Monday, March 18, 2013

Residency Match Results Bad for Primary Care (Again)

Once again, though not trumpeted as much as in previous years, reports of this year's residency match results are in, and some media outlets are claiming this to be good news for primary care.
The LA Times claimed Match Day 2013 results are good for future internal-medicine patients, stating "America’s future doctors are increasingly interested in become primary-care physicians -- good news for America’s future patients."  OBGYN News' claim was my favorite: Primary care spots are hot in largest-ever Match Day.

They are basing this on a few things. First, the actual numbers of US medical student graduates going into primary care fields such as internal medicine have in fact increase. For example, 3,135 students will be going into internal medicine, which is a 19% increase from 2009 and 6.6% increase from last year.
However, the main source of positive news is coming from the NRMP (the folks who do the match) themselves. According to their press release:

Match results can be an indicator of career interests among U.S. medical school seniors. Among the notable
trends this year:
• 3,135 U.S. seniors matched to internal medicine, an increase of 194 over last year.
• 1,837 U.S. seniors matched to pediatrics, an increase of 105 over last year.
• Family medicine matched 1,355 U.S. seniors, 33 more than last year. More than 95
percent of family medicine positions were filled.

Based on these numbers it would seem that more students are choosing careers in primary care. However, this is not the case, and in some instances things are actually worse.
You have to look at the total number of slots as well as the percent that our US students are choosing primary care fields.
Below is a table that has the match results for the last three years. It is important to note that there was almost 1000 more US seniors graduating, which according to the NRMP they attribute to the rising number of U.S. students to three new medical schools graduating their first classes as well as enrollment expansions in existing medical schools.
Despite having almost 1000 new graduating medical students, the addition of these students to the primary care fields are limited.  The real way to see what are students are choosing it to look at the percent of graduating students choosing a specific field (% US grads matching in my table).  The results are pretty bleak. 

There is virtually no change in student choosing internal medicine from 2011 to 2013 (18.9% to 19.1%). Family medicine, which looked to have a slight bump last year is actually down from 2011 to 2013 (8.35% to 8.26%). Peds is up from last year, but still down from 2011 (11.34% to 11.2%).  One also needs to look at how many of the positions that were offered (a major increase from prior years) were filled by graduating US seniors.  Internal medicine, which was filled by 57% of US seniors dropped significantly to just below half!. Family dipped from 48% in 2011 to 44.6% in 2013. Peds dropped by 1%. 

In other words....
  • More residency slots were offered across the board in primary care specialties, but more of these new slots were being filled by non-US graduates, than use graduates
  • Despite having three new medical schools worth of graduates, the pool of newly minted primary care physicians isn't really expanding that much
  • Our US seniors ARE NOT choosing primary care as a career, and if anything, are choosing primary care slightly less than previously, and certainly not more.
While internal medicine hasn't really changed, it is important to note that of those going into internal medicine, only 2% of seniors plan to go into primary care.

I blogged about this in 2011, when the media seemed to decry a boom for primary care. What I said two years ago is even more true today. This is a crisis. Many of the few primary care docs we have are retiring, leaving practice, or going cash only or retainer. If something is not done to increase the value, reimbursement, and job satisfaction of our primary care doctors; we will have no one left to care for our sick and aging population. (And before you post a comment about NP's and PA's filling this gap, those students aren't going into primary care either. A surgical PA makes more money than a primary care MD).


Julia Elisabeth said...

Hi Dr. Mintz,

This is Julia, from the GW Class of 2018. I went to your blog because I wanted some inspiration for starting my own, and ended up taking great interest in your most recent posts, since IM/primary care is at the very top of my list of potential specialties. One thing that I would love to hear more about is the comment you made at the very end about PAs/PTs not having the ability to fill the primary care doctor gap. How does policy affect the number of PAs/PTs (e.g. where does their funding come from?)Is it more difficult, less difficult, or equally difficult to widen the pool of primary care physicians than PAs/PTs? I hope your heart does not sink at me asking this question, or that I'm not poking my finger into a hornet's nest -- I do not mean deflecting attention away from the primary gap shortage, but rather, simply trying to get a better understanding of all the forces at play in our goal to provide sufficient primary care to the US population, especially since I am in the Health Policy Track, and since I have heard this suggestion come up in conversations before.

See you around Ross Hall!


Dr. Matthew Mintz said...

Thanks for reading my blog. Great questions. More importantly, glad that you interested in Primary Care.
I will try to answer your questions.
First, the comment was not that PA's/NP's not having the ability to fill the primary care gap, but the fact that they likely won't because they are choosing to go into sub-specialty as well. Political pundits will often talk about PA's and other allied health professionals filling the Primary Care gap given both the shortage and our medical students not wanting to go into Primary Care. However, they often incorrectly make the assumption that all PA's go into primary care. While a greater percent of PA's go into primary care than medical students, the number is still low. This is because PA's can work in medical sub-specialties, the hospital, the ER, surgery, etc. They are choosing sub-specialty for the same reasons as our medical students.
As far as funding, the difference is that the allied health professionals don't have to do a residency like medical students. Once you graduate medical school, you can't practice medicine without a residency. NP's and PA's can practice upon graduation. Medical residencies are funded by Medicare, which is why this is a policy issue.