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May 6, 1998

Family Medicine: A Call to the Front Line

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JAMA. 1998;279(17):1403. doi:10.1001/jama.279.17.1403-JMS0506-7-0

Between 1965 and 1992 the proportion of physicians in general practice declined from 51% to 35%.1 Despite repeated expressions of concern by government agencies and health care experts,1-2,3 an imbalance in physician career preference has persisted, favoring oversaturated specialty fields. The 1992 report of the Council on Graduate Medical Education (COGME) set a national goal for at least half of graduates to begin careers in family practice, general internal medicine, or general pediatrics by the year 2000.4

Analysis of data from the National Residency Matching Program (NRMP) from the time since the COGME report suggests that this goal is being approached. Following a 4-year decline between 1988 and 1991, the number of family medicine residency positions filled in the NRMP jumped from 1658 in 1992 to 2002 in 1993, an increase of more than 20%. By 1997, the number of filled positions was 2905, an increase of 75%.5-68 Historically, approximately 95% of those entering family medicine have proceeded to enter primary care practice.9 Additionally, 60% of those entering pediatrics and 35% of those entering internal medicine have also entered primary care practice.9 Taking these figures together, it can be expected that 37.5% of the 1997 graduates will have a generalist career, up from 27% in 1992.5,8

There is evidence to indicate that financial incentives influence specialty choice,10 and managed care is providing new economic incentives for young physicians. Between 1985 and 1993, states with the highest penetration by managed care also had the highest rate of growth in primary care physicians' income.11

This attraction paradoxically may put underserved rural populations in some peril, as HMOs may be luring some generalists into prosperous urban areas.12 Recently, young physicians have begun to respond in earnest. In 1997, the Association of American Medical Colleges Medical School Graduation Questionnaire demonstrated a significant rise in graduates planning to practice in an underserved area.13,14 Many educators believe that recent changes—including allowing medical students to rotate through rural and inner-city clinical settings and providing required clerkships in community-based practices—are having a positive effect.15

A less apparent influence on specialty choice may come from distinctive cultural influences engendered in academic medical centers. Students and residents may encounter an unwelcoming attitude toward primary health careers and expressions of these sentiments can have significant effects on specialty choice.16

Alternatively, the trends in specialty choice might be explained by the increasing tendency of medical schools to recruit students with a particular interest in primary care. A program initiated in 1974 at Jefferson Medical College that combines a selective admissions policy with a special educational curriculum has proved effective.17

While medical student choice has an important effect on physician supply, the 650000 physicians already in practice in the United States have a greater potential to alter demographics. Though the demand for this option has thus far been underwhelming, the retraining of subspecialists for primary care careers remains a viable potential means of redistributing the physician workforce.18

Job satisfaction may explain why relatively few physicians have chosen to retrain. A recent large study showed that even in this turbulent period of health care transformation 80% of physicians surveyed were satisfied with their jobs and overall satisfaction was equivalent for primary care and non–primary care physicians.19

It appears that the precautions against overspecialization urged by health care leaders at the beginning of this decade are now being heeded by its end. The changes are far from complete, however, and opportunities for young physicians to practice medicine, even in the midst of a physician surplus, will continue to exist in the unsaturated primary care fields.

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Association of American Medical Colleges, Supplying Physicians for Future Needs: The Report of the Task Force on Physician Supply.  Washington, DC Association of American Medical Colleges1990;
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Council on Graduate Medical Education, Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century: Third Report to Congress and the Health and Human Services Secretary.  Rockville, Md Health Resources and Services Administration1992;
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Wall  EMSaultz  JW Retraining the subspecialist for a primary care career: four possible pathways.  Acad Med. 1994;69261- 266Article
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