Rekindling Student Interest in Generalist Careers

Rekindle: from Old Norse, kynda, to start (a fire) burning; to stir up, arouse, to cause to glow, or illuminate; and from Middle English, to bring forth young (1). Despite changes to the structure of the U.S. health care system in the past 30 years, most Americans continue to seek regular health care from primary care physicians (2). In our increasingly complex, fragmented, and consumerist health care system, patients still desire a continuous healing relationship with my doctor, who provides accessible, competent, comprehensive, whole-person care (3). Leading health economists argue that the supply of generalist physicians is not keeping up with demand, as driven by growth of the population and per capita gross domestic product (4). A deficit of 200000 generalist physicians is projected to occur by 2020 (5). Although experts may quibble about the numbers, most would agree that with fewer than 40% of current graduates from U.S. medical schools expected to enter generalist practice, the projected physician workforce will be out of balance (6). We must act now to rekindle student and resident interest in generalist careers or face a shortage of primary care physicians who are trained to care for the complex medical needs of an aging population. It will require a broad view and coordinated effort to ensure that an adequate number of potential generalists emerges from the education pipeline. Selection of Generalist Careers by Medical Students In a classic study of influences on the career choices of Harvard medical students from the 1940s through the 1970s, Funkenstein concluded that economic incentives and the prevalent ideology are more compelling for most students than are their personal characteristics and original career plans (7). In the post-war golden age of medicine (1945 to 1980), medical expenditures grew faster than the number of physicians, exerting market forces on career options (8, 9). By the late 1980s, generalist residency programs experienced a 30% decrease in applicants, and for the first time, a majority of programs did not fill their positions (6). Students were turned off by what they saw as overworked and dissatisfied generalist physicians and residents, and 40% of internists discouraged students from considering careers in internal medicine (10, 11). In 1985, Schroeder proposed that we promote generalism by 5 mechanisms: 1) narrowing the reimbursement gap between generalists and subspecialists; 2) selecting medical students with broader biosocial interests and backgrounds, who are more likely to choose primary care careers; 3) increasing the number of generalist faculty role models; 4) shifting the focus of education away from National Board Medical Examination knowledge toward clinical process and skills; and 5) regulating residency positions by specialty boards to redress the ratio of generalists to subspecialists (12). Although these recommendations were only partially heeded, internal medicine, pediatrics, and family medicine experienced a resurgence in popularity among medical school graduates in the early 1990s. The growth of health maintenance organizations and the institution of the resource-based relative value scale in Medicare reimbursement increased need and opportunities for primary care (13). Policy leaders set a goal that 50% of medical school graduates would choose to enter primary care careers; this target was attained by 1998 (14, 15). The primary care bubble burst in the late 1990s as the economy entered a recession and reimbursement for cognitive services provided by generalists did not keep pace with increases in procedurally oriented disciplines (16). Patients and physicians alike rebelled against the gatekeeper model of the health maintenance organization (17). The number of senior medical students in the United States who matched into generalist residency positions has been decreasing since the late 1990s (Figure 1) (6). Since the peak in 1998, the proportion of all U.S. graduates who choose residencies in primary care has decreased from 50% to 40% (Figure 2). In the 2004 match, the proportions of positions filled by U.S. graduates were 71% for pediatrics, 55% for internal medicine, and 41% for family practice. The declining interest has been greatest for family medicine, which has seen a 41% relative reduction in the number of positions filled by U.S. graduates. The corresponding reductions for internal medicine and pediatrics have been 9% and 8%, respectively. Because these data include students who go on to subspecialize in internal medicine and pediatrics, the number of students who eventually practice primary care will be even fewer. Moreover, the number of students who choose residencies in primary care internal medicine decreased by 46%, and 24% fewer students chose programs in primary care pediatrics. Figure 1. Number of U.S. medical school graduates who matched in primary care specialties, 1999 to 2004. Figure 2. Proportion of