Why Medical Students Aren't Choosing Primary Care (and Why They Should)

By Matthew Mintz, M.D.

Most articles about why medical students don’t choose primary care will say that a career in primary care simply won’t pay off the enormous debt accrued in medical school. Indeed, the average 2010 graduate came away $157,944 in debt. And primary care salaries are in fact far lower than those of other specialties, a disparity that is increasing. However, I repeatedly ask medical students if they would choose a career in primary care if it would completely erase their student loan debt. A few hands go up, but not many. In fact, for a while now, the federal government has dedicated millions of dollars to repaying loans for students who choose primary care. Yet residency match numbers show that the percentage of students choosing primary care is not increasing.  Though loan forgiveness is a step in the right direction, medical students realize that by choosing a more lucrative specialty, they can pay off their loans just fine.
So maybe today’s students just want higher salaries? Despite a fragile health care system and lower reimbursements for doctors across the board, more students than ever are applying to medical school.  This actually bodes well for the future of health care because it indicates that students are signing up for medical school for the right reasons. I have read numerous medical school applications. This new generation of doctors has done an incredible amount of volunteer work and shows a clear commitment to patients and their communities. Today’s medical students don’t seek to become doctors so they can drive a Mercedes-Benz or shop at Neiman Marcus.
 
So if it’s not entirely because of student loan debt, and it’s not for higher salaries, why are most medical students not going into primary care?
 
In my opinion, it’s because they don’t like what they see when they are exposed to outpatient primary care during medical school. Their primary care preceptor is frustrated with treating complex medical conditions in 15-minute time slots.  Their primary care faculty waste time on the phone with insurance companies, exasperated because they are unable to get their patients the treatment they need. Frustrated patients sit in waiting rooms for 30 minutes or more only to get rushed through a 10-minute visit with their doctor, who is constantly behind schedule. 
 
Students sign up for medical school to have strong, meaningful relationships with patients. In fact, primary care should be the best place for these experiences. However, most students find in medical school that primary care is not what they had envisioned. Combine this with overwhelming debt and the substantially higher salaries their peers will earn, and it should be no surprise that students don’t choose primary care. It’s not primarily the salary or student loans; today’s students simply don’t like the current practice of primary care.
 
The good news for students interested in primary care is that the practice of primary care is changing. It has to because the current health care system is broken, particularly in the primary care setting.
 
Though no one knows what primary care will look like in the next decade or so, almost all possibilities appear promising.  On one side, you have the Democrat vision in which care is delivered in medical homes and accountable care organizations (ACO).  Here, the day-to-day practice of primary care physicians will change dramatically. They will be charged with managing the care of patients, assisted by teams of other health care providers. Reimbursement will be based not on how many visits you can pack into a day, but rather on your ability to keep your patients healthy, enabling the satisfying, long-term relationships physicians desire. The primary care physician is at the center of the ACO model and thus will be in great demand. Therefore, a dramatic increase in salary would be likely.
 
A completely different scenario is the Republican vision in which patients use tax-credits or tax-deferred savings to pay for their health care. The philosophy is that in a free market, the educated patient will pay for quality and value and this will ultimately drive down costs.  Whether or not this happens, the current 3rd-party payer system does not value the primary care physician’s main asset: time and attention. But patients value it, and (if using their own money) they will likely be willing to pay for it. In other words, rather than trying to squeeze the greatest number of patients into a given day, successful primary care physicians in this model will be rewarded directly by patients for their expertise and compassion, in much the same way other professionals are rewarded.
 
Or the whole system could simply collapse. Primary care physicians would decide that it is simply not worth it to stay in the current insurance-based system. Many primary care physicians have already either started retainer practices or no longer take health insurance. These models remove 3rd-party payers from the equation, allowing primary care physicians to do what they do best: take care of patients. Any one of these physicians will tell you that they have a rewarding and satisfying career and believe they are practicing medicine the way it should be practiced.
 
Again, it is unclear which of these scenarios will play out. It is likely we will see some combination of the three.  Regardless, any of these models leads to a more satisfying career, both emotionally and financially, than our students are exposed to today. 
 
I strongly recommend that students keep their minds open to primary care and realize that what they may see today will likely be very different and dramatically improved by the time they complete their residencies.  Students should also seek out exposure to other models of primary care when choosing rotations, such as insurance-free, retainer or community-based practices. Finally, students should take advantage of loan repayment opportunities. Once primary care becomes a competitive career option – and I believe it will – these opportunities will be hard to come by.
 
 
Dr. Mintz is an Associate Professor of Medicine in the Department of Medicine at the George Washington University Medical Center in Washington, DC, where he directed the Primary Care Clerkship for 10 years and currently serves as Director of the Practice of Medicine Course, Years I-III as well as the director of GW’s Premier Access and Executive Services. Dr. Mintz blogs at www.drmintz.com and can be followed on Twitter @drmintz.
Posted by Catherine Rizos on Jul 8, 2014 9:55 AM US/Eastern
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