In the Balance
Annals of Internal Medicine
Too Smart for Primary Care? Eric J. Warm, MD, and Celine Goetz, MD
D
uring a medical education conference, a prominent specialist asserted that students should not aspire to practice primary care because it does not demand excellence of its trainees. As a primary care physician and a fourth-year medical student, we were shocked by this statement. Together, we approached the speaker after his session to challenge his assertions. He stood firm. As a medical student at the time, one of us had personally experienced faculty members saying that she was too smart for primary care. Being told you are too smart for anything can be flattering. However, as someone who went to medical school to pursue internal medicine, it was confusing to be dissuaded by respected mentors. The other individual had unfortunately heard the same from many medical students over the years. The current crisis in primary care has given Americans a fragmented health care system that has produced poorer outcomes and greater disparities than countries with integrated primary care– based systems. Despite efforts to increase the primary care workforce, top medical students do not choose this path. The number of members of the Alpha Omega Alpha Medical Honor Society who choose to go to into high-paying, specialty-focused fields is significantly greater than those who go into primary care. Even within internal medicine, increasing numbers of top trainees pursue subspecialty training. Much separates medical students from primary care careers. Training experiences are often poorly designed. Potential earnings are less, administrative hassles are high, and lifestyle is less controllable. Add to this the lack of prestige primary care has in academic medical centers and attracting the best and brightest seems hopeless. A common response to these circumstances is anger and defensiveness. Many primary care physicians have test scores as high as their classmates and still choose primary care. Most primary care physicians believe their work is challenging and valuable and do not believe that they are wasting their potential. However, anger and defensiveness will not improve the situation. We need students to choose primary care, but they are unlikely to do so if the culture of academic medicine steers them in other directions. What has produced this hidden curriculum, and what should we do about it? A common assumption is that a person needs to be above average to be a specialist. You do not hear about physicians who fail to get a primary care job and need to settle for cardiology. Most leaders in academic medicine are specialists. Many years ago, academia was different. Most physicians were generalists, and the relationship between generalists and patients was the center of care. Many forces marginalized this relationship. The National Institutes of Health began funding narrow areas of research,
fueling specialization. Medicare reimbursement increasingly favored procedurally oriented specialties, and commercial insurers followed suit. Academic medical centers responded to these pressures, and by the 1980s, specialty faculty assumed the leadership roles they hold today. Even so, fewer specialty training slots remained than in the generalist disciplines. Training programs sought an easy way to differentiate candidates and began to rely on standardized test scores and medical school rank to set thresholds of acceptance. So, although it has come to pass that one must do well in medical school to pursue certain specialties, does one need to be a top student to do the work of a specialist—to replace a knee, stent an artery, or lift a face? More important, do we not require the brightest among us for primary care? Primary care physicians manage more cardiovascular disease than cardiologists, more depression than psychiatrists, and more rashes than dermatologists. In addition, every primary care physician witnesses specialists who use their particular procedural hammer to hit whatever nail they encounter and then send the patient back when they fail to make the diagnosis or alleviate the symptoms. And, in academic medical centers, it is not uncommon for specialist consultants to subsequently berate the primary care physician for a “bogus consult.” Students notice this. This begs the question that the speaker at the conference raised: Should physicians be the ones to provide primary care? There has been a recent push for nonphysician providers to staff primary care practices. There are many reasons for this, but a compelling and largely unacknowledged one is this: Most current academic physician leaders trained at a time when ambulatory care and education received marginal support and occurred in dysfunctional settings. Consciously or unconsciously, these leaders are reluctant to send their best students to places where training and pay seem suboptimal. This self-fulfilling prophecy, ongoing for more than 20 years, has fed the decline of primary care among physicians along with many other forces. However, simply eliminating physicians and incorporating physician extenders into broken care models holds the false promise of easily creating more functional environments for patients and providers. But, there is hope. We are in the midst of a national conversation shaped by the Patient Protection and Affordable Care Act that is placing the value of primary care squarely at the intersection of politics and business. The See also: Print Related article. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711 © 2013 American College of Physicians 709
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/928838/ by a Scott Memorial Library User on 07/31/2017
In the Balance
Too Smart for Primary Care?
patient-centered medical home movement has imagined a world of primary care delivery marked by collaboration, interprofessionalism, and mutual accountability. The Center for Medicare & Medicaid Innovation and associated projects, such as the Comprehensive Primary Care Initiative, are discovering better ways to partner public and private payers to improve care delivery. Primary care faculty in academic medical centers should seize this opportunity to redefine the value of their work. Students view cardiologists as experts in stent placement and gastroenterologists as experts in endoscopy. Primary care physicians are experts as well (in diagnosing undifferentiated illness, managing populations, organizing care teams, and basing care relationships on shared decision making). Each of these skills is supported by a well-researched body of evidence but needs to be further advanced by study. Countless specialty medicine careers have been launched by such an opportunity. Primary care physician faculty members should use the power of inquiry to achieve as highly as their specialty counterparts and then seek leadership roles within academic medical centers to embrace primary care best practices, improve primary care training sites, and aggressively close the prestige gap.
