January 27, 2012 | Posted By Wayne Shelton, PhD

For most of the past 20 years I have had the privilege of talking with and learning from medical students in small group discussions. As medical students leave the classrooms of the first and second year and transition into the third year, they confront a new reality: they are now actually encountering patients directly for the first time and are working with physicians in the daily care of patients. The more encounters they have with patients and their families and with their clinical mentors, the more stories they have to tell, which often lead to vexing questions that shed light on many of the problems of our health care system in the United States. 

One of the common themes throughout each year is the growing disenchantment with primary care, for a variety of reasons. Most of the students are assigned at some point to a clinical mentor who is a practicing internist seeing many patients each day in a primary care setting. Students often present cases of patients with complex medical and psychosocial issues that require interaction with and support from the physician. Not infrequently do we hear accounts of how patient non-compliance is a barrier to a constructive outcome. The idea of seeing patients over time with the same medical problems, while not heeding medical advice, strikes many students as a frustrating aspect of primary care. Also the students talk of these same physicians continuing to work into the evening, doing mountains of administrative work because of multiple insurance forms to complete. 

During the third year medicine clerkship and other clerkships, medical students also work with and are mentored by other physicians, representing a broad range of specialists and sub-specialists. As smart young people, they are checking out all of these various clinical settings, not only for the purpose of learning and passing the exam at end of the clerkship, but also for the purpose of deciding on their future career choice. They form impressions from what they see and hear. They see the nature of the work physicians do and the various kinds of procedures each type of physician performs. Naturally smart and capable young people are drawn to fields where there are complex problems to solve and interesting skills and technology to bring to bear in solving them. Such is the nature of many medical specialties, which the majority of students say they find more interesting than what they see in primary care. Add to that the fact that they know roughly the kinds of incomes these specialists make versus primary care physicians, and the gap could be wide—indeed, hundreds of thousands of dollars—and most medical students are leaning strongly toward going into a medical or surgical specialty. This is the point at which another key factor begins to come into focus for medical students as they discuss their plans for their post graduate education: the mounting debt.

By the third year medical students have often racked up over $100,000 of debt and they realize they are well on their way to two or three times that much, and in some cases more, by the time they graduate. So let’s get this straight: 1) because they are smart and like scientific challenges, they are naturally attracted to complex specialties and sub-specialties versus the daily grind of seeing what many take to be less interesting and often unsolvable problems in the primary care setting, and 2) they see the significant difference in the number of years the repayment of their debt would take if they became a primary care physician versus a specialist, not to mention the cramp on their lifestyles. As one student recently said, my debt obligation after medical school is going to be like having a large home mortgage, only without having a home. In addition to these powerful structural influences that naturally sway students toward specialization and away from primary care, there is the influence of how they perceive the “social status” of specialties versus primary care.

Medical students are like anyone else: they want to feel their work is important and appreciated by their peers. One of the strongest influences of this type is simply what medical students hear from some physicians about how they view physicians in primary care. It is very common to hear stories of students about how physicians in primary care, especially in family practice, are not respected by physicians in sub-specialty areas. One student recently revealed that she had heard one of her mentors who is a sub-specialist speaking about family practice physicians in a demeaning way, as though they did not know much about medicine. I have heard students say similar things many times over the years. This student naturally viewed what she heard from this physician as one more negative reason to not consider primary care, even though she was interested. Apparently it made her question going into a field that one of her valued physician-mentors did not respect. After she described what she had heard from this physician, I ask the question, why would you allow yourself to be influenced by an arrogant jerk? It was easy for me to say and the students in the class agreed while we were in class; but in real life, these comments and attitudes make primary care all the more unattractive to our medical students.

So, not surprisingly given all these strong influences, the dominant narrative I hear from medical students continually reflect the strong preference of specialization over primary care. This is an alarming trend at a time when it is critical that we have more dedicated primary care physicians in the health care system. This fact is also obvious to practically all the medical students, as they see when we discuss the problems in our current system. One recent story from a medical student puts this problem in perspective.

