A Little More Realism About Declining Interest in Primary Care

We have posted before about the how fewer doctors in training seem interested in primary care careers. Up to now, the responses from medical organizations, including some that ought to be promoting primary care, have not seemed very direct.

Thus it's a bit refreshing to see a bit more realism in two articles in the latest American Journal of Medicine (which unfortunately requires a subscription).

An article(1) by directors of internal medicine clerkships (hands-on clinical experiences generally during the third year of medical school) noted that "many factors external to the internal medicine clerkship but inherent to internal medicine practice profoundly influence students' career decisions." These include lower income levels for primary care physicians, but more on-call responsibilities, and especially "the high administrative burden," and "the proliferation of third party payers and resulting decrease in practice autonomy."

They allowed that their clerkships can be tweaked to improve them, and perhaps to make primary care look more attractice to students. But they again concluded,

Many of the factors most salient to the career choice process are beyond the scope and control of the clerkship.
Practicing clinicians and thier national organization smust address flaws in the current practice environment that create unmanageable administrative burdens, comparatively low compensation , and time demands that preclude balancing professional obligations with career choices.

In addition, an editorial(2) stated that

the United States faces serious challenges in health care: cost, access, quality, and a projected shortage of caregivers. Rather than acknolwedge these issues, some leaders hope tinkering with the structure of medical education will reinvigorate primary care medicine and help fix a failing health care system.
This optimism is misguided and does not address the real problem.

The authors then listed five paradoxes:

• As the United States spends more on health care, the number of uninsured grows.
• Increased costs and external oversight fail to improve the quality of health care.
• As the need for primary care increases, interest in such careers declines.
• Although society needs well-trained physicians and ground-breaking research, medical schools and teaching hospitals pursue clinical dollars.
• In the nation's capital, political capital is worth more than operating capital.

To begin to address them, they quoted the "Stockdale Paradox," authored by Admiral James Stockdale, the highest ranking military prisoner in the Vietnam War,

You must never confuse faith that you will prevail in the end - which you can never afford to lose - with the discipline to confront the most brutal facts of your current reality, whatever they might be.

However, the editorial is a bit vague about what brutal facts must be confronted. (They only suggested that solutions included an "honest, open discussion," a "more transparent and less fragmented" health care system, more reimbursement for primary care and care of the chronically ill, better performance by medical schools, and having leaders "work together.")
I submit that the missing link here is concentration and abuse of power, which even the authors of this editorial seemed to shy away from confronting.
But we won't here on Health Care Renewal.
Thanks to Retired Doc's Thoughts for the tip.
References
1. Hauer KE et al. Educational responses to declining student interest in internal medicine careers. Am J Med 2005; 118: 1164-1170.
2. Henderson MC et al. Confronting the brutal facts in health care. Am J Med 2005; 118: 1061-1063.

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