Monday, July 12, 2010

Primary care specialty choice: student characteristics

I have written about both the characteristics of medical schools (recently, in A New Way of Ranking Medical Schools: Social Mission, June 20, 2010; also Rankings of Medical Schools: Do they tell us anything?, September 5, 2009) and of medical students, including the people being accepted into medical school, the specialty choice of those graduating, and what aspects of both schools and students are associated with the kind of doctors students become (Who will care for the underserved? The role of off-shore medical schools, June 2, 2010, Primary Care and Residency Expansion, January 7, 2010, "Uncomplicated" Primary Care?, October 8, 2009, Medical Student Selection, December 4, 2008). A recent study, “Primary care specialty choices of United States medical graduates, 1997-2006” (Academic Medicine June 2010;85(6):947-58) by DB Jeffe, AJ Whelan and DA Andriole from the Washington University School of Medicine in St. Louis provides further information to inform this discussion.

The authors used two surveys administered annually by the Association of American Medical Colleges (AAMC) to medical students: the Matriculating Student Questionnaire (MSQ) given when students begin school and the Graduation Questionnaire (GQ) given at graduation. They were able to match the questionnaires of nearly 2/3 (64.9%) of medical students graduating in the 10 years 1997-2006 to look at the degree to which the answers students gave to questions on the MSQ and GQ would predict their choice of specialty. It takes a while to get through the description of how they grouped questions, and “weighted factors”, but there are a number of important findings. Most of them not surprising, but this study provides additional data support for things we have been seeing.

Fewer graduates are entering primary care. For some reason the AAMC’s GQ counts 6 “primary care” areas, including, in addition to the usual family medicine, general internal medicine, and general pediatrics, also obstetrics/gynecology, internal medicine subspecialities (IMSS), and pediatric subspecialties (PdSS). However, this study separates them out. The percent of students entering the first 4 of these dropped from 1997 to 2006 (GIM from 15.7% to 6.7%, GP from 10.2% to 6.6%, FM from 17.6% to 6.9%, and OBG from 8.2% to 6.1%), while the subsubspecialties increased (IM from 6.8% to 11.4%, Peds from 2.2% to 4.4%). This increase in the last 2, however, did not compensate for the decrease in the first 4 so there was a net decrease from 60.7% to 42.1% for all these “primary care” specialties. The increase was in, then, surgical specialties, and more significantly in specialties such as radiology, anesthesiology, and emergency medicine. And the trend continues – although not part of the study, the article reports that the total % of students entering these 6 specialty areas in 2008 was down to 30.3% from the 42.1% in 2006. Remember, this is not just real primary care – it includes medical and pediatric subspecialties!

The more important part of this article is its correlation of certain demographic and attitudinal characteristics with specialty choice. Being female is important: over the 10 years of the study 45.1% of graduates were women, but they were over-represented in each of the 6 fields except IM subspecialties: 77.3% of OBG, 72.6% of GP, 58.2% of PdSS, 50.8% of FM and 49% of GIM. Indeed, the authors suggest that one of the reasons for the continued downturn in entry of medical students into PC fields is that the % of women in medical school, which was increasing during the study period, tended to compensate somewhat for the decreased interest in PC among men. Now that the % of women in medical school has stabilized, at roughly 50%, while interest in PC continues to go down, this is no longer having the same compensatory effect.

Compared to white students, underrepresented minority (URM) students were somewhat less likely to choose the PC specialties of GIM, GP, and FM, while Asian/Pacific Islander (As/PI) grads were less likely to choose FM, OBG, GP and PdSS, according to the text, but there are subtleties to this. For example, white students were 68% of the total but 75.3% of those entering FM; however, the % of URM students in FM (14%) was also greater than in the overall cohort (12.7%). The difference is that As/PI were much lower in FM, 9.9% compared to 18.2% of the overall cohort. In this report URM students include black, Hispanic, and American Indian/Alaskan natives, while the As/PI group includes some groups that are truly underrepresented in medicine and are usually counted by Federal grantmakers as URM, as well as some groups, e.g., South Asian, Japanese, Chinese, that are in fact over-represented in medicine. Many of these are among the 15.7% of students who had one or more parents who was a physician or the 24.1% more who had a non-physician professional parent. This is important because “…a student’s having a physician parent had a pervasive negative effect on graduates’ choice of any generalist-primary care specialty…” while those with non-physician professionals as parents were more likely to choose GIM, GP, and IMSS.