The student described a patient who had come into the hospital, accompanied by his wife, with swollen lymph nodes. After a thorough workup it was determined that he had a lethal form of leukemia. Many patients with these kinds of diagnoses may receive chemotherapy and/or radiation. With or without further aggressive treatment, this patient will require intensive medical care until he dies. At this acute level of care, hospitals provide services to patients with or without insurance when the patient’s condition becomes acute and emergent. For patients without insurance, who are not covered under Medicaid, the cost of services will never be reimbursed. This patient had no access to care at the primary care level, which might have allowed this patient to discover his diagnosis at an earlier stage. But now that he is very, very sick, he will have access to emergency care and possibly specialty care that may provide expensive procedures, knowing full well that only marginal benefits at best can be accomplished. Thus, is the nature of the U.S. health care system, or, more aptly, non-system that does not emphasize primary care medicine? 

One only needs a little common sense to realize our current strategy of rescuing patients at the last minute is 1) not good for patients, 2) perilous for the financial viability of hospitals and 3) potentially catastrophic for the health care system and national economy at large. Also given these structural factors, hospitals have incentives for specialists to perform as many procedures and treatments as they will get reimbursed for. Even if hospitals could reduce the amount of services while not reducing, and perhaps even improving, the quality of care, they have no incentive to do so. This complex set of structural incentives express the perversion of our health care system writ large. 

Students are fully aware of the enormous challenges of the current health care system and of the challenges they will face when they enter that system as practicing physicians. Some, perhaps most, have seen the idealism they possessed when they entered medical school wane. Clearly, they are in a bind between protecting their own interests versus helping to solve the glaring problems in the health care system. We are not being fair to our medical students. They deserve more from us. These bright, young people are ready to meet the needs of patients if they devise a system that makes sense. The changes must include the following:

•?Providing free tuition for medical students who commit to a career in primary care for at least five years

•?Reimbursing physicians not by how many procedures they perform, but for providing the appropriate level of care for patients—this means all physicians should be salaried

•?Paying physicians in specialty areas less, and primary care physicians more with a loud and clear message from leadership of all areas of medicine: primary care is of the utmost importance to the overall quality of patient care in the U.S.

Health care costs in the United States are now approaching 20% of GDP. We know that much of the excessive utilization of health care resources that does not add to quality of care has to do with the incentives for physicians to do more procedures instead of keeping patients well. Our health care (non) system is evolving in a direction that will both make providing medical care for all Americans impossible and will bankrupt our economy. As the basic insights from medical students show, the structural incentives that motivate entering and practicing physicians must change if we are to put healthcare on a more viable path. And we owe this much to the next generation of new physicians and to their patients.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

2 comments | Topics: Doctor-Patient Relationships , Education , Health Care Policy , Health Insurance , Philosophy


Richard R. Pesce

Richard R. Pesce wrote on 02/22/12 1:45 PM

Great analysis of he current problem. My solution is as follows:
1: one year of the cost of the recent war would be enough to send every student in the system through school for free.
2. If the student elects his, then he is in a pool where 80% of students enter a primary care tract. The 20% that will Go into subspecialty care achieve that during a residency long competition.
3. The salary differential would be about 20%. The primary care physicians would get a baseline salary of 200k.
4. This presupposes a single payor system, doing away with insurance company hassles.
5. National medical licensure instead of state. Better control here.
6. Physicians would be able to add additional but regulated services to add income.
sheila otto

sheila otto wrote on 02/22/12 3:13 PM

Although I agree with the description of problem which is multifaceted, the solutions are a bit more elusive. A primary care physician will typically spend three years in a residency after completing medical college. A sub-specialist training is more extensive and time consuming. For example, a surgery resident will often undergo a five year residency then an additional 2-3 years in a surgery sub-specialty. During the additional training time, s/he is getting residents' pay, not attending level pay. So, I think there has to be some financial recognition of the time spent in training (and not making full pay). However, there should not be "disincentives" built in to choosing the primary care career one really loves. The satisfaction of the work itself has to be recognized as an intrinsic plus aside from the money. If the Obama reforms are to move forward, we will need many more primary care docs and Dr. Shelton's essay speaks to many of the challenges of meeting this goal.

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