Forced Primary Care?

[DocLove06]

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i hate asking hypothetical questions, but i'm starting to freak out about the future of medicine. In the future, will medical students have the ability to pick their specialty of choice? do you guys think that medicine will ever become like dentistry where only the top 5-10% of the class can specialize?

 

[Law2Doc]

i hate asking hypothetical questions, but i'm starting to freak out about the future of medicine. In the future, will medical students have the ability to pick their specialty of choice? do you guys think that medicine will ever become like dentistry where only the top 5-10% of the class can specialize?

There are absolutely a good number of people graduating med school each year (about half in US allo and greater from other tracks) whose only options are noncompetitive fields, the majority of which are primary care. This number will absolutely go up if residency slots are increased to address current needs, or more likely, if US med school ranks continue to rise, more US allo students will simply end up in primary care slots at the expense of non-US hopefulls. I actually wouldn't recommend med school to someone who only wants to do a certain competitive specialty -- the odds aren't that good, and there's certainly a good chance you'll be stuck doing something else. But it's a mistake to look at primary care as a dirty word. There are pluses and minuses to all medical fields, and you may be surprised as to what you find enjoyable and what you dislike.

 

[bkpa2med]

There are absolutely a good number of people graduating med school each year (about half in US allo and greater from other tracks) whose only options are noncompetitive fields, the majority of which are primary care. This number will absolutely go up if residency slots are increased to address current needs, or more likely, if US med school ranks continue to rise, more US allo students will simply end up in primary care slots at the expense of non-US hopefulls. I actually wouldn't recommend med school to someone who only wants to do a certain competitive specialty -- the odds aren't that good, and there's certainly a good chance you'll be stuck doing something else. But it's a mistake to look at primary care as a dirty word. There are pluses and minuses to all medical fields, and you may be surprised as to what you find enjoyable and what you dislike.

Bravo

 

[howelljolly]

Forced primary care is going to happen. Medical schools have increased their class sizes, without a proportionate increase in residency spots... in particular without an increase in fellowship spots.

That means, students will be "forced" into the primary care residencies, since those are what tend to be unfilled at this time....

then...

You'll have an increased number of generalists. Since the number of fellowship seats is not increasing, those generalists will produce the same number of specialists. Ergo, the increased number of generalists will "force" an increase in primary care.

Heres an article which suggests a model for primary care which really makes it look like an a attractive field... the development of Primary Care into an art and specialty in and of itself. (I im pretty sure this link will work, but you might need a subscription)

Some of the main points are:

-survey says PCPs place a higher priority on "doing a good job and having a sane life than making a higher income"

-implimenting a team based approach, and restructuring reimbursement accordingly... comprehensive reimbursement, rather than volume based

-handling no more than ten pts per day; the rest of the day is spent on managing consults and team members, prescriptions, phone calls...

-having others "teach" the patient about lifestyle mods, etc.


http://www.healthbanks.com/PatientP...A0D5-F8776BBC08BB}&TabID={X}&ArticleID=621927

 

[dragonfly99]

<There are absolutely a good number of people graduating med school each year (about half in US allo and greater from other tracks) whose only options are noncompetitive fields, the majority of which are primary care. This number will absolutely go up if residency slots are increased to address current needs, or more likely, if US med school ranks continue to rise, more US allo students will simply end up in primary care slots at the expense of non-US hopefulls. I actually wouldn't recommend med school to someone who only wants to do a certain competitive specialty -- the odds aren't that good, and there's certainly a good chance you'll be stuck doing something else. But it's a mistake to look at primary care as a dirty word. There are pluses and minuses to all medical fields, and you may be surprised as to what you find enjoyable and what you dislike.>

Agree for the most part with this, though I don't think the number (of US MD students) who really have no choice but a noncompetitive field is as large as that. It's more like the bottom 1/3 of the class. I guess it might depend on which school you go to also (i.e. bottom half of class @Harvard might still have a chance at a number of specialties). Part of this depends on where somebody wants to do residency also. I mean, if you are willing to do ER or anesthesia somewhere cold and rural, and/or at a resource-poor city hospital, you might be able to get a spot even if you aren't necessarily @the top of your class. Sometimes, though, people decide that they'd rather have a cush medicine or peds residency than go to a bottom of the barrel radiology one, etc. Also, some people start out being gung ho to do some sort of surgery that requires 7-9 years of residency and fellowship, and then realize there's no way in hell they want to stay in training that long, or be relatively poor for that long. So then people switch to wanting to do something like IM, peds or maybe ER.

