Primary care?
Not me

Today's residents are deserting primary care for more lucrative specialties and more desirable lifestyles.

By Barbara Weiss
News Editor

In the early 1990s, new medical school graduates flocked to generalist residencies, spurred by the vaunted need for primary care gatekeepers. When the need failed to materialize, the rush subsided. In family practice, the decline has been fairly steady over the past few years. In 1998, 85.5% of positions in family practice residencies were filled—66.2 percent by seniors graduating from American medical schools. In the match conducted this March, only 79.1 percent of family practice positions were taken—and only 47.2 percent of them by US seniors.

Other generalist specialties are suffering as well, with fewer applicants matched to pediatrics and internal medicine positions. Ob-stetrics/gynecology experienced a slight uptick in 2002, but had been trending downward in both positions filled and number filled by US seniors in recent years.

General surgery seems to be in decline as well. Over the last five years the percent of positions filled dropped from 97.7 to 94.4 percent, and the percent of US seniors dropped from 83.3 to 75.3 percent. Writing in the Archives of Surgery, Kirby Bland and George Isaacs note that in 1981, 12.1 percent of seniors chose general surgery as their first choice; they project that by 2005, only 4.8 percent of students will do the same.

Of course, higher paying fields such as orthopedic and plastic surgery continue to fill virtually all of their positions. But students are not merely seeking more lucrative pastures. There is a shift in priorities towards "medical specialties that provide [a] controllable lifestyle," note Bland and Isaacs. The current generation is taking a hard look at length of training, number of hours on call, likelihood of litigation, amount of stress, and how much they'll be able to control or predict their work schedule. Specialties with better lifestyle options—like anesthesiology and radiology—are more popular.

The missing residents

Many medical students who do choose primary care are apparently changing their minds once they're in a program, either switching out of their residencies for another field or leaving medicine altogether.

Norma E. Wagoner, dean of students at The University of Chicago, Pritzker School of Medicine, and her colleague J. Robert Suriano, professor emeritus of the University of Cincinnati College of Medicine, surveyed 358 residency directors who oversee 3,519 positions among them. According to preliminary data from the survey (presented at a symposium in March sponsored by the Arnold P. Gold Foundation on humanism in medicine), 108 residents were dismissed for poor performance in the last three years; 179 transferred to another program; and 66 left medicine altogether.

Residency directors say those who left medicine were unprepared for the work demands of graduate medical education; were never really committed to the specialty; or wanted to stay home and raise families. Of those who switched to a different specialty, the directors said they had entered the program without understanding the demands of the specialty or wanted a lifestyle that required less dedication of self and time.

"This is a time of change in societal values," Wagoner ex-plained. "Program directors were brought up to honor the Christian work ethic. Delayed gratification and unremitting toil were the rules of the day, and residency programs were built on that model. But young people coming through now want to spend more time with their families." Another factor, she added, is the "huge indebtedness" that tempts students to shun primary care for more lucrative fields. Today's medical students graduate with an average debt load of almost $100,000, according to the Asso-ciation of American Medical Colleges.

The burnt-out residents

The residents who stay seem an increasingly discontented lot. Despite AAMC guidelines that have cut down on the number of hours worked per week, primary care residents today seem wearier and less enthusiastic than previous generations.

Two studies published in the March 5 issue of Annals of Internal Medicine attest to the problem of resident burnout, and an editorial by Jordan J. Cohen, president of the Association of American Medical Colleges, in the same issue addresses the problem: "The stresses, both professional and personal, that residents now experience do seem to be much more intense than in the past. Patients are sicker, hospital stays are shorter, and attendings are more hassled; many more residents are married, many have children, and a great many more are women."

One of the Annals studies looked at IM residents at the University of Washington and found that 76 percent of them met the criteria that define burn-out, and they were significantly more likely to provide suboptimal care.

The second study looked at the emotional and financial status of all US internal medicine residents. It showed that higher educational debt correlated with self-reports of cynicism and multiple depressive symptoms.

Four or five depressive symptoms were reported by 35 percent of these residents (40 percent of the females and 32 percent of the males); 23 percent thought they had become less humanistic during their training; 61 percent said residency had made them more cynical. The women overwhelmingly (85 percent) believed that residency would increase the complications of pregnancy. (Intriguingly, however, residents with children reported less depression and cynicism than childless colleagues.)

In another national study of residents, DeWitt C. Baldwin Jr., senior fellow at the AMA's Institute for Ethics, has found equally disturbing results. His preliminary data, presented at the Arnold P. Gold symposium, show that just over 70 percent felt that sleep deprivation decreased their capacity to care for patients. "Nearly 30 percent attributed significant medical errors to fatigue and sleep loss," said Baldwin. Those factors correlated with more conflict with colleagues, more instances of working while impaired, decreased satisfaction with learning, and increased levels of stress, accidents, alcohol use, and use of medications to stay awake.

This disaffection of residents is not, of course, an isolated problem. Practicing physicians are more vocal about their discontent too. The authors of the national study reported in the Annals write that "the residents' role models and teachers often openly express discontent with the practice of medicine."

That message has filtered down to college students as well. The number of applicants to medical schools continues to decline; applications in 2001-2002 dropped 6 percent from the previous year. Medicine, once aspired to as both a noble profession and a guarantee of financial security, strikes many current students as simply a stressful and poorly-paid job.

Medical schools are already changing to adjust to student values, says Norma Wagoner. Residencies will also have to become more flexible and be willing to accommodate. How well they do that may determine whether primary care, obstetrics and gynecology, and general surgery have enough practitioners in the future to provide care to succeeding generations.

Match Program 1998–2002

How serious is the resident drain?

 

Barbara Weiss. Primary care? Not me. Medical Economics 2002;14:42.