The disturbing decline of primary care
Career Plans for Trainees in Internal Medicine Residency Programs
By Richard A. Garibaldi, MD, Carol Popkave, MA and Wayne Bylsma, PhD
Academic Medicine
May 2005
Primary care is in crisis. Over the past five years, there has been a significant trend among medical students to move away from internships in primary care disciplines and to select, instead, residency programs oriented to subspecialty training.
In 1998, 54% of PGY3s (in internal medicine programs) planned to practice general internal medicine compared with 27% in 2003. Strikingly, in 2003, only 19% of PGY1s (in internal medicine programs) planned to pursue careers in general medicine.
Many reasons for the decline in interest in generalist careers have been described. These include both positive features that are attracting residents to subspecialty careers and negative forces that are perceived by medical students and residents that make general internal medicine and primary care less appealing. The positive features attracting residents to subspecialty careers include the intellectual content of the subspecialty field, technologic innovations, increased prestige, controllable lifestyle, a growing demand among consumers for subspecialty care, and higher income potential. Conversely, the negative factors making primary care less appealing include the trainees’ perceptions of job dissatisfaction among primary care practitioners, lack of prestige, indebtedness, lower income potential, greater stress, bureaucracy, changing consumer preferences away from primary care, and a lack of clarity about the future of primary care practice as other types of providers enter the field.
http://www.academicmedicine.org/cgi/content/full/80/5/507
Not only has there been a shift from general internal medicine to the medical subspecialties, there has also been a dramatic decline in the number of graduating medical students selecting family medicine residencies. The graph depicted at the following link demonstrates the trends in enrollment in all primary care residencies: http://www.graham-center.org/x468.xml
Comment: The following two principles have been well documented in the health policy literature. A strong primary care infrastructure improves quality and reduces costs. Excess capacity in specialized services significantly increases costs without a commensurate improvement in population health care outcomes.
This disturbing trend in the shift of enrollees from primary care into subspecialty and surgical programs is not good news for those concerned about the continuing escalation of health care costs, which is almost everyone. Not only are specialists’ fees higher, but their practice patterns increase the intensity of services. An appropriate capacity in specialized services is certainly desirable. Many have clearly benefited from the best that our high tech system has to offer. But the United States is unique in having excess concentrations of high tech, specialized services which are over-utilized, dramatically increasing costs without a demonstrable improvement in overall medical benefit.
Few from the health policy arena would disagree with the concept that these trends need to be reversed. But not enough is being said about how that might be accomplished. When you look at the reasons given by students for making their choices, it is difficult to imagine a simple program which might shift their interests.
But just imagine what might happen if we had a single system of funding health care. A single payer system budgets capital improvements not only to ensure adequate capacity but also to avoid the excess capacity that tends to result in excessive frequency and intensity of services. In a single payer system, health care professionals negotiate for reimbursement rates. There is no reason that negotiations could not also address some issues with the work environment. Most physicians who work within integrated health care systems find greater job satisfaction, and single payer financing is very conducive to the expansion of integrated systems of care. Also the administrators of a single source of funding would be in a position to pressure academic centers to make greater efforts to be certain that the ratio of trainees is appropriate to the needs.
Reforming the way we pay for health care certainly will not solve all of the problems that have resulted in the decline of primary care. But it would be a great start. You can accomplish much when you control the funds. Private plan administrators are accountable to their investors, but public program administrators are accountable to the taxpayers. Isn’t that much more reasonable since the taxpayers are also the patient-beneficiaries of the health care system?