By Anna Goldman
“Why don’t you aim higher? You’re too smart for that.”
It’s a familiar reaction when medical students tell their teachers they are considering a career in primary care. On the first day of my third year of medical school, the palliative care physician I was assigned to work with wrinkled her nose when I told her I wanted to go into primary care. “You should think long and hard before you choose to do that,” she warned, “If you want a decent life, don’t do it.”
I used to know with certainty that I wanted to be a primary care doctor. Before beginning medical school at Mount Sinai School of Medicine, I did a Masters in Public Affairs and learned about the importance of primary care both for patients and for the ailing health care system. It seemed simple: I could help meet society’s need for more primary care physicians while engaging in personally fulfilling work. I imagined my future practice as a wholesome alternative to pressured, “get-‘em-in, get-‘em-out” primary care practices —money-making be damned. I would linger and listen.
I assumed that money, or the lack of it, was the main reason why primary care had become such an unpopular specialty choice. Time pressure during office visits was also a problem. But, these challenges appeared relatively minor given the positive impact I could have as a primary care doctor. When I began my training, however, I learned that the medical school environment, in many ways, can discourage aspirations toward primary care.
Early on, I noticed that conversations surrounding specialty choice did not reflect the concern in the outside world over the shortage of primary care physicians. The questions commonly posed by doctors speaking in an advisory capacity to students start with: “What do you find most fascinating?”; “Do you enjoy working with your hands? Doing procedures?” And then the perennial questions about lifestyle: “How hard do you want to work? How much money do you want to make?” “What time do you want to go home?”
With primary care come a lower salary and hectic working conditions. But medical students considering primary care also face another type of deterrent: less respect from many colleagues who regard primary care as less rigorous and intellectually intense than the medical specialties. Primary care’s power to improve patient outcomes and its critical role in health care reform has so far not been enough to boost the field’s prestige and counterbalance negative perceptions that persist among physicians.
How can we improve things? We can start by including in medical school curricula a substantive education on health policy and the problems faced by our national health care system. Specialty choice must be contextualized for students so that they understand the ramifications of their career decisions for the system as a whole. Currently, key issues are absent from the dialogue. For example, by becoming a specialist, you undoubtedly “help people” in the sense of helping a patient who is right in front of you. But, you do not necessarily help the community. When a region is oversaturated with doctors practicing the same specialty, it can lead, according to several studies, to unnecessary procedures being performed (a case of supply creating demand) and further drives up health care costs without improving outcomes for patients. Greater awareness of issues like these can help realign values of both medical students and teachers to match the interests of society.
On a national level, we can restructure our reimbursement system to channel resources toward primary care and away from specialty medicine. Not only will this result in better patient care and more efficient use of health care dollars, it will also ease time and financial pressure on primary care physicians, making the job more attractive to medical students. In addition, we can strengthen programs that invest in medical students who pursue primary care, such as the National Health Service Corps.
I have applied to residency programs in both internal medicine and family medicine, and I will find out where I’ll end up on March 16, “Match Day”. Despite my concerns, I still plan to pursue primary care. .
Primary care must be prioritized and genuinely valued in academic medical training. It’s the only way that more medical students will aspire to enter this crucial field.
Anna Goldman is a medical student at Mount Sinai School of Medicine in New York.