Friday, November 13, 2009

Primary Care’s Image Problem -

In my medical school class of 140, Kerry was one of the best and the brightest. Gregarious, unassuming and a dedicated fitness buff with a weakness for ice cream, she managed to sail through the weekly exams that most of us struggled with during the first two years. Later on, in the third year on the hospital wards, she quickly became what every one of us so wanted to be: the indispensable medical student.

When it came time to choose specialties in our last year of medical school, most of us thought Kerry would do what every high achiever and even the not-so-high achievers were already doing: line herself up for a coveted spot in one of the prestigious subspecialties, a field like dermatology, orthopedics, plastic surgery or radiology.

But Kerry wanted to become a primary care physician.

Some of my classmates were incredulous. In their minds, primary care was a backup, something to do if one failed to get into subspecialty training. "Kerry is too smart for primary care," a friend said to me one evening. "She'll spend her days seeing the same boring chronic problems, doing all that boring paperwork and just coordinating care with other doctors when she could be out there herself actually doing something."

Unfortunately those comments would not be the last ones I would hear disparaging primary care. Even today, similar beliefs persist among medical students and trainees, though they have long since been condensed, reduced to an oft repeated acronym among those choosing specialties: I'm heading for the ROAD (radiology, ophthalmology, anesthesia and dermatology).

That ROAD has had devastating effects on the physician work force in the United States. While 50 years ago half of all physicians were in primary care, almost three-quarters are now specialists. The future implications are even more dismal. According to one study published last year in The Journal of the American Medical Association, as few as 2 percent of medical students are choosing to step away from the ROAD or from other similar "high prestige" and competitive specialties in order to pursue general internal medicine. The statistic has the power to bring even the best efforts at reform and universal coverage to a grinding halt. Even with other health care practitioners like nurses and physician assistants helping to care for as many patients as they can, universal health care will be doomed if there are not enough primary care doctors.

Experts in medical education have pointed to three reasons for this lack of enthusiasm: debt, income and lifestyle. The vast majority of medical students finish their schooling saddled with enormous educational debt — the average amount is in excess of $140,000 — and primary care remains one of the lowest-paid specialties.

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