News/Commentary

When I was a young medical reporter, I used to ask doctors I interviewed why they chose to go into medicine.

I asked my good friends who were doctors the same question.

With only a few exceptions, I would get a puzzled look, or a comment like this: “I don’t know. Ever since I was little, I wanted to be a doctor.” Shrug. They were genuinely surprised by the question. They didn’t think it intrusive. They couldn’t explain.

The drive to pursue a career which requires more education than any other—- just to win the privilege of showing up to begin to practice medicine—- comes from the person’s values. Those values may include the wish to help others, a personal family experience that fires them up or, of course, the money.

One of my best friends was an internist, many years older than I. He told me he remembered the precise moment he decided to be a doctor. His grandmother was dying and in intractable pain. He said that he said to himself, “When I grow up, no one will ever have to hurt like this again.” He was five years old. He grew up. He fixed a lot of pains, physical and emotional, over decades of practice in internal medicine. Another child might have fled, understandably. He did not. His course was set by that experience.

In this medical journal commentary, the writers are summarizing what appears to influence students to choose primary care, a burning issue for us individually and as a nation.

- Students who can avoid debt are more likely to choose primary care.

- Students who grew up in rural areas are more likely to make primary care their choice.

- Students who want to care for patients in under-served areas are more likely to choose primary care.

- Students who attend public medical schools are more likely to choose primary care.

- Training in rural areas may influence students to choose it.

- Female students are more likely than male students to choose primary care but are less likely to choose rural areas for
practice.

- Good primary care experiences in medical school can influence a student.

- Students who are impressed by an internist’s practice and lifestyle are more likely to choose primary care.

As the editors note, the choice of specialization is complex.

What is clear, they conclude, is that (mostly) public medical schools produce more students who want primary care.

NEJM

The journal’s editorial board has offered this as a free, full text. Below is an excerpt.

…“What can be done to alleviate the adult primary care shortage and increase the percentage of such doctors who are trained in the United States? The way in which primary care practices are organized and collaborations among doctors, nurse practitioners, and physicians’ assistants will be key determinants of the number of physicians needed, their professional experiences, and their job satisfaction. However, merely increasing the numbers of medical schools, medical students, or residency positions that could produce primary care physicians will have limited effects if U.S. medical students continue to shun such careers.

“In the near term, with or without health care reform, the United States will continue to rely disproportionately on IMGs to provide primary care. In the long term, augmenting the incomes of primary care physicians, increasing the proportion who accept patients regardless of their type of insurance, implementing new payment models, and reducing or eliminating income disparities between specialists and generalists will probably be essential, as will expanded government support for primary care training through Medicare, Title VII of the Public Health Service Act, and related programs. Revitalizing and expanding the National Health Service Corps (NHSC) is also important. Physicians in the NHSC loan-repayment program are about 7 times as likely as others to choose a primary care career, and students who avoid debt by receiving NHSC scholarships are about 4.5 times as likely as others to enter primary care.¹ All physicians in the corps practice primary care; patients who need specialists are referred to the nearest qualified hospital or clinic. Although the NHSC requires a commitment to practice in an underserved area for a limited number of years, participation may lead to a sustained commitment to primary care.¹ Unfortunately, the program shrank under the Bush administration: in fiscal year 2008, there were sufficient funds for only 76 new scholarship awards (49 to medical students) and 867 new loan-repayment awards (223 to physicians).

“The relationship between medical student debt and career choice is complex, and studies have had conflicting results. Whereas some students have sufficient means to graduate without debt, the risk of accumulating a large debt probably deters some undergraduates, particularly students from low-income families, from even applying to medical school. Although avoiding or promptly repaying debt is more important for some than for others, tuition decreases, scholarships, and loan-repayment programs can promote primary care careers.

“Money is not the only consideration, however. Medical career choice involves many factors.¹ For example, students who grew up in rural areas and those with a demonstrated interest in caring for underserved groups are more likely than others to practice primary care. And students at public medical schools are more likely to choose primary care careers than those at private schools, as are students in rural as opposed to urban schools. Training in rural locations is an important factor in students’ choice to practice in such locations. Women are more likely than men to choose primary care but less likely to practice in rural areas. Positive experiences with primary care during medical school, such as in clerkships, encourage students to pursue primary care: those with favorable impressions of internists’ patients, practice environment, and lifestyle are more likely to become internists.⁴ Such findings can inform policy — for example, by focusing attention on which students are admitted to medical school (and expanding opportunities for applicants from less-affluent families) and on the quality of experiences with primary care during training (including opportunities to work in locations with physician shortages).⁵

“Of course, students notice when teaching hospitals invest in facilities for lucrative specialties but not for primary care. During specialty rotations, students may observe well-managed offices with spacious modern facilities, in contrast to crowded older primary care clinics with harried physicians.¹ Such discrepancies make it more difficult for faculty to facilitate primary care careers through teaching and mentoring. The national trends notwithstanding, at some (mostly public) medical schools, high percentages of students still enter residencies in family medicine, internal medicine, or pediatrics (see table). These schools’ experiences could inform approaches elsewhere.”

Citation: New England Journal of Medicine, Volume 360:2696-2699, June 25, 2009, Number 26