The nation's primary care physician residency programs are plagued by a lack of interest, support and funding. This situation, in turn, is helping to drive the nation's chronic shortage of primary care physicians, said the chair of the Council on Graduate Medical Education, or COGME, who spoke before the Medicare Payment Advisory Committee, or MedPAC, here on Sept. 18. 

Russell Robertson, M.D., chair of COGME and a family physician, explained his organization's perspective on medical education issues and growing concern about the shortage of primary care physicians. According to Robertson, about 65 percent of all physicians in the United States are subspecialists, and 35 percent are primary care physicians, an imbalance that, in part, can be traced back to shortages in the primary care physician pipeline.

"When you look at other nations with comprehensive policies with regard to universal access to health, the ratio of generalists to (sub)specialists is about 50/50," said Robertson, chair and professor of the department of family and community medicine at the Northwestern University Feinberg School of Medicine in Chicago. "(These nations) also generally have a higher per capita number of physicians than we do. This is part of what is framing where we are."

Robertson identified various factors that are undermining primary care residency programs, including medical school admission policies, medical school student experiences and a general lack of support for the programs themselves.

Medical school admissions policies are "problematic," said Robertson. Although students from rural and urban medically underserved communities continue to apply to medical schools in relatively steady numbers, they are more likely to be rejected, he noted. 

In fact, the AAFP's Robert Graham Center in Washington has published datashowing that medical schools receive a steady stream of applications from students who reside in rural areas, said Robertson. These students are likely to return to these rural areas and practice primary care, according to Robertson, but "they just don't get in(to)," medical school, he said.

In addition, said Robertson, medical schools are unintentionally expanding the shortage of primary care physicians by creating an environment that discourages medical students from pursuing careers in the primary care field. Most medical schools have a formal curriculum and what is called a "hidden curriculum," one that entails private discussions between students and well-intentioned professors, who try to dissuade students from entering the primary care field, Robertson said.

"When you say you want to become a primary care physician or a family physician, the (professors) say, 'Well, you are such a smart person, why would you want to invest your career in that specialty?'" said Robertson. "That happens, and it is happening today. It is just a reality."
 

The training medical students receive at academic centers also tends to discourage careers in primary care medicine, said Robertson. In academic centers, students are exposed to optimal subspecialty care. "They see a phenomenal environment and cutting-edge care," he said.

However, students who train with primary care physicians may have a starkly different experience, often working with a primary care doctor who is struggling financially. 

For example, Robertson said he was involved with a summer training program a few years ago in Wisconsin in which students were paid a $2,000 stipend to train with a primary care physician. "(Students) came back with two distinct impressions," he said. In nearly every case, the students described the primary care physicians they worked with as "the most wonderful person I have ever met; he or she is an unselfish and dedicated individual, and in no way would I want that lifestyle." 

"Unfortunately, that is the impression, wrongly, that a lot of medical students have," said Robertson. "There are some phenomenal things that are being done in primary care right now with the patient-centered medical home, but, unfortunately, students are not seeing that during these formative years."

Tom Dean, M.D., of Wessington, S.D., the only family physician on MedPAC, said during the question-and-answer segment that primary care has "hit sort of a nadir" in recent years.

"I think we are headed back up, and I think the future is bright," he said. "But how do we communicate that to incoming students, and how do we create an environment early on to support the specialties we need?"

"I don't think there is a conscious decision (on the part) of medical schools to try to block people from getting into primary care," Robertson responded. "I think they are kind of stuck in the environment in which they find themselves, and it takes a long time to make a change."

One of the keys is to get medical students out of medical centers and into communities, a mission well-suited to primary care departments, said Robertson. As chair of a family and community medicine department, Robertson has built strong relationships with federally qualified health centers located in medically underserved areas.

"We are trying to function as a conduit to get students into these settings," he said. "We have the support of the medical school administration in doing that."

Robertson also decried the lack of adequate funding for Title VII of the Public Health Service Act, which provides funds specifically to academic departments and programs to increase the number of primary care health professionals. There is a direct correlation between Title VII funding and the production of primary care physicians, said Robertson. Yet, Title VII funding in 2008 was less than half of the 2002 funding level for the program.

Hospitals, for their part, predominantly fund GME slots for subspecialists, resulting in a decline in hospital-funded GME slots for primary care physicians, according to Robertson. 

In the five-year period from 2002 to 2007, 37 family medicine residency programs closed, he said.

"We are in a big hole right now," Robertson noted. "The number of physicians we are producing who want to be adult primary care providers is still going in the wrong direction."

Robertson also said the income gap between primary care physicians and subspecialists is adding to the decline in the number of students going into primary care, but it is not the key factor in determining physician specialty choice. "The key factor, if you are looking at finances, is return on investment," he said. "And the difference between a primary care specialty and a procedurally different specialty over the course of an individual's career is about $3.5 million in terms of lifetime income. 

"Students are aware of that as they decide what they want to do."

The average primary care physician makes about $120,000 a year, far less than the yearly incomes of orthopedic surgeons and radiologists, said Robertson. But many more medical students would choose careers in primary care medicine if their salaries were increased, he added.

James Arvantes /AAFP News Now