Editor’s note: This is the second article in a four-part series discussing aspects of a state and national shortage of primary care physicians. Subsequent articles will discuss the impact on rural medicine and look at how a universal healthcare plan might affect the problem. The decline in the number of primary care physicians in Alabama, as medical school graduates choose sub-specialties over primary care, has reached such critical proportions that the U.S. Bureau of Health Professionals has designated 60 of Alabama’s 67 counties as “Health Professional Shortage Areas.” Several factors have led to the migration toward sub-specialties, including the reimbursement gap between primary care and specialty services, coupled with increasing medical school debt, along with a desire for a lifestyle that better balances work and family. The situation is intensified by the fact that many medical schools don’t offer effective family physician mentors and tend to direct their students more toward specialty medicine. “It all depends on the culture of the particular medical school,” said Dr. Michael Harrington, professor and chairman in the Department of Family and Community Medicine at UAB. “If a school focuses on research, its students are less likely to choose primary care medicine. It is a difficult issue because you don’t want to stop research, but because of that focus, students may move in that direction.” Harrington adds that professors can also influence student’s choice of specialty, as can the school’s curriculum. “If professors push specialties, that’s where the students tend to go. Students usually hear one of two things: ‘You’re too smart to be a primary care physician. You should specialize.’ Or, they hear, ‘You’re not smart enough to be a primary care physician. You have to know too much, so you need to concentrate in one area.’” Dr. Tracy Brookings, a pediatrician at Growing Up Pediatrics in Birmingham, says that as a student at UAB, she saw a push toward specialties. “There weren’t a lot of primary care role models,” Brookings said. “There was a definite push toward academics, and we got a sense that there was more prestige in a specialty than in primary care.” Brookings chose pediatrics because she enjoys the relationships that develop over the years when caring for infants and children. “It’s nice to watch children grow up, and I see a variety of things when treating babies all the way up to teenagers,” she said. While doing her pediatric residency, other residents would ask Brookings why she wanted to work so hard to make less money, which is a major reason students are avoiding primary care. According to the American College of Physicians, the average debt burden for medical students is between $120,000 and $160,000. The monthly payment on a debt of $150,000 at the end of residency at 2.8 percent interest is $1,761, according to the Association of American Medical Colleges. These costs lead many to choose higher-paying specialties. “If you look at the income potential of different specialties, primary care medicine is at the bottom,” Harrington said. “A family practice physician generally makes $150,000 to $200,000 a year, compared to a dermatologist who can make $400,000 a year, work less hours and require little additional training.” Dr. Matthew Parker recently completed a family practice residency, but financial issues forced him to leave his primary care practice to become clinical director for occupational and environmental medicine at St. Vincent’s Hospital. “I never envisioned myself in occupational medicine,” Parker said. “I have always wanted to be a family doctor. Because of financial issues, though, I had to make the decision to take care of my family.” Parker left medical school owing about $200,000 in loans, which continued to accrue interest during his residency. “I lost my dream of being a family doctor in a small community, but I’m not crying about it. You just do what you have to do,” he said. Parker’s favorite thing to do is deliver babies, but insurance payment issues made that difficult to do. “Yeah, I still wish I could be a Doc Hollywood, but right now that’s just not realistic.” Dr. Jared Cox, a fourth-year resident in urology at UAB, says that he briefly considered family medicine when he finished medical school at Louisiana State University, but in the end, he decided to specialize. “It really wasn’t because of finances or lifestyle,” Cox said. “I just like procedures better than anything else. I like to find the problem and fix it. In family practice, you treat chronic problems like diabetes and high blood pressure, and that’s just not for me.” Cox says that his medical school encouraged primary care and helped pay off medical school debt for those who chose family medicine. He says that the University of Alabama School of Medicine is currently pushing for family practice residents at the school’s satellite campuses in Tuscaloosa and Huntsville. “They are not as exposed to the sub-specialties on those campuses,” Cox said. “At UAB, 80 percent of the internal medicine residents go into sub-specialties.” The issue of work-life balance has become an important one to new physicians, and many hospitals and medical practices are trying to attract doctors by using “hospitalists” — physicians who help relieve the physician shortage by doing shift work. These physicians work only in hospitals. They don’t have outside practices. The use of hospitalists frees up time for physicians, which helps make them more efficient in their clinics. The physician hospitalists also benefit from a set schedule. To further address the factors contributing to the decline of primary care physicians, the American Academy of Family Physicians (AAFP) has made recommendations for steps to help reverse the decline. Those recommendations include: • All medical schools should continually assess their enrollment numbers to address ongoing concerns about a physician shortage. • Federal funding for graduate medical education should reflect physician workforce policy with preferential funding for training primary care physicians, and less funding for the training of other physicians. • Develop policy regarding workforce balance, monitoring of physician specialty need, and physician reimbursement changes, which would make generalist physician practice more attractive. Dr. Amy McGaha, assistant division director of medical education for the AAFP, says that these recommendations were made because a strong family medicine workforce is dependent on recruitment of students to the specialty, comprehensive training of family medicine residents and support of practicing family doctors who provide the kind of care our nation needs. “The challenge for the future is to clearly communicate with policymakers, educators, medical students and the public on the importance of a well-trained, adequately equipped and equitably distributed family physician workforce for America,” McGaha said. July 2008