Primary Care Is a Key Issue For Healthcare Reform

The good news about this year’s residency “match,” which places medical students into residency training programs, is that 400 more U.S. medical school seniors applied for these positions in 2009 than in 2008. That, plus the continuing increase in applications from international medical graduates, promises a growing supply of new physicians to serve our rising population.

The bad news is that young physicians are still shunning primary care. The number of family practice residency positions dropped slightly this year, and only 91 percent of them were filled. Of those, 42 percent were filled by U.S. medical school seniors, down from nearly 44 percent in 2008. The situation was better in pediatrics, where 97 percent of the positions were filled, 70 percent of them by U.S. students. In internal medicine, nearly all slots were taken, 54 percent of them by Americans. But the American College of Physicians has found that about 75 percent of internal-medicine residency graduates go into subspecialties, rather than into general internal medicine.

When Jacob Goldstein drew attention to this perennial issue in the Wall Street Journal Health Blog, many physicians responded. One of them, Bohdan A. Oryshkevich, blamed students’ lack of interest in primary care on the heavy indebtedness they carry when they enter practice. If primary care is the key to reform, he reasoned, we can’t have real reform without changing how we pay for medical training:

“Since medical students are the ones in control of health care reform, health policy makers better begin addressing college students who plan to enter medical school. The monetarization of medicine begins in college with the exorbitant fees charged for medical school applications. That is where the medical economics of America begins. That is where the battle for hearts and minds begins.”

Oryshkevich urged policymakers to adopt public financing of medical education, which is the norm in some European countries, such as Denmark and France.

A specialist wrote that “the key to obtaining the best care for patients in my community rests on the shoulders of the primary care physicians.” He blamed managed-care companies and hospitals for the decline of primary care, saying that limited insurance networks and restrictions on hospital privileges were making it difficult for some PCPs to stay in business. Also, he charged, “these same goliath forces” were trying to replace primary-care doctors with nurse practitioners, physician assistants, and other midlevel practitioners.

Other physicians discussed the usual problems: Many primary-care services are not reimbursed by health plans; Medicaid pays a fraction of the cost of delivering care; and evaluation and management services that are PCPs’ stock in trade are poorly reimbursed, compared with procedures. It’s unclear how much medical students know about these business realities. More likely, they just know that most specialists earn more and have better hours than PCPs do.

What is clear, however, is that until our system is redesigned so that students want to go into primary care, we will not be able to control runaway costs or guarantee access to everyone. Put that in your pipe and smoke it, Congress!