Expert opinion | I am a medical student. This is what’s driving many of us away from careers in primary care
Primary care providers are often buried in paperwork long after patients have gone home. And the practice is changing as patients face barriers such as inadequate insurance.
“Can I see a show of hands for students interested in primary care?” my third-year medical school class was asked during orientation last summer. Only a few hands went up, some hesitantly half-raised.
“OK … how about surgical subspecialties? Orthopedics? ENT (Ear Nose and Throat)?” A dozen more hands shoot up. “Anesthesia?” About a quarter of the room responded without hesitation.
My classmates and I are medical students at Cooper Medical School of Rowan University in Camden, an urban community where many of our patients face barriers to accessing healthcare. Their challenges have taught me how essential primary care is for managing chronic illness, preventing complications, and keeping communities healthy.
Why then are students at my school and other medical schools nationally losing interest in specializing in primary care?
The reasons are not hard to understand. Primary care specialties like internal medicine, family medicine, and pediatrics are among the lowest paid in medicine. For students carrying six-figure debt (and now facing limits on student loan borrowing), higher-paying procedural fields like anesthesia, dermatology, ophthalmology, and surgery hold obvious appeal.
And while primary care doctors may spend fewer hours in the clinic than colleagues in surgical subspecialties, their work does not end there. Primary care providers are often buried in paperwork and in-basket tasks long after patients have gone home. During my family medicine rotation, one physician told me that he typically finishes seeing patients by 6 p.m., but does not stop charting until 9 or 10 p.m. Medical students see that despite the reputation for better “work-life balance,” many primary care physicians are working hours that rival those of surgeons.
Beyond the familiar issues of pay and hours, the practice of primary care is changing as our patients face barriers such as inadequate insurance, which has contributed to a decline in routine primary care visits. Patients often do not seek help until they are seriously ill, and by then, issues that might have been manageable earlier have evolved into an intricate web of medical problems.
In our student-run, free clinic in Camden, routine visits frequently extend far beyond their scheduled time because of the increasing complexity of patients’ needs. Conditions like diabetes are rarely seen in isolation; they have often progressed into complications such as cardiovascular disease, kidney disease, and infections requiring coordination with multiple specialists.
I recall seeing a man in his 50s with severe diabetes and peripheral vascular disease. He had already undergone multiple amputations of his toes. Though scheduled for an hourlong medical visit, the appointment took over twice as long to complete the workup, arrange specialty referrals, and finish our documentation.
Medical students witness every week how the system’s failures fall hardest on primary care, and how much harder it is to practice in underserved communities like Camden, where physicians are needed most. It is no wonder many of us look elsewhere. I fear the challenges will only get worse when newly passed federal legislation enacts sweeping cuts to Medicaid, the federal and state program providing coverage to low-income people and those with disabilities.
Much of the declining interest in primary care among medical students stems from a system that actively disincentivizes it. When I talk with classmates, I rarely hear a lack of passion driving students away from primary care. Rather, it is the comparatively low pay, the endless documentation, and visits that routinely extend well beyond what a single doctor can manage in the allotted time.
Addressing the primary care crisis involves recognizing and rewarding the value of medical care that is foundational to wellness along with specialized expertise of doctors in this field. We deserve a healthcare system that supports all providers working on the front lines, not one that pushes doctors away from careers that provide the care that patients need most.
Ian Millstein is a rising fourth-year medical student at Cooper Medical School of Rowan University, currently pursuing an MPH in Health Management at the Harvard T.H. Chan School of Public Health.