Is debt to blame for primary care workforce shortage?

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Despite the fact that more medical students favor internal medicine as a meaningful career path – 58% in 2007 vs. 42% in 1990 – a growing number said that the need to repay student loans discouraged them from choosing this line of work, study results published in Archives of Internal Medicine indicate.

The proportion of students who participated in two national surveys in 1990 and 2007 who said student loan payments influenced their decision not to pursue primary care as a career rose 10 percentage points, from 16% to 26%.

“Bolder payment and practice reform will be required to reduce the remuneration gap between primary care and subspecialty physicians and to address the adverse work conditions in general internal medicine that students identify in clerkships,” Mark D. Schwartz, MD, of the New York University School of Medicine in New York City, and colleagues wrote.

The number of U.S. medical students choosing primary care residency training programs in internal medicine declined 54%, from 575 in 1999 to 264 in 2008. Furthermore, the proportion of students that complete residencies in internal medicine and then go on to practice, declined from 54% in 1999 to 20% in 2008, according to background information in the study.

As the need for primary care clinicians keeps growing to meet the demands of the aging baby boomer generation, and as more Americans gain access to health insurance with the Affordable Care Act, some organizations have projected a shortage of as many as 35,000 to 40,000 adult care generalists by 2025.

In efforts to develop better strategies to attract more students to primary care careers, Schwartz and colleagues analyzed survey responses from a data set that included 2,421 senior medical students — 1,244 respondents from a 1990 survey and 1,177 respondents from a 2007 survey.

The later student cohort was comprised of more women students, 52% vs. 32% (P<0.001) and had more student debt — $101,000 vs. $63,000.

The researchers found that although the proportion of medical students who planned careers in internal medicine or one of it's subspecialties stayed about the same, 24% in 1990 vs. 23% in 2007, only 9% and 2% of these students actually planned on training in general, primary-care internal medicine.

Despite these findings, more students in the later cohort reported satisfaction with the internal medicine clerkship, 78% vs. 38% (P<0.001), and more considered esteem a significant factor in pursuing internal medicine, 82% vs. 68% (P<0.001).

During the study period, the number of internal medicine clerkships that included outpatient rotations increased from 44% to 94%.

However, inclusion of outpatient rotations in clerkships had mixed results on residents' perception of the field, with 35% and 31% of the 1990 and 2007 groups reporting that their experiences made internal medicine more attractive, and 25% and 33% reporting that it made it less attractive.

Students in both surveys felt that the types of patients seen by internists (72% in 1990 vs. 55% in 2007) and the time commitment and workload (54% vs. 46%) were undesirable.

Income disparity is believed to be the foremost obstacle to attracting more students to primary care careers — a nearly three-fold income gap exists between generalist and subspecialist physicians, according to the researchers, resulting in a disparity of about $3.5 million during a 40-year career.

"Persistent unfavorable perceptions of income disparity, workload, and stress appeared to counter the gains from perceptions of meaningful work. Thus, many of the 'next steps' need to improve the attractiveness of [internal medicine] and general [internal medicine] careers may fall outside the purview of medical educators and within the realm of health policy," the researchers wrote.

Offering more scholarships and better loan repayment options for medical students pursuing primary care may help solve some of these problems, data from earlier studies indicate, but the researchers noted that these types of opportunities are available to fewer than 5% of U.S. students.

In addition to such incentives, improving working conditions to promote a greater work-life balance “by carefully designing patient-centered medical home models,” and “shifting away from the fee-for-service system driven by volume incentives to one driven by value incentives,” may be beneficial, the researchers proposed.

Schwartz M. Arch Intern Med 2011; 171: 744-749.

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