Will the focus on primary care physicians lead to discrimination in admissions?

[goofball]

What also blows my mind is if there is a primary care shortage, shouldn't their salaries go up due to supply and demand? Well it's not, and low salaries aren't typically a motivating factor for people. Clearly there is a big disconnect between the bleeding heart Mother Teresa wannabees that get admitted to medical school who suddenly are gunning for ROADS specialties once they start school and the applicants that ADCOMs thought they saw.

I think some people will argue that there is no primary care (or physician) shortage, just a geographic maldistribution.

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[SpacemanSpifff]

Of course that's not what we really want. But what else can we expect to happen? Pre-meds, believe it or not, are normal people like you and I. They aren't some special morally superior beings that have no interest in money and instead run on do-goodery. They are normal people with normal interests and expectations. If we wanted everyone to help the underserved, then we would have to move away from society.

I remember when I worked at my last job, there were people from all different backgrounds that were working the same position as me. One of them came from another airline's management, another came from the front-line at the airport, another was previously a pre-med and had to go back to work, and my boss used to work in reservations. Aside from specific fields like investment banking that have a specific track for people to take, most jobs in corporate America look at people with all sorts of different resumes. People write their own story.

On the contrary, medical school admissions has made the facade so bad that you can't tell anything about anyone anymore. When I go into the WAMC forum, I can read about a wide variety of activities. Whether someone is volunteering in the ED, volunteering at a free clinic, volunteering for an Alzheimer's something, tutoring underprivileged children, or doing the millions of other things you see all the time; it shows one thing. Conformity. These ECs generally say nothing about people. If they did, there wouldn't be a PCP shortage nor would the underserved still be underserved.

What also blows my mind is if there is a primary care shortage, shouldn't their salaries go up due to supply and demand? Well it's not, and low salaries aren't typically a motivating factor for people. Clearly there is a big disconnect between the bleeding heart Mother Teresa wannabees that get admitted to medical school who suddenly are gunning for ROADS specialties once they start school and the applicants that ADCOMs thought they saw.

So when everyone and their mother is pretending to be a bleeding heart applicant, can there by any other way besides accepting students that will be forced to do a PCP specialty because they have no other choice.

True. Obviously it's a difficult problem to solve. I have been wondering if compensation for rural docs will be supplemented in the near future. Seems like a plausible incentive.

 

[goofball]

I'd just like to say that Planes2Doc is probably one of the most consistently insightful posters there is on this board. It's pretty crazy.

 

[Planes2Doc]

I think some people will argue that there is no primary care (or physician) shortage, just a geographic maldistribution.

Excellent point! Then I think "shortage" is the wrong term to use most definitely. I have never had any issues finding a huge listing of primary care docs in the well-to-do areas.

True. Obviously it's a difficult problem to solve. I have been wondering if compensation for rural docs will be supplemented in the near future. Seems like a plausible incentive.

Compensation would work in theory, but unless the government backs this, I do not think compensation for rural docs will go up. How can a doctor be paid more money by seeing less patients? Sadly this doesn't follow the laws of economics. Unfortunately people will need to deal with living in rural or poor areas for a lot longer until a realistic fix can be made.

I'd just like to say that Planes2Doc is probably one of the most consistently insightful posters there is on this board. It's pretty crazy.

Thanks so much! I appreciate it!

 

[notbobtrustme]

Most medical schools are upfront about the fact that they give preference to applicants from rural areas. A bit like affirmative action I guess.

err, that's not the case. There are a few schools that are rurally-focused, but the majority of schools don't care where you come from. Likewise, most schools actually don't have a primary care mission and schools taut their ability to place students into competitive specialties. Many top schools don't even have a primary care department.

 

[Non Pizza Lunch]

You learn that pretty fast in medical school. This is why ROADS specialties are so competitive, unlike fields like neurosurgery.

Not to derail too much, but even though Neurosurgery has a terrible lifestyle, it remains an incredibly competitive specialty. Comparable board scores (~240), one of the highest number of research requirements, and keep in mind you are fighting for often 1 or 2 spots - in the few number hospitals that are even big enough to have a neurosurgery residency!

 

[circulus vitios]

Yes, they do fall short. Hence the problems we have. That said, do you have a better suggestion? We already know MCAT & GPA predict in the wrong direction in many cases (in terms of primary care and underserved needs).... So what do you suggest? The best predictor of future behavior is past behavior. That suggests that we look for people who have experience working w the populations we desire to see served or who have done similar activities....

