Declining interest in primary care careers.

The residency training programs in primary care internal medicine, family medicine, and medicine-pediatrics have matched fewer residents in recent years,1 and preliminary impressions this year suggest that interest in primary care residency training continues to wane. The study by Connelly et al. in this issue is thus timely and sheds additional light on the predictors of primary care career choice for medical trainees (students and house officers).2 The authors highlight the correlation between trainees who have identified primary care role models and those who claim to be leaning toward primary care careers. However, the association between learners who have found specialty role models and those who declare that they will be selecting careers in specialty fields appears to be even more impressive. These observations raise the question: which role models are most influential? This query is important because in the real world of medical training (as opposed to this study, in which trainees were instructed to choose a single role model), medical trainees are often lucky enough to be exposed to role models from a variety of departments and specialties.3 On a similar note, Connelly's data suggest that encouragement toward specialty careers in medicine seems to be even more powerful than encouragement by peers and superiors toward careers in primary care.2 The authors of this study took an “appreciative inquiry” approach and looked primarily at the influence of positive role models and encouragement. The variables that they explored may tell only part of the story, because it is likely that negative factors also have considerable impact.4,5 We can only guess about the relative influence of negative primary care role models or discouragement from others about careers in primary care. Other factors that may dissuade medical trainees from choosing primary care careers could include perceptions about lifestyle, income, and the prestige or respect of the field within the medical community. Income potential may be particularly relevant to those with a high level of indebtedness at the time of medical school graduation. As educators and mentors, we are genuinely committed to the well-being of trainees and we are invested in helping them to make informed decisions about career choice. This duty to serve the learners' best interests takes precedence, even in a time of crisis, for residency training fields such as primary care internal medicine. None of us would propose “stacking the deck” by exposing medical trainees to only the most professional and humanistic primary care physician role models while sequestering or sheltering them from fine specialist role models. We are obliged to help learners discover their own career path, not choose one for them. Because providing a spectrum of role models across the various fields of medicine should help learners with decisions related to career path, this should be a high priority for our medical institutions. A serious problem is that the deck is, in fact, stacked against the primary care fields. Despite changes that have occurred in the past decade to increase the amount of training that occurs in ambulatory settings, the majority of medical education still occurs in the hospitals, where primary care physicians generally spend much less time than specialists. We recognized last autumn that in our hospital's internal medicine residency training program, interns had over a thousand hours of inpatient exposure and less than one hundred hours in outpatient settings. Furthermore, in some programs, residents' time in clinic is wedged into a ward month wherever it can fit, and clinic time is often resented rather than appreciated. The playing field and the opportunity to influence medical trainees toward primary care fields is far from level. The results of the study by Connelly et al. may be helpful for gaining additional insight and understanding about who among the learners are most likely to be attracted toward primary care careers.2 Knowing this may allow us to focus our efforts and resources on interested candidates. Because role modeling was found to be the strongest predictor of career choice, now may be the time to think creatively about ways to ensure that medical trainees are seeing and forming relationships with primary care role models. One such idea might be to strongly encourage all medical trainees (medical students and house officers) to see annually, as patients, a primary care physician. Of course, a list of outstanding primary care physician role models would comprise the slate of physicians from which trainees could choose. In addition to the potential for better health (including mental health) outcomes for our overworked trainees during busy years filled with stress, this would provide them with a unique exposure to the world of primary care. A second initiative would be to institute faculty development programs designed specifically to enhance primary care physicians' aptitudes and prowess as role models. This could have a positive effect, because it is known that many of the attributes associated with excellence in role modeling represent behaviors that can be modified and skills that can be acquired.6 Until it becomes clearer which interventions are most effective in increasing the primary care workforce, institutions and leaders in medicine should promote the primary care fields and draw attention to primary care role models whenever and wherever possible.