AAMC Reporter: October 2004

Viewpoint: "Burden of Debt Creates Scarcity of General Practitioners"

Joseph Silva, Jr., Dean, University of California, Davis, School of Medicine

In this time of rising tuition for medical education, there is a danger that graduating doctors will choose more lucrative subspecialties over general medicine so that they can pay off their debt sooner.

If fewer doctors train in the primary care services, our country is in trouble, especially as the baby boomers age. Who will take care of us?

Nearly 10 years ago, the Institute of Medicine (IOM) concluded that family physicians, general internists and general pediatricians play an unequivocally vital role in healthcare in the United States. These general practitioners — already outnumbered by specialists — handle the majority of patient visits to doctors’ offices.

Since the publication of the IOM study, things have gone from bad to worse, despite increased national efforts and educational reforms to encourage new doctors to enter primary care. Growth in the number of primary care physicians per capita trailed far behind that of specialists from 1980 to 1999.

Residency programs feel the shortage acutely. In 2004, only 1,185 U.S. medical school seniors entered first-year family medicine residencies out of 14,609 applicants, compared with 2,340 in 1997.

Without enough primary care physicians, access to medical care suffers. When patients visit their cardiologists for influenza, our healthcare dollars are stretched unnecessarily thin. And when specialists are called upon to treat patients outside of their training and experience, the quality of medical care declines as well.

Evidence of this trend is readily apparent. A recent study in the Journal of the American Board of Family Practice reported that in Colorado, specialists spent, on average, about one-quarter of their time in direct patient care providing primary care services. The authors estimated that specialists provided one-third of the primary care services in the state.

I am not optimistic that trends will improve without intervention. Since 1984 the cost of medical education has skyrocketed 312 percent, far beyond increases in the consumer price index. Medical education debt after graduation from public schools soared from a median of $22,000 to $100,000 in the same period, according to a recent AAMC report on tuition and physician debt.

It’s no secret that primary care physicians, despite having demanding careers, are remunerated significantly lower than their colleagues in the subspecialties. After expenses and before taxes the net income in 2000 for family physicians, general pediatricians and general internists was around $150,000 while gastroenterologists, cardiologists and orthopedic surgeons averaged about double that amount.

So far, no evidence has been found that medical students choose their specialty because of debt. Recent data show that students who enter pediatrics are more likely to report educational debt and have greater debt than students entering radiology, for example. But as debt continues to grow, can we count on this trend continuing?

Concern about debt has already reared its head. The AAMC surveyed qualified students about why they did not apply to medical school. The cost of medical school and subsequent debt was the reason cited most often by minority students. This is a major concern as we try to achieve a diverse physician base in all fields of medicine.

If we want to achieve effective, sustainable healthcare for all Americans, we must actively encourage medical students at the federal and state levels to enter primary care.

Over the past five years Congress has cut the number of residents that teaching hospitals can train and decreased funding for graduate medical education. This, coupled with new threats to direct and indirect graduate medical education payments, continues to challenge teaching hospitals’ ability to train physicians.

Since 1978, Title VII of the Public Health Service Act has provided grants for departments of family medicine intended to increase the number of family and primary care physicians and the number of practices in rural and underserved communities. Recent studies have shown that funding is strongly related to attaining these objectives. Despite proven success, Title VII funding is constantly in danger of being reduced or even eliminated.

The National Health Service Corps is another positive program that could use more support. It provides scholarships and a stipend or partial debt forgiveness for students willing to practice in areas deemed medically underserved. In 2003, it expended $31.4 million in loan repayments to 320 physicians as well as scholarship awards for 70 others. The program is unable to accommodate all of its applicants.

Let’s build on these proven programs and encourage other innovative approaches. Our nation cannot afford to make primary care physicians an endangered species.

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