nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Tuesday, April 26, 2011

STUDY: Medical Student Interest In Primary Care Continues To Plummet

For some physicians it may be about the money.  For me it was about the job.

First, here's the data from the research that appeared in the Archives of Internal Medicine (Vol. 171 No. 8, April 25, 2011).

This was a review of two previous national surveys of over 2000 students between 1990-2007.  They focused on students who were planning to go into internal medicine.  The study looked at the number who were interested in "general" internal medicine (that is, including primary care) and those who were not.  The number who wanted to include primary care fell from 9% to 2%.  They also asked whether primary care was a reason they chose internal medicine:  the number who said "yes" fell from 57% to 33%.

So, over this period, students were running away from primary care.  Note that Obamacare's success is tied to access for the newly insured by encouraging primary care careers.  There aren't enough PC practitioners now, much less after we add 32 million people to the rolls.

And as I've written before, providing financial incentives for medical students to enter primary care has been tried before, and failed.  More about that below.

For Onion Peelers,
The total sample of 2421 students comprised 1244 at 16 schools in 1990 (response rate, 75%) and 1177 at 11 schools in 2007 (82%). ...Similar proportions of students planned IM careers (23% vs 24%), although plans to practice general IM dropped from 9% to 2% (P < .001). The appeal of primary care as an influence toward IM declined from 57% to 33% (P < .001).

This is not a bad study.  Response rates are high enough to preclude a situation where only students with certain plans would answer the survey.

OK, back to why medical students are trending away from what we so desperately need.  Most people who write about this are health policy mavens or economists.  They see financial incentives.  It's true that a gastroenterologist gets reimbursed handsomely for doing a colonoscopy, while a PC doc gets little, even if the treatment she provides is critical.

Here's the rub.  I haven't heard any of my classmates or colleagues over the years express those financial incentives as being an influence in choice of specialty.

What I have heard--and felt myself--is that the job of primary care is unrewarding.  I went into medicine to help people, but if I just wanted to do that there are a lot of other careers that fit that motive.  What I "needed" in a career was something that was very mentally challenging;  requiring mental focus, complex data analysis, rigorous thought processes, a mountain of knowledge retained, and frequent engagement of my best judgment for subtle differences in diagnosis and therapy.  That's the juice.

By contrast, primary care involves screening for rare abnormalities, from among common presentations of common things that (by most estimates) would have cured themselves about 2/3's of the time.

So, you see 10,000 cases of sore throat.  And over the years, among those patients I've seen a couple of retro-pharyngeal abscesses, a case of cancer, and several that were caused by an STD.  But this leaves about 9, 900 that were garden variety sore throats.

In a word, it's boring.

90% of the primary care job is a handful of illnesses, prominently respiratory illness, back pain, headache, and arthritis.  The substantive illnesses have been sucked up by the specialists.  What kind of professional challenge can this provide?  And don't tell me every patient is different; of course they are, and you consider that.  But most sore throats are just...sore throats.  And don't tell me that every now and then something rare shows up in one of these common cases;  of course it does, but it doesn't take much to keep that in mind and not overlook it.  And I did my duty, not shirking just because there wasn't the excitement of diagnosis and treatment:  the patients got good care.

Maybe some doctors see their training as something painful they had to go through to return to normal everyday life.   I loved it for how hard it was, and looked forward to new and different challenges throughout my subsequent career.  I finally found that, but it wasn't in primary care.

I didn't make that much, and after 10 years I'm still paying off college debt from our children.  The money was never that important.

If you offered me twice the income to move to a small town and be their family doctor, I wouldn't take it.  And almost none of my classmates--who did accept the deal--stayed with it.

Good luck, Obamacare.

Doc D

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