No, that is also flawed. The vast majority of premeds volunteer and underserved communities still remain underserved.

 

[Gut Shot]

What also blows my mind is if there is a primary care shortage, shouldn't their salaries go up due to supply and demand?

Because the vast majority of medicine is financed by third party payers, salaries are tied to reimbursement levels rather than simple supply vs. demand. And the way those reimbursements are determined has everything to do with lobbying rather than a rational overarching strategy. The pressure is finally reversing, though. The next few years will be extremely interesting to watch.

 

[goofball]

Because the vast majority of medicine is financed by third party payers, salaries are tied to reimbursement levels rather than simple supply vs. demand. And the way those reimbursements are determined has everything to do with lobbying rather than a rational overarching strategy. The pressure is finally reversing, though. The next few years will be extremely interesting to watch.

I'm not sure "interesting" is the word radiologists would use...

 

[music2doc]

No, that is also flawed. The vast majority of premeds volunteer and underserved communities still remain underserved.

This was assumed in the subtext of that statement...

The question isn't whether what we are doing is working; it's "what do you suggest to improve upon it?"

 

[Gut Shot]

I'm not sure "interesting" is the word radiologists would use...

All the more reason to do what you like rather than what's hot, and to live well within your means.

 

[IslandStyle808]

Been reading some disturbing things recently. From Medscape:

http://www.medscape.com/viewarticle/782043


Basically, women, nontrads, and rural folk are more likely to go into primary care. I interpret this article as arguing for discrimination in favor of these groups.

I doubt that most schools will discriminate based on this stuff, since very few schools take the primary care thing seriously. But unfortunately, a few schools like OHSU, UW, Quinnipiac, etc DO look like they take the primary care thing seriously.

So is this an unintended consequence of the focus on primary care, a discrimination against traditional, urban, and male students?

I mean, it's well known that some schools strongly prefer nontrads, but that's only a few schools. I'm worried that in the future, more schools will use this primary care thing as an excuse to discriminate against some people and preferentially admit others.

Is this a reason for concern, or am I reading too much into this?

You're reading too much into it. All schools have a mission and will pick people that fit into that mission. My state school prefers people who go into primary care and will try to pick people who will potentially enter these fields.

 

[calvnandhobbs68]

Obstetrics/Gynecology is technically primary care, and many of those IM/Peds subspecialties such as cardiology I feel could still be as well. Also, there is a shortage of emergency medicine too and I feel like many of the schools encode that as part of their primary care cause, but I may be off base.

ha uh no I wouldn't be lumping cardiology in with primary care...pretty much anything you need to get a referral to is by definition not primary care.

I personally think the amount of students that go into "primary care" should be gauged by 4 year post graduation surveys including information about which students are pursuing fellowships in their field (which tends to indicate that they aren't going to be a PCP). Like I said in another thread, all the students going into IM from Harvard? Yeahhh they aren't doing it to open up a general IM practice.

 

[NickRiviera MD]

ha uh no I wouldn't be lumping cardiology in with primary care...pretty much anything you need to get a referral to is by definition not primary care.

I personally think the amount of students that go into "primary care" should be gauged by 4 year post graduation surveys including information about which students are pursuing fellowships in their field (which tends to indicate that they aren't going to be a PCP). Like I said in another thread, all the students going into IM from Harvard? Yeahhh they aren't doing it to open up a general IM practice.

funny you mention Harvard IM..."HMS no longer calculates the number of students going into primary care because it is impossible to determine how many of those who go into internal medicine will eventually go into primary care versus specialty care."

http://hms.harvard.edu/news/relief-joy-mark-match-day-2013-hms-3-15-13

 

[mimelim]

funny you mention Harvard IM..."HMS no longer calculates the number of students going into primary care because it is impossible to determine how many of those who go into internal medicine will eventually go into primary care versus specialty care."

http://hms.harvard.edu/news/relief-joy-mark-match-day-2013-hms-3-15-13

Ya, impossible to track down what professionals do...

 

[rain4venus]

I personally think the amount of students that go into "primary care" should be gauged by 4 year post graduation surveys including information about which students are pursuing fellowships in their field (which tends to indicate that they aren't going to be a PCP). Like I said in another thread, all the students going into IM from Harvard? Yeahhh they aren't doing it to open up a general IM practice.

