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The disparagement of primary care: AAFP president, researcher discuss PCP shortage

There is a prevailing culture among medical school faculty members that discourages students from entering primary care, particularly family medicine, and contributes to the ongoing shortage of generalists, according to data published in the Annals of Family Medicine.

Joanna Veazey Brooks, PhD, MBE, reviewed 52 primary care physician oral histories spanning 5 decades, and found that 63.5% of PCPs reported receiving discouraging comments from administration and faculty officials regarding family medicine. Those sentiments mirrored the comments Brooks heard in previous discussions with primary care residents.

Brooks interviewed 37 primary care residents in 2014 during her time as a Robert Wood Johnson Scholar in health policy research at Harvard University. During their conversations, it became apparent where primary care stood in the minds of many faculty members.

“These interviews covered a number of topics, but many — not all — of these residents reported being discouraged from choosing primary care in the various medical schools they attended, and receiving comments like, ‘You’re too smart to want to do primary care,’ or ‘That’d be a waste of your skills,’” Brooks, an assistant professor at the University of Kansas School of Medicine, told Healio Family Medicine, said. “Some organizational and educational environments are more supportive than others, and some residents reported having a number of strong primary care mentors, but the disparagement and hostility are still present.”

This type of negative view of family medicine leads to fewer students pursuing general medicine, which further discourages those interested in family medicine through peer influences. Such “cultural and structural” barriers and are a major part of why the field’s future appears so precarious, according to Brooks.

In 2015, a study published in Family Medicine found that of the 18,241 students who graduated from U.S. MD-granting medical schools between July 2013 and June 2014, 8.5% entered family medicine residency programs, representing just 46% of the 3,595 total family medicine residents. Of the remaining 54%, more than half were from international schools.

In addition, out of the 131 MD-granting medical schools in the United States, 69 schools produced 80% of graduates who entered into family medicine residencies. There were no family medicine departments or divisions in 11 schools, and only 26 graduates of these schools entered into family medicine residencies.

Last March, the American Academy of Family Physicians (AAFP) issued a statement warning that not enough students were choosing family medicine to fill the future need. Despite a slight upward trend in graduating medical students expressing an interest in entering family medicine, this year’s growth is the smallest since 2012, at a time when primary care physicians are increasingly being asked to do more.

“Since 2009, we have had a modest yearly increase in the number of medical school graduates who have gone into primary care, but it’s not enough,” AAFP President John Meigs, Jr., MD, FAAFP, told Healio Family Medicine. “We do have this slow growth, but probably a third of our medical school graduates ought to be going into primary care — and some would argue a half. In some of the other developed countries around the world, their workforce would be a half to [a] 2-1 [ratio of ] primary care to specialty care. However, here we have an upside-down pyramid in the United States.”

According to Meigs, the current shortage in family medicine physicians has its roots in the post-World War II period in the United States, when the ever increasing trend toward specialization began. The increasing complexity of medicine and expanding knowledge and procedures led to an academic response that leaned strongly toward creating more specialists of limited scope, Meigs said.

Despite some positive signs — more than 30% of all current medical students are AAFP members, according to Meigs — he added that the field is only netting 12% to 15% when it comes time for students to choose a residency.

“That needs to double,” Meigs said. “The U.S. health care system for way too many years deemphasized the comprehensive primary care and the value of the continuous comprehensive connected care, that actually provides better care and lower cost. That’s the crux of the problem.”

According to Meigs, one of the solutions to this problem, so far, has been the implementation of the Teaching Health Center Graduate Medical Education program. Created as a $230 million, 5-year initiative under the Affordable Care Act, its purpose is to increase the number of primary care residents and dentists training in community-based settings. This program was reauthorized by the Medicare and CHIP Reauthorization Act (MACRA) in 2015, providing $60 million annually  in 2016 and in 2017.

The limitation for this program is that Congress only renewed the funding for an additional 2 years, when the program takes students 3 years to complete, Meigs said.

“One of the best programs to recruit medical students in both primary care and in underserved areas are the teaching health center programs, which have been developing in the last few years,” Meigs said. “They need to fund those training programs in the regular system, so there is some stability and continuity ongoing, allowing the program to better recruit, and the students to feel better about taking those positions.”

Meigs added that MACRA’s focus on value-based service, and moving away from the current volume-based fee-for-service payment model, may also help begin to alleviate the large income gap between family medicine and the specialties.

However, both Meigs and Brooks stated that any solution to the lack of students entering family medicine will have to focus on changing a culture that undervalues and underappreciates the services provided by PCPs.

“At most medical schools, and in the United States more broadly, primary care specialties are typically seen as lower status than their specialty peers,” Brooks said. “It is difficult to disentangle all of the factors that determine status, however. Certainly, income is a factor, but I argue in my paper that in order for a policy to be most effective in addressing this trend, the policy needs to address not only economic inequality but also the longstanding cultural and structural obstacles to primary care.” – by Jason Laday