting their career choice, students who attended schools where “badmouthing” of primary care was prevalent were significantly less likely to choose primary care. The reverse was true for students identifying a more positive experience on their primary care clerkships. Erikson and colleagues estimated that 8% of total variation in students choosing careers in primary care was due to school-level factors.
Examples of Successful Medical School Innovations
Some medical schools in North America are taking steps to change the discourse around primary care and family medicine to reduce the negative effects of the adverse social environment on students’ perceptions of these disciplines. These two examples share common threads and can serve as best practices for medical schools intent on graduating more students who enter primary care.
First, the University of New Mexico School of Medicine’s “Vision 2020” states that the university’s Health Sciences Center “will work with community partners to help New Mexico make more progress in health and health equity than any other state by 2020.”9 In fulfilling this vision, all medical students spend substantial blocks of time outside the university under the tutelage of primary care preceptors during their preclinical and clinical years; all earn a public health certificate,10 and all complete a required, eight-week family medicine clerkship during their third year. In addition, five of the nine leadership positions at the Health Sciences Center (the chancellor, two of the four vice chancellors, and two of the four associate vice chancellors) are filled by family physicians. As a result of these factors, the School of Medicine is consistently among the top 10 medical schools in the United States in the percentage of its graduating medical students who match into family medicine residencies.
Next, the Northern Ontario School of Medicine has a social accountability mandate to improve the health of the people and communities of Northern Ontario.11 Ninety-one percent of students are from the region and reflect its rural nature and ethnic mix, including First Nations and Francophone students. It was the first medical school in the world to require a longitudinal integrated clerkship. All third-year students are assigned to family practices where their clinical learning is determined by the patients who walk through the door of the practice. Sixty-one percent of graduates have chosen family medicine residencies (the largest percentage of any medical school in Canada), and 65% practice in the region.11
A Different Discourse, A Different Movement
In response to the popular medical school rankings that heavily weight research funding and subjective assessments of a school’s reputation, Mullan and colleagues12 ranked medical schools based on three dimensions related to social mission—producing an adequate number of primary care physicians, an adequate distribution of physicians to underserved areas, and a sufficient number of minority physicians. Although somewhat controversial in 2010, this work has gained support from medical schools that are engaged in grant-funded initiatives (see List 1) promoting the importance of medical schools fulfilling a social mission, such as graduating primary care physicians. In each of these initiatives, the discourse within the participating medical school has changed, emphasizing primary care, prevention, public health, and social determinants. The Affordable Care Act accelerated this change, as did the shifting environment both in the companies that purchase health insurance for their employees and among the insurance companies that receive capitated payments. These changes emphasize prevention, wellness, and access to primary care.
List 1 Examples of Grant-Funded Initiatives Promoting the Social Mission of Medical Schools Cited Here...
- Association of Academic Health Centers’ Social Determinants Initiative
- Regional Medical–Public Health Education Centers Initiative funded by the Association of American Medical Colleges–Centers for Disease Control and Prevention Cooperative Agreement (32 schools)
- W.K. Kellogg Foundation–funded Beyond Flexner initiative at the George Washington University School of Public Health and Health Services (6 schools)
- National Institutes of Health–funded Urban Universities for HEALTH Learning Collaborative (5 schools)
- Primary Care Extension/IMPaCT grant from the Agency for Healthcare Research and Quality and the Commonwealth Fund (18 schools)
- Practical Playbook for Public Health and Primary Care from the de Beaumont Foundation, Duke Community and Family Medicine, and the Centers for Disease Control and Prevention
Financial Strategies for Encouraging Interest in Primary Care
Current health care financing favors “high tech/low touch” medicine, and payment incentives foster students’ exposure to and interest in procedural specialties. This training milieu does not encourage students to pursue careers in primary care. In addition, Medicare graduate medical education (GME) payments support a fixed cap on the number of GME slots, leaving it to the AHCs to determine the ratio of specialty-to-primary-care trainees, a process that may not be responsive to community need or accountable to the public. However, new GME funding proposals may encourage students’ interest in primary care. For example, teaching health centers offer a payment mechanism whereby community-based family medicine residencies, where primary care physicians rather than specialists are the dominant role models, receive federal funding to hire and train family medicine residents.13 In addition, each state’s Medicaid GME contribution can be allocated to funding the residencies needed by the state. In New Mexico, the state legislature passed a bill in 2014 to allocate Medicaid GME funding to primary care residency positions in the state’s federally qualified health centers.14 Unlike federal GME funding through the Centers for Medicare and Medicaid Services, states can determine how these GME funds are allocated, and these Medicaid-funded residency positions can exceed the current cap on federally funded positions.
U.S. medical students’ declining interest in primary care has many sources—the discipline’s comparatively low pay, high student debt, and poor role modeling. Rodríguez and colleagues identified another important factor—medical students’ negative perceptions of family medicine. Even in countries like the United States and Canada, with similarly poor perceptions of family medicine, students’ interest may increase if family medicine role models are ubiquitous and if students are immersed in community-based preceptorships, the longer the better, under the tutelage of family physicians. Today, supporting these changes are a growing number of medical school networks that promote primary care and its sister challenges—medicine’s integration with public health, an investment in community engagement, and the acceptance of medicine’s role in addressing social determinants.
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13. . Section 340H of the Public Health Service Act, as added by Section 5508 of the Patient Protection and Affordable Care Act of 2010:111–148
14. 51 Legislature-State of New Mexico-second session. . House Bill 310. An act making an appropriation to the Human Services Department to fund the creation of primary care residency slots through the Federally Qualified Health Centers Teaching Health Center Program. 2014