If not, mentors will continue to discourage medical students from pursuing primary care careers, adding to the list of reasons why our profession is failing to meet the needs of society. If we want to rebuild primary care and our health system, we need to be smarter than that. From the University of Cincinnati, Cincinnati, Ohio, and New YorkPresbyterian Hospital, New York, New York. Potential Conflicts of Interest: None disclosed. Forms can be viewed at
www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum ⫽M13-0801. Requests for Single Reprints: Eric J. Warm, MD, University of Cin-
cinnati, 231 Albert Sabin Way, Mail Location 0557, Cincinnati, OH 45267-0557; e-mail, [email protected]. Current author addresses and author contributions are available at www.annals.org. Ann Intern Med. 2013;159:709-710.
PERSONAE PHOTOGRAPHS Annals of Internal Medicine invites submissions of Personae photographs for our cover and offers a $500 prize for the best photograph submitted each year. Personae photographs are pictures that catch people in the context of their lives and that capture personality. We prefer black-andwhite digital files. Please submit photographs or questions to Nicole Briglia ([email protected]).
710 19 November 2013 Annals of Internal Medicine Volume 159 • Number 10
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/928838/ by a Scott Memorial Library User on 07/31/2017
www.annals.org
Annals of Internal Medicine Current Author Addresses: Dr. Warm: University of Cincinnati, 231
Albert Sabin Way, Mail Location 0557, Cincinnati, OH 45267-0557. Dr. Goetz: Department of Internal Medicine, New York-Presbyterian Hospital, 525 East 68th Street, New York, NY 10021.
www.annals.org
Author Contributions: Conception and design: E.J. Warm, C. Goetz. Drafting of the article: E.J. Warm, C. Goetz. Critical revision of the article for important intellectual content: E.J. Warm, C. Goetz. Final approval of the article: E.J. Warm, C. Goetz.
19 November 2013 Annals of Internal Medicine Volume 159 • Number 10
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/928838/ by a Scott Memorial Library User on 07/31/2017
Annals of Internal Medicine
Too Smart for Primary Care? Eric J. Warm, MD, and Celine Goetz, MD
D
uring a medical education conference, a prominent specialist asserted that students should not aspire to practice primary care because it does not demand excellence of its trainees. As a primary care physician and a fourth-year medical student, we were shocked by this statement. Together, we approached the speaker after his session to challenge his assertions. He stood firm. As a medical student at the time, one of us had personally experienced faculty members saying that she was too smart for primary care. Being told you are too smart for anything can be flattering. However, as someone who went to medical school to pursue internal medicine, it was confusing to be dissuaded by respected mentors. The other individual had unfortunately heard the same from many medical students over the years. The current crisis in primary care has given Americans a fragmented health care system that has produced poorer outcomes and greater disparities than countries with integrated primary care– based systems. Despite efforts to increase the primary care workforce, top medical students do not choose this path. The number of members of the Alpha Omega Alpha Medical Honor Society who choose to go to into high-paying, specialty-focused fields is significantly greater than those who go into primary care. Even within internal medicine, increasing numbers of top trainees pursue subspecialty training. Much separates medical students from primary care careers. Training experiences are often poorly designed. Potential earnings are less, administrative hassles are high, and lifestyle is less controllable. Add to this the lack of prestige primary care has in academic medical centers and attracting the best and brightest seems hopeless. A common response to these circumstances is anger and defensiveness. Many primary care physicians have test scores as high as their classmates and still choose primary care. Most primary care physicians believe their work is challenging and valuable and do not believe that they are wasting their potential. However, anger and defensiveness will not improve the situation. We need students to choose primary care, but they are unlikely to do so if the culture of academic medicine steers them in other directions. What has produced this hidden curriculum, and what should we do about it? A common assumption is that a person needs to be above average to be a specialist. You do not hear about physicians who fail to get a primary care job and need to settle for cardiology. Most leaders in academic medicine are specialists. Many years ago, academia was different. Most physicians were generalists, and the relationship between generalists and patients was the center of care. Many forces marginalized this relationship. The National Institutes of Health began funding narrow areas of research,