LizzyM said something similar earlier in this thread as well... Does this kind of information exist? It would definitely be useful for applicants to know which schools are actually producing PCPs.

As for the USNews Primary Care rankings... Are they just counting how many students match into "primary care" residencies? The top few schools seem to be those that have legitimate primary care missions.

 

[NickNaylor]

Ya, impossible to track down what professionals do...

It's not like the AMA does this or anything...

 

[LizzyM]

Some physicians do a IM fellowship and then end up opening a practice in a small town and at first will see everyone/anyone. They close the practice eventually to new patients except those with the health conditions of interest. Is that person a PCP or a specialist?

 

[Mt Kilimanjaro]

There are several articles about the demographic issues. Here's one: http://www.ncbi.nlm.nih.gov/pubmed/2407254

I think this PCP imbalance problem is a byproduct of the post-Flexner medical education system that largely trains affluent men and women to become physicians. Put 100 wealthy suburbanites into an understaffed, underfunded clinic in rural America and 99 of them will leave the first second they can. It's not because they're terrible people, just because they are not accustomed to the environment and have no deep connection to the place or the people.

Put someone from that same community (or a similar one) with a 26 MCAT and a 195 Step 1 score in the same clinic and they are much more likely to stay.

But who gets into medical school? Who even makes it to the point of putting together a complete application? AAMC data leads me to believe it's not the latter group.

 

[goofball]

I think another issue might be race. Indians and Asians are disproportionately represented in medical schools (not a bad thing, just shows that disproportionately more of them apply). They have a number of factors pushing then away from rural primary care. One is familial expectations/prestige. But another is racial: why should an Indian/Asian doctor even care about what happens in rural white/black America? Why would an Indian/Asian doc want to go to a community like that, where he would be treated as a perpetual outsider?

Honestly, there's no way to fix that directly without a racist admissions policy. But expect things to drastically change once reimbursements do. I think younger, traditional applicants are much more concerned with the pragmatic issues of a career in medicine than the older crowd.

 

[rain4venus]

Put someone from that same community (or a similar one) with a 26 MCAT and a 195 Step 1 score in the same clinic and they are much more likely to stay.

But who gets into medical school? Who even makes it to the point of putting together a complete application? AAMC data leads me to believe it's not the latter group.

People keep asking if the people in that group are really the ones we want as our PCPs, but that's clearly not the way to look at it. It's not "Do we want outstanding applicants as PCPs or mediocre applicants?" It's "Do we want PCPs or not?"

Unless the situation changes and PCPs actually start making some money. As it is, primary care isn't even financially worth it to most people if they get their school completely free. Just a couple years after graduation a specialist with loans will overtake a FM doctor on NHSC.

 

[Planes2Doc]

People keep asking if the people in that group are really the ones we want as our PCPs, but that's clearly not the way to look at it. It's not "Do we want outstanding applicants as PCPs or mediocre applicants?" It's "Do we want PCPs or not?"

Unless the situation changes and PCPs actually start making some money. As it is, primary care isn't even financially worth it to most people if they get their school completely free. Just a couple years after graduation a specialist with loans will overtake a FM doctor on NHSC.

This is a terrific point! It's amazing looking at all of these posts and realizing how big of an issue it really is. Even if you implement things like loan forgiveness through PCP work (similar to pro-bono law work), it might mean that the physicians can still half-ass the things they do.

I guess the best case scenario would be to take the people who are forced into it no matter what. I think that as more medical schools open up and residency spots stay static, FMGs will find themselves being forced into these positions. Speaking of FMGs, why do they entirely fail to match versus picking up a PCP spot in an undesirable area???

 

[music2doc]

This is a terrific point! It's amazing looking at all of these posts and realizing how big of an issue it really is. Even if you implement things like loan forgiveness through PCP work (similar to pro-bono law work), it might mean that the physicians can still half-ass the things they do.

I guess the best case scenario would be to take the people who are forced into it no matter what. I think that as more medical schools open up and residency spots stay static, FMGs will find themselves being forced into these positions. Speaking of FMGs, why do they entirely fail to match versus picking up a PCP spot in an undesirable area???

