Number one: Med schools are expanding a little, and this probably will fill a few of the primary care residency spots (which currently go to FMG's and IMG's) with US grads. However, the schools are not expanding nearly enough to fill up all the residency spots we have (with US grads). That would take a long, long time and a LOT of expansion. Doubtless some of the new US grads will be forced into primary care residencies, but if the working conditions in primary care aren't that good, many people will eventually find their way out (become hospitalists, start doing cosmetic procedures, work part time or quit clinical medicine). Also, just filling a few more spots with US grads rather than FMG's doesn't necessarily increase the supply of primary care docs...it just means they'll be American born and trained ones rather than US IMG's or FMG's.
Yes, there has been talk of changing reimbursements to "fix" primary care, and also of "pay for performance" (pay doctors more for providing "better" care, and/or pay less/penalize them for providing "worse" care). The problem with rewarding PCP's for getting HgbA1c below a certain level, etc. is that the bureaucrats who will decide the "acceptable" levels for various lab tests, etc. often don't understand the nuances of practicing clinical medicine. For example, in certain patients it can be dangerous and inappropriate to lower BP or HgbA1c to the supposedly "best" level according to current treatment guidelines. Patients are not widgets, they are individuals. Also, some doctors are very good doctors but work with difficult patient populations - patients who don't follow their doctor's recommendations, have very unhealthy lifestyles, chaotic social situations and such, which makes it much harder to get them to "goal" for these various parameters. In a pay for performance type system, I think doctors will be likely to try and fire these types of patients from their practices, or choose not to work in inner city type areas, etc. Furthermore, all this "pay for performance" stuff won't necessarily increase pay to primary care doctors. The powers that be could just as easily decide to penalize the docs who don't make the goal of lowering the patients' blood pressures or HgbA1c's enough.
I think for primary care to work in this country, people really have to buy into it being important - that means patients and policy makers as well as physicians. The problems in primary care go far, far deeper than just money/reimbursements. I am still worried r.e. the future of primary care.
But went to a school that I think is in the "Top Tier" and had many friends get some private gigs that paid very well, but are definitely putting in crappy hours and usually doing the scutwork of law. Plus, the market is just saturated right now anyway. In the end glad we went this route, more time off, great benefits. At this point I'm just thankful she has a relatively stable/secure job.