I DEFINITELY agree with lawdoc that folks should reconsider med school if they would only want one of the very competitive fields like derm, radiology, etc. Just because you have your heart set on being a dermatologist doesn't mean you will be able to, even if you bust your a-- in med school. What people forget is the others (med school classmates) were also in the top 10% of their college classes and not EVERYONE is going to get to be in AOA and/or top 20% of the med school class. If you don't think you'd enjoy medicine in general and be open to a number of different fields, don't go to med school. It's too risky.

 

[Excelsius]

1. The first graduates to be forced into primary care will likely be DOs
2. Even some competitive fields, like NS, have over 80% match rate
3. If you fail to get the residency you want the first time, you can try next year
4. Some surgical subspecialties only require a residency in a general surgery field and a fellowship only after several years - probably enough time to do extra work (research) to become competitive for fellowships

Also, thanks for confirming that school name matters.

 

[dragonfly99]

howelljolly,
I don't see primary docs only seeing 10 patients/day ever happening. That's a total pipe dream. There just isn't enough money in the system for that, and the main way to get more would be to take it from specialists (which they will FIGHT tooth and nail). Even seeing maybe 18 patients/day would be much better than what a lot of primary docs are doing right now, though.

Excelcius, the "school name" thing is complex. I think going to a med school that is known to be hard to get in to and to be rigorous can help folks who are in, say, the middle of their classes, get into moderately competitive specialties. I mean if the PD's know that the average GPA of entering students is 3.8 or 3.9 and the MCAT averages mid to high 30's, they might be able to cut someone some slack for not making it into AOA. At the same time, a person who goes to that type school and ends up in the bottom 25 or 30% might have been better served (residency-wise) going to a school where he/she might have been able to compete better to get in the top half of the class at least. Many factors play into residency's selections of candidates. Even if someone went to an unknown med school, if he/she has a letter of recommendation from someone famous in his/her field and the student honored the 3rd year clerkship, that might trump the application of someone with a high USMLE score and high class rank, even if the 2nd someone is from a famous medical school.

I think the 80% match rate for neurosurg is deceptive because people who don't have high USMLE scores, high class rank and good LOR's from neurosurgeons (or who aren't super hard core in other ways too) just don't apply to neurosurgery. It's a crap lifestyle and very stressful...it's something I think that few people feel called to do, once they think about it hard.

 

[Excelsius]

...

Excelcius, the "school name" thing is complex. I think going to a med school that is known to be hard to get in to and to be rigorous can help folks who are in, say, the middle of their classes, get into moderately competitive specialties. I mean if the PD's know that the average GPA of entering students is 3.8 or 3.9 and the MCAT averages mid to high 30's, they might be able to cut someone some slack for not making it into AOA. At the same time, a person who goes to that type school and ends up in the bottom 25 or 30% might have been better served (residency-wise) going to a school where he/she might have been able to compete better to get in the top half of the class at least. Many factors play into residency's selections of candidates. Even if someone went to an unknown med school, if he/she has a letter of recommendation from someone famous in his/her field and the student honored the 3rd year clerkship, that might trump the application of someone with a high USMLE score and high class rank, even if the 2nd someone is from a famous medical school.

I think the 80% match rate for neurosurg is deceptive because people who don't have high USMLE scores, high class rank and good LOR's from neurosurgeons (or who aren't super hard core in other ways too) just don't apply to neurosurgery. It's a crap lifestyle and very stressful...it's something I think that few people feel called to do, once they think about it hard.

