As a medical student, every time I meet a physician for the first time, I will inevitably be asked about my specialty of interest. When I say, “family medicine,” reactions are generally split by a rule of thirds: one third will encourage me, one third will respond with a half-hearted nod and a change of subject, and the final third will start a familiar speech I’ve heard dozens of times.
“You’ve probably never been told this,” they begin, “but as a primary care doctor, you’ll be undervalued, underpaid, overworked, and, really, you won’t be making a difference in your patients’ lives. You should consider specializing instead.”
The speech is discouraging, to say the least. Its frequency is striking, and gives me the feeling that my career passions are pitted against the culture of my own field. I can understand why these perceptions exist; in the U.S., the primary care system is struggling to keep up with insufficient doctor-to-patient ratios and endless administrative tasks. Visits are often crammed into 10-15 minutes, during which patients and physicians can only begin to scratch the surface on management for diabetes or investigation of new and mysterious symptoms.
The primary care system feels very broken, and it’s hard to know where to begin to fix it. However, if one thing is clear, the solution to the primary care crisis is not fewer physicians. In fact, deterring students from primary care fields may exacerbate issues already impacting primary care services across the country. A study from the Association of American Medical Colleges predicts that without an increase in residency positions, there will be a primary care physician shortage of 20,000 to 41,000 physicians by 2036, accelerated by a rapidly growing population of older Americans as well as a large population of older doctors nearing retirement.
We should be collectively embracing and nurturing our students’ primary care interests if we want to expand this field. Yet, if my own experience is any indication, this will require not only changes in the primary care landscape, but also a major cultural shift in academic settings.
Does Academic Culture Influence Specialty Choices?
One study demonstrated just how influential the culture of medicine and its “hidden curriculum” can be. A survey asked fourth-year medical students about factors that influenced their specialty choices and found that students were significantly less likely to choose a primary care specialty at institutions with high levels of negative talk about primary care. This finding makes sense; after all, as students we are highly receptive to the opinions of our mentors and use their guidance to navigate our path through a challenging career.
The same study also found that students with a higher proportion of positive clinical experiences in primary care were more likely to pursue one of the primary care residencies. This demonstrates the importance of frequent and early introduction to the specialty in medical school curricula.
While this does not directly change the quality of interactions with other specialists in academia, it does create an environment that encourages interest in primary care and provides opportunities to meet primary care physician mentors who can encourage these interests. In fact, of all the providers who have questioned my decision to be a family medicine physician, not one was a primary care physician themselves.
My own positive experiences during clinical rotations played an important role in my interest in family medicine, a field I had not been exposed to as a pre-med or pre-clinical medical student. On my rotation, I found family medicine to be energizing and enlightening; it offered a career path where I could prevent and manage chronic disease, help my patients navigate a complex healthcare system, and foster trusting and long-term relationships with patients.
Despite many instances of discouragement from doctors in other fields, I found a passion for family medicine and primary care — I only hope that more students can explore their interests in the amazing facets of primary care without the same burden of skepticism.
A Challenging but Necessary Task
To be sure, changing the culture of an institution is not a quick or simple fix. But just take a look at the cultural shifts that are already occurring in medical training, and you’ll see that it is possible. In the past few years we have witnessed the unionization of residency programs, the shift to a pass/fail Step 1, and evolving medical school curricula that emphasize public health and social justice issues.
If we want to bring more students into a career in primary care, we need to address the “hidden curriculum” that discourages them from even considering it. This change is possible, and might even be necessary, if we are to hope for a brighter future for the American primary care system, fueled by passionate new doctors.
Danielle Gabuzda is a fourth-year medical student in the MD/MPH program at the University of Miami Miller School of Medicine.
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