fueling specialization. Medicare reimbursement increasingly favored procedurally oriented specialties, and commercial insurers followed suit. Academic medical centers responded to these pressures, and by the 1980s, specialty faculty assumed the leadership roles they hold today. Even so, fewer specialty training slots remained than in the generalist disciplines. Training programs sought an easy way to differentiate candidates and began to rely on standardized test scores and medical school rank to set thresholds of acceptance. So, although it has come to pass that one must do well in medical school to pursue certain specialties, does one need to be a top student to do the work of a specialist—to replace a knee, stent an artery, or lift a face? More important, do we not require the brightest among us for primary care? Primary care physicians manage more cardiovascular disease than cardiologists, more depression than psychiatrists, and more rashes than dermatologists. In addition, every primary care physician witnesses specialists who use their particular procedural hammer to hit whatever nail they encounter and then send the patient back when they fail to make the diagnosis or alleviate the symptoms. And, in academic medical centers, it is not uncommon for specialist consultants to subsequently berate the primary care physician for a “bogus consult.” Students notice this. This begs the question that the speaker at the conference raised: Should physicians be the ones to provide primary care? There has been a recent push for nonphysician providers to staff primary care practices. There are many reasons for this, but a compelling and largely unacknowledged one is this: Most current academic physician leaders trained at a time when ambulatory care and education received marginal support and occurred in dysfunctional settings. Consciously or unconsciously, these leaders are reluctant to send their best students to places where training and pay seem suboptimal. This self-fulfilling prophecy, ongoing for more than 20 years, has fed the decline of primary care among physicians along with many other forces. However, simply eliminating physicians and incorporating physician extenders into broken care models holds the false promise of easily creating more functional environments for patients and providers. But, there is hope. We are in the midst of a national conversation shaped by the Patient Protection and Affordable Care Act that is placing the value of primary care squarely at the intersection of politics and business. The See also: Print Related article. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711 © 2013 American College of Physicians 709
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/928838/ by a Scott Memorial Library User on 07/31/2017
In the Balance
Too Smart for Primary Care?
patient-centered medical home movement has imagined a world of primary care delivery marked by collaboration, interprofessionalism, and mutual accountability. The Center for Medicare & Medicaid Innovation and associated projects, such as the Comprehensive Primary Care Initiative, are discovering better ways to partner public and private payers to improve care delivery. Primary care faculty in academic medical centers should seize this opportunity to redefine the value of their work. Students view cardiologists as experts in stent placement and gastroenterologists as experts in endoscopy. Primary care physicians are experts as well (in diagnosing undifferentiated illness, managing populations, organizing care teams, and basing care relationships on shared decision making). Each of these skills is supported by a well-researched body of evidence but needs to be further advanced by study. Countless specialty medicine careers have been launched by such an opportunity. Primary care physician faculty members should use the power of inquiry to achieve as highly as their specialty counterparts and then seek leadership roles within academic medical centers to embrace primary care best practices, improve primary care training sites, and aggressively close the prestige gap.
If not, mentors will continue to discourage medical students from pursuing primary care careers, adding to the list of reasons why our profession is failing to meet the needs of society. If we want to rebuild primary care and our health system, we need to be smarter than that. From the University of Cincinnati, Cincinnati, Ohio, and New YorkPresbyterian Hospital, New York, New York. Potential Conflicts of Interest: None disclosed. Forms can be viewed at
www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum ⫽M13-0801. Requests for Single Reprints: Eric J. Warm, MD, University of Cin-
cinnati, 231 Albert Sabin Way, Mail Location 0557, Cincinnati, OH 45267-0557; e-mail, [email protected]. Current author addresses and author contributions are available at www.annals.org. Ann Intern Med. 2013;159:709-710.
PERSONAE PHOTOGRAPHS Annals of Internal Medicine invites submissions of Personae photographs for our cover and offers a $500 prize for the best photograph submitted each year. Personae photographs are pictures that catch people in the context of their lives and that capture personality. We prefer black-andwhite digital files. Please submit photographs or questions to Nicole Briglia ([email protected]).
710 19 November 2013 Annals of Internal Medicine Volume 159 • Number 10
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/928838/ by a Scott Memorial Library User on 07/31/2017
www.annals.org
Annals of Internal Medicine Current Author Addresses: Dr. Warm: University of Cincinnati, 231
Albert Sabin Way, Mail Location 0557, Cincinnati, OH 45267-0557. Dr. Goetz: Department of Internal Medicine, New York-Presbyterian Hospital, 525 East 68th Street, New York, NY 10021.
www.annals.org
Author Contributions: Conception and design: E.J. Warm, C. Goetz. Drafting of the article: E.J. Warm, C. Goetz. Critical revision of the article for important intellectual content: E.J. Warm, C. Goetz. Final approval of the article: E.J. Warm, C. Goetz.
19 November 2013 Annals of Internal Medicine Volume 159 • Number 10
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/928838/ by a Scott Memorial Library User on 07/31/2017