all graduating medical students in the United States who matched to generalist residency programs, 1991 to 2004. Twenty years later, few of Schroeder's recommendations have been implemented, and Funkenstein may still be right. Unless we can substantially reshape market forces, the practice environment, and reimbursement, we will be fighting an uphill battle for the hearts and minds of our students and residents (18). We present recommendations, some familiar and others newer (and perhaps bolder), to address this critically important dilemma (Table). Table. Strategies To Increase Choice of Generalist Careers Recommendations 1. Improve Satisfaction and Enthusiasm among Generalist Physicians Who Are Role Models In a national survey of 460 students and residents, having a positive role model was a strong predictor of choice of a generalist career among senior students (odds ratio, 6.5 [95% CI, 4.2 to 10.2]) (19). However, students and residents are likely to encounter generalist physicians who are poor role models because they are unhappy and stressed, are under tremendous time pressure, feel burned out, and are considering leaving their practices (20). The Community Tracking Study of more than 12000 U.S. physicians from 1996 to 2001 found that the strongest predictors of dissatisfaction were threats to clinical autonomy, increasing time pressure, and the challenge of maintaining high-quality care (21). Dissatisfaction among practicing generalists trickles down through housestaff to medical students. In a national survey, student perceptions of resident and attending satisfaction was a strong predictor of generalist career choice (odds ratio, 3.9 [95% CI, 2.7 to 5.6]) (10). Most students interact with resident and attending physician role models before choosing a career path, and in a systematic review, generalist role models were linked to choice of a career in primary care (22, 23). Peer support for primary care from residents was also a strong predictor (odds ratio, 5.7 [95% CI, 1.6 to 20.1]) (19). Unless generalist physicians and residents convey joy in and commitment to their careers, it will remain difficult to recruit students to generalist specialties. We suggest some strategies to improve satisfaction and enthusiasm among current practicing generalists. First, narrow the reimbursement gap between cognitive and procedural services. From 1998 to 2000, inflation-adjusted income increased 9% for medical subspecialists and radiologists but decreased 2.1% for generalist physicians (24). Although physicians tend to underplay the importance of money in their career choice, the Community Tracking Study noted a doseresponse relationship between annual income and job satisfaction (25). In addition, medical students have increasingly chosen specialties with higher income potential from 1996 to 2002 (26). The resource-based relative value system of Medicare reimbursement, which is to be updated in 2006, should create financial incentives for what primary care physicians do well. Working together, leaders from the 3 primary care disciplines could develop a schedule of care management fees that would pay generalists for the currently nonreimbursable care, such as e-mails, telephone calls, and case management, that they provide as part of managing patients with chronic diseases (27, 28). Some Medicaid programs already pay a case management fee, which provides incentive to improve quality and efficiency of ongoing care (29). Generalists must study budget-neutral models for case-based reimbursement that will promote improved care for patients who require complex care for chronic disease (30, 31). Second, decrease clinical time pressure with more flexible and controllable schedules. A preference for a controllable lifestyle was the strongest predictor of career choice, accounting for 55% of the variability in specialty choices of graduating medical students in the United States. Generalist specialties were perceived as noncontrollable (26). From 1989 to 1998, the average duration of a visit to a physician's office in the United States increased from 18.4 to 19.9 minutes (32). Nevertheless, most generalist physicians still felt they needed more time per visit to provide quality care. In 1997, physicians said they needed an average of 23% more time than they were allotted for a visit with a new patient (20). Physicians who reported that they needed more time than allotted for patient visits scored lower on 7 of 10 domains of job satisfaction. Innovations are needed to help physicians work smarter, not just faster. The bewildering array of new expectations and demands by patients, insurers, and regulators causes physicians to rush through visits to provide recommended care. When the associated paperwork is added in, is there still time for healing on our lengthening to-do lists? Research into medical errors in ambulatory care is beginning to link time pressure and physician stress with lower quality in managing chronic diseases (33). Physicians may f