Though highly-touted as a deterrent to entering PC (and, perhaps, of more significance now than in the early part of this study period) debt had only a “modest” effect; students with higher debt were less likely to choose GP, PdSS, GIM, or IMSS, but more likely to choose OBG, and choice of FM was essentially unaffected. The probability of students from public medical schools entering PC was much greater than from private schools, a consistent finding of all studies, presumably reflecting the curriculum and emphasis of those schools as well as the characteristics of the students they select. The authors linked a number of questions to assess students’ “choice of medicine as a career goal” (including the importance of innovation and research, social responsibility, and prestige), and students’ “perceptions about medicine and medical practice” (including altruistic beliefs and the belief that the demands of medicine interfere with family/other interests). All were high, and few led to big differences in specialty choice. Among the most significant of those that did were “intention to practice in an underserved community” (more PC, especially FM), and “interest in academic faculty positions” (very low FM -- the odds of being interested in academic practice compared to full-time non-university practice was only 12% for someone entering FM, compared to GIM’s 86%, IMSS’ 185% and PdSS’ 316%!).

Among areas that the questionnaires did NOT look at was the probability of entering rural practice; other studies have shown that, except for family medicine, essentially no students are entering practice in rural areas (see Primary Care and Rural Areas, April 28, 2010, Medicare Costs in Rural America: A case of reaping what we haven't sown?, March 26, 2009, Ten Biggest Myths Regarding Primary Care in the Future, January 15, 2009 ). Despite their assertion (probably correct) that “…the predictive validity of planning to practicing in an underserved community at graduation has been established,” intention to practice in an underserved community is not a surrogate for intention to practice in a rural area, because practicing in a rural underserved community means living in a rural community, while one can practice in an urban underserved community and live in a more upscale neighborhood. This is particularly true for pediatrics (see Primary Care, Pediatrics, and Physician Distribution, May 21, 2009).

So what does all this tell us that is new? Not much. There is a dramatic decrease in the number and percent of students entering true primary care specialties, combined with some increase in the number entering obstetrics/gynecology, internal medicine and pediatric subspecialties and a large increase in specialties that are in no way primary care. It tells us that students who are interested in and attracted to, and are wooed by, “high-status” research and specialty care medical schools are less likely to enter primary care; that being the child of a physician or having a high family income makes one less likely to enter primary care; that students interested in caring for the underserved and women are more likely to enter primary care (although not rural practice). So what does this mean “we” should do?

Well, that depends on who “we” are. If “we” are the selective, high-status medical schools who are low on social mission (see A New Way of Ranking Medical Schools: Social Mission, June 20, 2010) and “we” value what “we” do, maybe “we” shouldn’t do anything. The same might be said if “we” are the schools that tend to be high on social mission and production of PC physicians. If, however, “we” are the American people, who need more primary care and rural physicians, or the politicians and policy makers who actually can have some influence, “we” need to make policies that reward schools that select the students whose demographic and attitudinal characteristics make them more likely to enter primary care, underserved, and rural practice. And those schools whose curriculum (formal and informal) and faculty attitudes and relative status-within-the-institution favors those same outcomes. And pay, on the back end, more money to those who do what “we” don’t have enough of (primary care, underserved and rural practice) than those who do what “we” have too much of already.

Whether or not “doing the same thing over and over again and expecting different results is the definition of insanity”, it is sure not going to accomplish any change in the physician workforce.


tooearly said...

as interesting as these relationships might appear to be, they are only statisitical associations and offer us nothing more than possible hints as to the likely solutions to too few people pursuing PC. Do we have any chance of getting something closer an RCT for some of thee relationships to be tested?
I am a third generation primary care doctor. Despite the "pervasive negative effect on graduates’ choice of any generalist-primary care specialty…” that my parents and grandparents career had on my sibs and me, we went into primary care.

thegooddrlaura said...

I just found this blog entry nearly a year after it was written, just after the allopathic match in 2011. Thank you for this blog and this topic in particular. I'm signing up as a follower.

Anonymous said...

I am a graduating medical student who is not planning on pursuing primary care. I have a strong interest in social justice and working with underserved populations but the primary care field is too emotionally draining and miserable. None of my colleagues wanted to go into primary care because of the hassels associated with it. The lack of pay was a part of that but also, in primary care you often just feel defeated. People generally go into primary care if their test scores on the steps are not high enough. I think the way the statistics sorted out in this group of "people more likely to go into primary care" are the same people who are more likely to have lower test scores. There are some who generally love primary care, but they are few. Most of us go into it when we don't have other choices. The change that is needed is systematic...make primary care easier and give PCPs more agency to make choices (take power from insurance companies, give us good options for people who can't afford medications) and it will become a better choice for many of us.

Unknown said...

I take exception to the statement that only students who don't score well go into primary care. I have tried to cultivate an awareness in my peers that the smartest students should go into primary care. I got a 245 on Step 1, which could put me on the ROAD to riches, but I'd much rather get a broad training in a really good family medicine residency, and get more socio-ethical remuneration out of my job than the radiologists and anesthesiologists can appropriate.

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