Of course, there is nothing simple about the name. But the bottom line is that it matters. It is probably better to be in the top 1/3 of the class of a bottom 1/3 school than the bottom 1/3 at a top 1/3 school, but if we remove the extremes, if you're just an average student at both institutions, you're better off at the top 1/3 school. It will probably be much easier to get a recommendation letter from a famous doctor at the tp 1/3 school than at the bottom one.

All medical schools teach pretty much the same thing. So I assume that you are referring purely to the competition of other med students driving the curve. I don't know how curves really work in med school, but many people who ace undergrad are actually not that smart (as proven in the allo forum too) because you can get the grades you want by working the system. I'd imagine that intrinsic intelligence would play a much bigger role at doing well in med school than it did in undergrad, so high GPA undergrad class might not automatically = fiercer competition. I could argue that people who make it in with low GPA will probably be much harder to beat simply because of their fierce determination. Maybe that's why doing well in med school is more related to your verbal score than your GPA.

The lifestyle of any surgeon can be considered crappy, NS or not. Some people do have extreme views on this field - like that thread in the NS forum - but others look at it differently. I am not sure if NS is much worse than any other surgery, such as general surgery with the brutal schedule. It is easier to find unhappy general surgeons (still few) than unhappy neurosurgeons, at least in my experience.

 

[Law2Doc]

Of course, there is nothing simple about the name. But the bottom line is that it matters. It is probably better to be in the top 1/3 of the class of a bottom 1/3 school than the bottom 1/3 at a top 1/3 school, but if we remove the extremes, if you're just an average student at both institutions, you're better off at the top 1/3 school. It will probably be much easier to get a recommendation letter from a famous doctor at the tp 1/3 school than at the bottom one.

It matters far less than you seem to think. Certainly not as bright lined as your above example. In fact, the "famous doctor"s are often far less receptive to med students, so the folks at the next tier schools sometimes have much better access to faculty willing to help them, albeit less well known. This tends to translate to beter LORs. So no, that example isn't necessarilly right, and it's probably not "much easier", but instead, the converse.

As for your 80% match rate, it's clear you are mistakenly looking at these statistics without looking beyond them. Things can be 80% because they are easy, or they can be 80% because there is enormous self selection, or med school imposed selection. In residency stats, the latter is more common. Folks don't apply to things they have no shot at. Some schools won't let them, others don't want to waste the time or money, still others have more realistic assessment of their credentials.

 

[DireWolf]

One of two things will happen:

1. Reimbursement will go up for primary care and more physicians will subsequently choose this career path.

2. Reimbursement will stagnate or decrease for primary care and even less physicians will choose this career path. As a result PAs and NPs will gradually take over this field within the next 20 years.

 

[Excelsius]

It matters far less than you seem to think. Certainly not as bright lined as your above example. In fact, the "famous doctor"s are often far less receptive to med students, so the folks at the next tier schools sometimes have much better access to faculty willing to help them, albeit less well known. This tends to translate to beter LORs. So no, that example isn't necessarilly right, and it's probably not "much easier", but instead, the converse.

As for your 80% match rate, it's clear you are mistakenly looking at these statistics without looking beyond them. Things can be 80% because they are easy, or they can be 80% because there is enormous self selection, or med school imposed selection. In residency stats, the latter is more common. Folks don't apply to things they have no shot at. Some schools won't let them, others don't want to waste the time or money, still others have more realistic assessment of their credentials.

I am not talking about issues with individual characters. The discussion was about "famous doctors," and it is very likely that access to these doctors will be concentrated at the famous schools. You can argue that some famous professors may not want to be available to students. That may be true for some, but not so for others. This is much like in famous undergrad institutions. I took some courses at one of these places and while some professors patronized almost everyone (except grad students in the class), others were as receptive as to invite students to their home to see a "course-related" film. Additionally, some professionals give students more respect if they are from certain schools... Anyway, access to individual doctors is irrelevant in this case.

