As told by Steven L. Berk, M.D.
Only 25 percent of internal medicine graduates will stay in primary care, down from 54 percent a decade ago.
The U.S. is facing a serious shortage of physicians, which will become most apparent by 2020. Medical student enrollment per 100,000 populations has been declining. The population is aging and doctor visits for those over age 65 are sharply increasing. The physician workforce is also aging and the career goals of graduating physicians may be focused on working fewer hours.
The American Association of Medical Colleges (AAMC) has recognized this potential workforce crisis, and has committed to the development of strategies that will increase the number of graduating medical students by 15 to 30 percent. However, this crisis will not be averted unless the increasing imbalance of generalists to specialists is also addressed.
Facing Dire Consequences
Studies conducted by many organizations such as the Accreditation Council on Graduate Medical Education (ACGME), the AAMC, the Robert Wood Johnson Foundation and Pew Commission have established the importance of having at least 50 percent of all physicians in primary care. Unfortunately, the percentage of physicians in primary care is dropping. The consequences of this deficit in primary care physicians are also well established: inefficient and costly care, more heart disease secondary to lack of preventive measures, detection of some cancers at a later stage and an increase in infectious disease that could have been prevented by vaccination.
Medical schools establish curricula, create the teaching environment, choose students, hire faculty and in a subtle way, define what disciplines are most prestigious. When the medical school experience ends and the dust clears, only about 10 percent of students go into family medicine. Most students who choose internal medicine or pediatrics are destined for specialty careers. Only 25 percent of internal medicine graduates will stay in primary care, down from 54 percent a decade ago.
For graduates of family medicine, on the other hand, statistics from the American Academy of Family Physicians indicates that more than 90 percent make careers in primary care and almost 40 percent do so in communities of fewer than 25,000 people or in low- income areas. There are several explanations for the loss of interest in primary care. Student debt is a source of discouragement for some students contemplating a primary care field. In addition, anecdotal data suggests that medical school culture dissuades students from family medicine and into more technologically-oriented disciplines.
Reviving a Discipline
The time is right for medical schools to take responsibility for the demise of primary care and look for innovative approaches to rejuvenate these disciplines. Efforts like the selection of students (perhaps from small towns and urban areas) who are likely to become primary care physicians, developing continuity clinics for all third year students and selective scholarships are all being used with varying levels of success.
In the late 1980s and early 1990s, an extraordinarily successful pilot program enabled students to do both their fourth years of medical school and first years of primary care residency at the same time. Twelve participating schools reported the success of the program, but the pilot was not continued by the ACGME and strong efforts to reestablish the program in 2008 were unsuccessful.
The Family Medicine Accelerated Track (FMAT) at the School of Medicine was created out of this successful accelerated track experience and the need to promote primary care among our students.
Finishing on the Fly
FMAT consists of a modified three‐year curriculum that will lead to the M.D. degree followed by a standard three‐year family medicine residency program, ideally to be completed in one of the university's family medicine residency programs. The track is open to 14 students per year who are selected within the first year of medical school. FMAT students are encouraged to select family medicine residency positions at one of the TTUHSC campuses and there will be financial benefits for students who match with a TTUHSC program. However, FMAT students will enter the National Resident Matching Program and may select residency programs outside of TTUHSC.
The program creates a high level of enthusiasm among students and is considered prestigious. Student debt is decreased 50 percent, because of a first-year full scholarship, no fourth-year tuition and because students will have a resident salary one year earlier. While we cannot change the salary inequities that exist between specialty and primary care, we can make a difference in student debt and how it affects career choice.
The three-year curriculum for FMAT students requires modifications and enhancements to the current curriculum, so as to ensure that FMAT students obtain all required training using a timeline that permits them to fulfill all of the graduation requirements within three years. Graduation is in essence based on fulfilling competencies. Recently the Carnegie Foundation released a study recommending that three-year curricula should be an option for medical schools and a focus on learning outcomes and competencies must be the currency for advancement.
Our three-year program has been approved by the Liaison Committee on Medical Education (which has approved three year curricula for all students in some Canadian medical schools), and other schools have interest in similar programs. This summer, nine highly-motivated students with credentials that put them in the top half of their classes are working with basic scientists and role model family physicians in a course that will prepare them for a longitudinal family medicine clerkship in the second year. The eight-week period that opens up in the third year will be used for some of the fourth-year requirements such as a sub-internship and ICU. Many electives taken by fourth-year students such as orthopedics, ENT and emergency room will be elective options in the family medicine residency curriculum.
West Texas needs more family physicians and the School of Medicine is committed to meeting the needs of our community by making the training and practice of family medicine more attractive to students.