The pipeline to primary care is drying up

Last week, a study published in Science posited that there is no ceiling in sight for the  human lifespan. I am not sure whether to be thrilled or frightened. But I do wonder if I am going to have a primary care provider (PCP) helping me navigate this uncharted territory ten years from now, let alone when I am really old.

Another medical school class walked across the graduation stage recently, and though at my institution a quarter of the class entered a primary care field at the end of their residencies, most in internal medicine and about half of those going into pediatrics, will subspecialize or go into hospital Medicine.

{mosads}A PCP is a health-care provider trained as a generalist, one who provides not just preventative care (as most envision), but who serve as coordinators of care for patients with multiple chronic conditions who see many specialists. Why is this important you ask? Consider the saying, “if you go to Midas, you will get a muffler.”

This is not to criticize my specialist colleagues, as I myself was an infectious diseases specialist for 10 years before returning to primary care. It is easier to overlook issues in another area of the body while focusing on the organ system of your own specialty.

With the current trend of medical students choosing not to go into primary care, this shortage is a very real issue, and I agree that debt repayment is a simplistic explanation for this trend.

When I query my students who expressed an interest in primary care on entry into medical school why they decided not to choose it as a career path upon graduation, most say that they found on closer look that the job appeared tedious and that primary care physicians seemed less happy or satisfied with their jobs than physicians in other fields.

As a practicing primary care internist for the past two decades, I can honestly say that my job is never dull. Two days in clinic are never alike, and the relationships I have developed with my patients make my days feel fruitful and sustaining.

Are there tough days? Yes. But even filling out forms and arguing with insurance companies to get a procedure or drug covered for a patient can feel worthy and in some ways triumphant. I am not alone, most internists agree with these sentiments. Why then are we not reflecting this to our students?

Job satisfaction, whether in health care or any other industry is not so much about compensation, but about autonomy and respect. Medicine, once thought to be a “calling” rather than a profession, has in many ways become just that — a job.

For PCPs at the bottom of the compensation list, resurrecting and sustaining the notion of medicine as a calling is necessary. More than simply increasing monetary compensation, the health-care system, our specialist colleagues and patients need to show by their words and actions that primary care is a valued service.

In society today where being “special” is a desired notion, being a generalist is equated with the inability to become a specialist rather than a distinctive career choice. Students tell me that they are dissuaded from going into primary care by mentors who tell them that they are, “too smart to go into primary care” and should think about becoming a surgeon, radiologist or another specialist instead. This advice from mentors is often well meaning and meant to be a compliment. But it could also be a result of an implicit bias that equates compensation with competence since most primary care fields are at the bottom of the pay scale ladder.

In my experience, patients prefer and value their PCPs over seeing specialists both in the outpatient and inpatient setting. However, lackluster recruitment of the best and brightest and lack of strong primary care training during residency can result in poor practice patterns and frequent and unnecessary referrals to specialists. As a result patients begin to see their PCP as a gatekeeper rather than a quarterback and view the specialist as the expert.

Many studies have shown that both the quality and cost of health care improves when patients receive high quality primary care. It would therefore seem like an easy case to be made and easy to recruit interested students to our field. Instead the pipeline to primary care is drying up.

Fair compensation and working conditions from the health-care system, excellent training in strong primary care residency programs, and nurturing and encouraging our best students in medical school to go into primary care, will all go a long way toward ensuring a healthy primary care pipeline.

And finally, since patients are our focus, we need to clearly communicate to them the role, scope of practice and value that a PCP can bring to their experience of healthcare – especially as they age.  

All of us will need a well trained PCP in our corner.

Roshini Pinto-Powell MD, FACP is an associate professor of medicine and of medical Education at Dartmouth College. She is a public voices fellow with the Op-Ed Project.