Mark D. Schwartz, MD; William T. Basco Jr, MD; Michael R. Grey, MD, MPH; Joann G. Elmore, MD, MPH; Arthur Rubenstein, MBBCh
Grant Support: By grant R01 HS11955-01 from the Department of Health and Human Services, Agency for Healthcare Research and Quality (Dr. Schwartz), and the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Mark D. Schwartz, MD, New York University School of Medicine, Division of General Internal Medicine, Veterans Affairs New York Harbor Healthcare System, Medical Service (111), 423 East 23rd Street, New York, NY 10010; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Schwartz: Division of General Internal Medicine, New York University School of Medicine, Veterans Affairs New York Harbor Healthcare System, Medical Service (111), 423 East 23rd Street, New York, NY 10010.
Dr. Basco: Division of General Pediatrics, Medical University of South Carolina, 135 Rutledge Avenue, PO Box 250561, Charleston, SC 29425.
Dr. Grey: High Street Health Center, 140 High Street, Springfield, MA 01199
Dr. Elmore: University of Washington School of Medicine, 325 Ninth Avenue, Box 359780, Seattle, WA 98104-2499
Dr. Rubenstein: University of Pennsylvania, 3620 Hamilton Walk, Room 295, John Morgan Building, Philadelphia, PA 19104-6055.
Despite changes in the structure of the U.S. health care system, patients continue to need and seek out generalist physicians. However, the proportion of U.S. graduates of medical schools who choose to enter generalist residency training decreased from 50% in 1998 to less than 40% in the 2004 match. Unless we act now to reverse this trend, we may face a shortage of primary care physicians to care for the complex medical needs of an aging population.
This article reviews the history of and trends in career choice and proposes 4 evidence-based recommendations to rekindle student interest in generalist careers: 1) We must improve satisfaction and enthusiasm among generalist physician role models. 2) Schools of medicine should redouble their efforts to produce primary care physicians. 3) We must facilitate the pathway from medical school to generalist residency. 4) The U.S. government should increase funding for primary care research and research training. In the absence of a major overhaul of economic incentives in favor of generalist careers, we will need to work at these multiple levels to restore balance to the generalist physician workforce and align with the desires and expectations of patients for continuing healing relationships with generalist physicians.
Rekindle: from Old Norse, kynda, to start (a fire) burning; to stir up, arouse, to cause to glow, or illuminate; and from Middle English, to bring forth young (1).
Number of U.S. medical school graduates who matched in primary care specialties, 1999 to 2004.
Proportion of all graduating medical students in the United States who matched to generalist residency programs, 1991 to 2004.
Table. Strategies To Increase Choice of Generalist Careers
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Advocate Lutheran General Hospital
May 14, 2005
Employ the Invisible Hand
Schwartz et al offer many constructive suggestions to stimulate medical student interest in generalist careers. However, I offer an additional idea. Mobilize the invisible hand of Adam Smith toward elevating internal medicine, pediatrics, and family medicine on students' ranking lists for the matching program. Simply increase the salary for residents in these specialties. Free market economics uses price changes to signal variations in supply and demand. There is no real justification for the tradition of paying residents equally, regardless of specialty.
Loan forgiveness programs are also desirable, but the reward comes too far into the future. Also, the signaling effect of a significant variation in resident salaries among the specialties should not be underestimated.
Schwartz MD, Basco WT, Grey MR, Elmore JG, Rubenstein A. Rekindling Student Interest in Generalist Careers. Ann Intern Med. 2005;142:715–724. doi: 10.7326/0003-4819-142-8-200504190-00040
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Published: Ann Intern Med. 2005;142(8):715-724.
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