Primary care’s image problem

From the doctor’s point of view, is primary care rewarding or is it just plain boring?

Medical student Suchita Shah spent five weeks awhile back doing a clinical rotation at a primary care and general internal medicine clinic.

She blogged about the experience a few months ago. Then her blog entry was picked up at Kevin, MD, one of the leading voices in the medblogging world, which is where I discovered it. It seems to sum up many of the issues ailing primary care these days: namely, that many (maybe even most) medical students no longer seem to find it worth their while.

Shah writes:

It was awesome because I was the “doctor.” I essentially had full responsibility for each patient. From calling him in from the waiting room to deciding what medications he needed and at what dose, and everything in between, he was my responsibility. After I saw the patient, I’d present the case to my attending for a few minutes, we’d discuss and he’d teach for a minute and modify my plan a little if necessary, then the real doctor would go in and say hello and sign the orders I had suggested. I was my patient’s health care provider – a phenomenal feeling and an awesome transition in that I now think of myself as a capable clinician-in-training.

But that’s why I found primary care to be boring. I could do it. As a 3rd-year medical student. The cases I saw were by and large obesity, hypertension, diabetes and hyperlipidemia. A little tweaking of drug doses here and there, lots of education about lifestyle changes, plenty of questioning to assess for target organ damage, referrals for specialist followups… and far too much of “staying the course.”

Medical students and doctors like to be challenged and this wasn’t challenging, she writes. “And if this is what most of family medicine/primary care is like… I don’t want to do it for the rest of my life.”

Houston, I think we have an image problem.

To be sure, there’s a lot that’s frustrating these days for primary care physicians. There’s the paperwork, the crummy reimbursement, the pressure to churn patients through the exam room. But are these reasons to disdain the entire field of family medicine or general internal medicine?

The responses to Shah’s guest blog were interesting. “ALL of medicine is boring. And/or frustrating, time-consuming, aggravating or headache-inducing. Welcome to the real world,” one physician wrote.

From another doctor:

really? as a med student, u really feel like u have mastered primary care medicine? as a professor of medicine, i have a reference point, and i can assure u that u have not.

If you spend much time reading blogs and online discussions among medical students, however, the attitude that primary care is unexciting is far from unusual. And it’s not clear how much of this is based on reality and how much is perception.

It’s true that primary care doesn’t pay as well as most of the specialties. For medical students lumbered with enormous educational loans, career decisions often come down to the financial realities. It doesn’t seem to be only about the money, though; there also seems to be a perception that primary care itself isn’t interesting enough or worthwhile enough to be the focus of one’s career.

An article published a couple of years ago by the Association of American Medical Colleges reflects on why this is so. The devaluing of primary care isn’t new, and it often starts in medical school with a so-called hidden curriculum that devotes fewer resources to learning primary care, fewer good opportunities for students to experience primary care firsthand, and often even subtle discouragement or disdain by medical school faculty, the article explains.

But the article also hits on another factor: the high expectations of many medical students for a career that’s both intellectually and financially rewarding. These students, after all, are quite elite – very bright, very hard-working, competitive and achievement-oriented, with high aspirations for their future – and this sometimes leads to feelings of entitlement. When this is the mindset, primary care often simply can’t compete, especially if students perceive (mistakenly) that it’s easy enough for any rookie to do.

Primary care obviously isn’t suited for everyone. In the final analysis, students need to choose a specialty that’s a good fit for them, and the American health care system needs a good supply of specialists as well as primary care doctors.

But it would be too bad if students wrote off primary care on the basis of a limited experience that may not have been representative.

It looks as if Shah may have completely missed what makes primary care interesting and challenging, a physician commenter wrote: “Every patient encounter is an opportunity to discover something and someone new. I chose primary care partly because I didn’t want every patient of the day to be a life and death situation. I am happy to be brilliant once or twice a day and very much enjoy discovering what makes each of my patients tick, what they love and hate and why they make the health choices they do. I love to hear about their jobs and hobbies and families, their grief and their joy. I can always find a way to plant a small seed of better health in each of their lives. I love my job!”

Update: Results from Match Day on Mar. 17 show an uptick in the number of medical students obtaining residencies in primary care. The National Resident Matching Program reports that the number of U.S. medical school seniors matched to a residency in family medicine rose by 11 percent this year. There was an 8 percent increase in the number of matches to internal medicine and a 3 percent increase in pediatric matches.

The numbers are a little bit misleading because the overall number of residency training slots in primary care has been increased. Family medicine programs, for instance, are offering 100 more positions this year. The number of Match Day applicants for all specialties also is up overall.

According to this year’s Match Day statistics, dermatology, orthopedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery and vascular surgery remain the most competitive specialties for applicants.

Match Day helps determine where fourth-year medical students will spend the next three to five years completing their residency training. It’s usually predictive of the student’s ultimate choice of specialty.

Photo: Wikimedia Commons