And how did you come to that conclusion? I don't think I implied anywhere that the average qualifications do not matter. It is already expected that to match into any residency spot, be it IM or radiology, you have to be close to the average standards for that particular specialty. There are some specialties that have average step 1 scores higher than NS, such as derm. I'd be more inclined to believe that the high acceptance rate has to do with students' choice of lifestyle, rather than no applying because they do not even approach the average requirements for NS. Qualified students choose to not apply. I think there are enough qualified graduates who could apply and cut the match rate by half or more. You seem to be saying that there aren't enough graduates who are within one standard deviation of the average for NS and that's the reason for the 80% rate. I disagree. If that analogy held, then more competitive residencies would have even higher match rate. I agree with dragonfly that the self selection is more about lifestyle than academics.

 

[Excelsius]

...
2. Reimbursement will stagnate or decrease for primary care and even less physicians will choose this career path. As a result PAs and NPs will gradually take over this field within the next 20 years.

This will affect every single specialty because it would mean that all those students going into primary care now have to match into other specialties (including DOs). There don't seem to be enough residency spots to handle this right now. It's also questionable whether PAs and NPs are qualified to be primary care doctors.

 

[olliemctuffy]

Man, why do you keep singling out DOs? DOs have residency programs in all kinds of fields outside of primary care, such as neurosurgery.

 

[Excelsius]

Man, why do you keep singling out DOs? DOs have residency programs in all kinds of fields outside of primary care, such as neurosurgery.

Many DOs apply for MD spots. I am only referring to these.

 

[Law2Doc]

One of two things will happen:

1. Reimbursement will go up for primary care and more physicians will subsequently choose this career path.

2. Reimbursement will stagnate or decrease for primary care and even less physicians will choose this career path. As a result PAs and NPs will gradually take over this field within the next 20 years.

#1 isn't likely to happen. With healthcare being deemed too expensive and with insurers having a stranglehold over reimbursements and having to find ways to improve their own bottom line it's a pretty safe assumption that reimbursements will go down, not up.

#2 also isn't much of a concern. People who graduate med school will go to whatever residencies are available. It's not like after 4 years of med school you are going to shrug your shoulders and say oh well. A primary care job is still going to be the only professional job you are qualified for, and the path of least resistance. I'll And if they don't, there are thousands of non-US med school grads waiting in the wings.

 

[nebrfan]

Clinton tried to do it back in 1993....

In an effort to create more family doctors, President Clinton's health plan would empower the Federal Government to decide how many doctors should be trained each year as family practitioners, radiologists, surgeons, neurologists and other specialists....It would establish Federal regulation in a field now governed by the choices of medical students and teaching hospitals....

President Clinton will also propose vastly expanding the roles of nurses, nurse practitioners, physician assistants, midwives, social workers and other health-care professionals who do not have M.D. degrees.

In the final draft of his health plan, Mr. Clinton says Congress should override many state laws that limit the scope of practice of such nonphysicians. Nurses support this proposal, but doctors vehemently oppose it. ...

Under Mr. Clinton's plan, the Government would enforce its decisions on the allocation of doctors by withholding money from any teaching hospital or training program that trains more than its quota of specialists.

http://query.nytimes.com/gst/fullpage.html?res=9F0CE3D6103BF936A2575AC0A965958260&sec=&spon=&pagewanted=1

...Obama has taken a liking to many of Clinton's advisors...and Clinton was arguably more moderate.

 

[howelljolly]

Clinton tried to do it back in 1993....



...Obama has taken a liking to many of Clinton's advisors...and Clinton was arguably more moderate.

Wow, thats bad. On the one hand you're telling doctors what they cant do, and on the other hand you're telling midlevels that they can do more...

 

[mig26x]

Clinton tried to do it back in 1993....



...Obama has taken a liking to many of Clinton's advisors...and Clinton was arguably more moderate.

I read the entire article and this was pretty scary:

"Under the proposal on medical education, the Secretary of Health and Human Services would determine the number of training positions in each specialty after receiving advice from a new panel, the National Council on Graduate Medical Education. The Secretary would appoint 10 regional councils to "allocate training slots" among residency programs in various parts of the country. The Secretary could revise these allocations "for good cause.""


WOW!!!