Serving the underserved and oneself

Every 10 years or so, a new report is put out about either the worrisome surplus of doctors or the dangerous shortage coming our way. Right now, it seems like by 2020 there will be a shortage of anywhere between 85,000-200,000 doctors, and primary care doctors make up the majority.

Who does this affect? The hardest-hit areas will be those places already hurting, like rural counties in Texas or Massachusetts, or rough parts of Chicago and Los Angeles. You don’t need to be a public health expert to realize that even though more people now have insurance, if they live in an area without a lot of doctors, especially primary care providers, they will still have greater difficulty receiving care.

Ironically, only 2% of US medical students are interested in general medicine, and the biggest demographic growth has been in specialists who practice in affluent metropolitan areas. It’s not hard to understand why. If you’ve gone through medical training, you’ve sacrificed a lot of money, time, and personal life to do the work you do. Why not live in a better neighborhood, closer to good schools and Whole Foods, if you can afford it? Why not choose a practice environment that allows you to work part-time or have weekends free, while still being able to put your children through college?

Many medical students may start out idealistic and state  that they want to serve underserved communities. However, studies show that two-thirds of medical students have selected a practice specialty even before embarking on clinical clerkships. I can guarantee that the majority were not thinking about primary care.

Aside: Some suggest that using personality and personal values as selection criteria for med school admission can increase the primary care workforce. I have mixed feelings about using personality as a factor in medical school admissions, since many students game the system these days by doing volunteer work and making promises they don’t intend to keep. That, however, is a totally separate post.

When these medical students have to make the choice about what kind of practice they want and what community they want to serve, differences emerge. In this study by Walker et al, which examined the motivations of 42 physicians of diverse backgrounds who worked in underserved or affluent communities, the most salient subtheme mentioned for leaving the underserved area concerned work hours and lifestyle. Physicians who worked in underserved areas were more likely to have a “unique connection” to the community they served, or to have a strong sense of mission, personal satisfaction, or moral obligation. The authors observed that none of the physicians who trained in affluent areas went to work in an underserved setting.

As the Robert Graham Center for Policy Studies in Family Medicine & Primary Care notes in their 2009 study on specialty choices of medical students and residents, there are many factors that steer medical students away from choosing a career in primary care and especially in an underserved/rural setting.

Really, what it boiled down to was the money.The physician income gap, alone, made it 50% less likely that a student would choose a career in primary care. The Center notes that “choosing a specialty that requires relatively little more training or expense than primary care, such as Radiology or Dermatology, pays tremendous dividends.” For example, a radiologist could make three times as much as a primary care doc, amounting to a $3.5 million difference in lifetime earnings. There is a huge financial and professional disincentive to earn less than one’s colleagues, not to mention the blow to self-esteem.

In addition, given that medical school tuition has increased anywhere from 100-300% in the last twenty years, it makes sense that medical students with loans to repay were also less likely to choose primary care.

Another was institutional: medical students who had no exposure to rural medicine were less likely to choose rural practice in the future. Some students felt pressured to choose a more “prestigious” specialty because of perceived institutional pressure. The study did note that public medical schools, especially those in rural locations, were much more likely to produce rural primary care doctors.

Interestingly, there was a gender difference when it came to rural practice. Although women are twice as likely to become primary care providers, they are only a third as likely to choose rural practice compared to males. A lot of this could have to do with lifestyle, closeness of family/social support, and patient attitudes towards female providers.

Question: how do you find ways to serve the underserved? If you practice in a rural setting or underserved area, what are points of satisfaction and frustration for you?

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About the friendly intern

Ask a question: The Friendly Intern My personal blog: Pathos and Pathology
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