Fewer med students are choosing primary-care profession, instead going for higher pay

Only 2 percent of graduating medical students say they plan to work in primary-care internal medicine, raising worries about a looming shortage of the first-stop doctors who used to be the backbone of the American medical system.

The results of a new survey published Wednesday suggest that more medical students, many of them saddled with debt, are choosing more lucrative specialties.

Just 2 percent of nearly 1,200 fourth-year students surveyed planned to work in primary-care internal medicine, according to results published in the Journal of the American Medical Association. In a similar survey in 1990, the figure was 9 percent.

Paperwork, the demands of the chronically sick and the need to bring work home are among the factors pushing young doctors away from careers in primary care, the survey found.

"I didn't want to fight the insurance companies," said Dr. Jason Shipman, 36, a radiology resident at Vanderbilt University Medical Center in Nashville, Tenn., who is carrying $150,000 in student debt.

Primary-care doctors he met as a student had to "speed to see enough patients to make a reasonable living," Shipman said.

At Wake Forest University School of Medicine, the general trend has been fewer students going into family medicine every year, said Dr. Brenda Latham-Sandler, the assistant dean for students and a family doctor.Last year was an exception.

In 2008, 15 percent of the medical school's graduates indicated that they plan to work in internal medicine, according to the statistics from the Association of American Medical Colleges, or AAMC. In 2007, 8 percent of the medical school's graduates went into internal medicine.

Those numbers may change if graduates who are enrolled in internal-medicine residencies decide to pursue careers as kidney, heart, lung or gastrointestinal specialists, Latham-Sandler said.

"We just don't have that information," she said yesterday. "If I had to guess, that number would be low."

Dr. Karen Hauer of the University of California, San Francisco, the study's lead author, said that it's hard work taking care of the chronically ill, the elderly and people with complex diseases -- "especially when you're doing it with time pressures and inadequate resources."

The salary gap may be another reason. More pay in a particular specialty tends to mean that more U.S. medical-school graduates fill residencies in those fields at teaching hospitals, Dr. Mark Ebell of the University of Georgia found in a separate study.

Family medicine had the lowest average salary last year, $186,000, and the lowest share of residency slots filled by U.S. students, 42 percent. Orthopedic surgery paid $436,000, and 94 percent of residency slots were filled by U.S students.

At the same time, medical school is getting more expensive. The average graduate last year had $140,000 in student debt, up nearly 8 percent from the previous year, according to AAMC.

Another likely factor: Medicare's fee schedule pays less for office visits than for simple procedures, according to the American College of Physicians, which reported in 2006 that the nation's primary-care system is "at grave risk of collapse."

Lower salaries in primary care did not deter Dr. Alexis Dunne of Chicago, who is 31 and carrying $250,000 in student debt.

Last year, a parade of specialists couldn't solve the mystery of her mother's weight loss, fevers and severe anemia. Finally, an internist diagnosed a rare kidney infection. The kidney was removed, and Dunne's mother has felt fine since.

Watching her mother go through the health crisis affirmed her decision to go into primary care. She also enjoys being "the point person" for her patients.

"You become so close to them you're almost like a family friend," said Dunne, who completed her residency at Chicago's Northwestern Memorial Hospital in July.

She also found inspiration from the doctors she met during training.

"They were the ones who would sit at a patient's bedside and spend more time with them rather than running off to surgery," she said.

A separate study in JAMA suggests that graduates from international medical schools are filling the primary-care gap.

About 2,600 fewer U.S. doctors were training in primary-care specialties --including pediatrics, family medicine and internal medicine -- in 2007 compared with 2002. In the same span, the number of foreign graduates pursuing those careers rose by nearly 3,300.

"Primary care is holding steady but only because of international medical-school graduates," said Edward Salsberg of AAMC, a co-author of the study. "And holding steady in numbers is probably not sufficient when the population is growing and aging."

And as American students lose interest, teaching hospitals will probably become less interested in offering primary-care programs, said Dr. David Goodman of Dartmouth Medical School.

In a JAMA editorial, Goodman called on Congress to create a permanent regulatory commission to encourage training for needed specialties.

■ Journal reporter John Hinton contributed to this report.