Probably didn't apply there or weren't offered an interview. Some may overestimate their chances -- they did choose the Caribbean after all and that alone demonstrates a lack of skill in instinctively determining risk ratios and general judgment capability.

 

[IslandStyle808]

There are several articles about the demographic issues. Here's one: http://www.ncbi.nlm.nih.gov/pubmed/2407254

I think this PCP imbalance problem is a byproduct of the post-Flexner medical education system that largely trains affluent men and women to become physicians. Put 100 wealthy suburbanites into an understaffed, underfunded clinic in rural America and 99 of them will leave the first second they can. It's not because they're terrible people, just because they are not accustomed to the environment and have no deep connection to the place or the people.

Put someone from that same community (or a similar one) with a 26 MCAT and a 195 Step 1 score in the same clinic and they are much more likely to stay.

But who gets into medical school? Who even makes it to the point of putting together a complete application? AAMC data leads me to believe it's not the latter group.

Coming from a rural area myself, this is true but not the only large reason. Physicians from the same community do also leave. This is because of low reimbursements from insurance companies which is not enough to keep a private practice open. Also, there are no hospitals or clinics in close proximity to some of these rural areas thus doctors can't be in vicinity of their patient base when they close down practice.

 

[Mt Kilimanjaro]

Coming from a rural area myself, this is true but not the only large reason. Physicians from the same community do also leave. This is because of low reimbursements from insurance companies which is not enough to keep a private practice open. Also, there are no hospitals or clinics in close proximity to some of these rural areas thus doctors can't be in vicinity of their patient base when they close down practice.

Are there really rural areas in Hawaii?

I agree. My point is that if we continue to let people from the same (largely wealthy, suburban) background into medical school, we will continue to have extreme difficulty getting people to stay in rural areas.

Some people from rural areas see careers like medicine and law as their ticket OUT. But many others see it as a way to give back to a broken place that they deeply love. But I'll hazard a guess that those people are not generally considered "top tier" med school applicants.

 

[IslandStyle808]

Are there really rural areas in Hawaii?

I agree. My point is that if we continue to let people from the same (largely wealthy, suburban) background into medical school, we will continue to have extreme difficulty getting people to stay in rural areas.

Some people from rural areas see careers like medicine and law as their ticket OUT. But many others see it as a way to give back to a broken place that they deeply love. But I'll hazard a guess that those people are not generally considered "top tier" med school applicants.

If you visit the outer islands (all islands except Oahu), it really gets country. You would be surprised how much people rely on naturopathic medicine since there are no physicians in close proximity.

My state school also recognizes that people from the islands need to be selected to stay there. However, they still select people from urban Oahu for the majority of seats. They are not really addressing the shortage issues by selecting the majority of people from Oahu. I am sure there are stellar students from the outer islands (not as many) but they probably don't get the same opportunities that their urban counter parts have. It is mainly the issue of people from the outer islander not being able to go to a college with good programs and connections.

The medical schools should be more proactive about recruiting people from the rural areas. In other words, they should be talking with students from these areas more instead of only going to urban areas and making talks in large college conventions. This would be of great help for rural students in understanding that medical school is possible for them too.

 

[obscurehero]

The issue of finding and training primary care physicians is an issue that has been debated for years. The interesting thing is that pure monetary motivation isn't enough sometimes to get medical students to go into FM/IM and become a PCP let alone in rural areas or at need/risk areas. There are loan forgiveness programs, scholarships, etc. for students to go into this area and yet the only students I see taking advantage of these programs are students who would go into those areas anyway.

Some medical educators have raised concern about education in general. Family medicine is usually just one of many specialties you are exposed to and the vast majority of your exposure is hospital-based. When you get trained to operate in a hospital are you more or less likely to seek a career also working in a hospital?

There are also real challenges to family practice. You need to be a small business person. You need to hire a whole staff of people to navigate reimbursement. You need to negotiate rates, make sure that you meet the criteria to even be covered. Its quite a mess and most of it you aren't trained to handle in medical school.

Then we look at culture/society. We don't value primary care. We go to the doctor when we absolutely have to in severe acute crisis. What does it matter that we could've avoided it had we only just gone for a checkup once a year...

Maybe if you made 600k/yr you'd go into a field you didn't really like and that wasn't really challenging, but you don't get paid that well as a PCP. So even if schools try to somehow select people who think they will become PCPs there's no way to do that until the medical culture changes.