Is There a Primary Doctor in the House?

Floyd Willis, a family physician at the Mayo Clinic in Jacksonville, Fla., grew up in rural Georgia during the 1960s watching his parents volunteer. His father helped local residents complete their Social Security and insurance forms, while his mother prepared meals for the hungry. At a young age, he knew he wanted a career where he could interact with people and serve his community. To Willis, family medicine seemed like the natural choice.

“When I went to Morehouse, there was such a strong predilection towards sending doctors back to underserved areas and helping to improve primary care,” Willis said.After graduating from Yale University with a bachelor’s degree in biology in 1982, Willis interviewed at several medical schools, but when he visited Morehouse School of Medicine in Atlanta, he saw that it was different. Morehouse, which was founded in 1981 with 32 students, was committed to training primary care physicians for practice in medically underserved inner-city and rural areas.

Willis graduated in the school’s second class and in 1989 after completing his residency in family medicine at the Mayo Clinic in Rochester, Minn., he started his own practice in Carrollton, Ga., a small rural community west of Atlanta.

In the past five decades, the percentage of U.S. physicians practicing primary care has dropped steadily, from nearly 50 percent in 1963 to 30 percent in 2010. This percentage is expected to drop even further when the Affordable Care Act pours an additional 32 million Americans into the health care system. While the U.S. health care system faces a dire shortage of primary care physicians, many medical schools continue to accept students without considering their interest in future specialty.

“We know what it takes to get more primary care physicians,” said Dr. Richard Streiffer, a professor in the department of family and community medicine at Tulane University School of Medicine in New Orleans. “It takes an admissions process that looks beyond the numbers.”

When applying to medical school, applicants report the grades that they earned in their college courses and their scores from the Medical College Admission Test. Admissions committees look favorably on applicants with high test scores and grade-point averages because these factors help predict how well applicants will perform during the first two years of medical school.

But some experts argue that placing excessive weight on test scores and grade-point averages leaves little room for considering other traits important to primary care, like altruism and serving the population as a whole.

“I think in some ways medical schools are hamstringing themselves by admissions policies that work contrary to that goal,” said Dr. Stephen Smith, a professor emeritus of family medicine at Brown University’s Warren Alpert Medical School, who believes that one of the reasons that medical schools place extreme emphasis on grade-point averages and test scores is to bolster their U.S. News and World Report rankings. “There’s some correlation between MCAT scores and success in medical school, but when you get to a certain threshold, it doesn’t make any difference.”

However, some admissions officers believe interest in future specialty at the time of acceptance is a poor indicator of what specialty students will ultimately pursue.

“What is valid is their passion for medicine, whether it’s neurosurgery or primary care,” said Dr. Marc Kahn, the associate dean for admissions and student affairs at Tulane University School of Medicine.

Dr. James Weiss, the associate dean for admissions at Johns Hopkins University School of Medicine, also admitted the admissions committee at his school doesn’t have any particular set standards as to what specialty it gives preference to. “Particularly because we know that almost 90 percent of students who go to medical school change their minds once they see all the other specialties,” he said.

However, other experts disagree, citing evidence that most applicants – particularly those interested in primary care – don’t change their minds as often as many admissions officers think.

“The myth is that medical students are sort of blank slates, and they decide their specialties based on what happens in medical school,” said Dr. Howard Rabinowitz, a professor of family medicine and director of the Physician Shortage Area Program at Jefferson Medical College in Philadelphia. “But the data does not support that at all.”

In an article published in Academic Medicine, Rabinowitz identified predictors of medical school applicants pursuing careers in primary care, including geographic background, attitudes and personal values. He said that a medical student who grew up in a rural community, like Willis did, and who is interested in primary care at the time of medical school admission, is highly likely to go into the field. Another study published last year in Academic Medicine by researchers from Washington University also found that students enter medical school with certain beliefs and attitudes that influence their specialty choices.

The U.S. Department of Health and Human Services estimates that nearly 17,000 additional primary care practitioners would be necessary for there to be 2,000 patients to one provider.

If the number of patients per primary care physician were to drop to 1,000, primary care physicians would have enough time to perform thorough physical exams and build durable relationships with patients, said Alan Sager, a professor of health policy and management at the Boston University School of Public Health. When you have smart, compassionate doctors with knowledge and time, you avoid trips to the emergency room and expensive and unnecessary referrals to specialists, he said.

As researchers from George Washington University wrote last year, medical schools are the only institutions in our society that can produce physicians. By accepting students who are committed to practicing primary care, medical schools will have an opportunity to help restore the foundation of America’s health care system.

“There’s great room for optimism, but we better seize the opportunities pretty fast,” Sager said. “If primary care melts down, it’ll be very hard to rebuild, and we’re living on borrowed time.”