2011 Residency Match NOT Good News for Primary Care

The there are currently few reports of this in the mainstream press, the AMA news announced "Residency Match sees continued growth in primary care." The American College of Physicians reports on their web site states "Residency Match Results Encouraging for Adults Needing Primary Care." Kevin Pho of KevinMD appropriately wonders whether this increase is enough to save primary care in his post "Match Day 2011: Family medicine grows, but enough to save primary care?" based on the assumption that this year's match meant good news for primary care.

Don't believe the hype.

This was not a good match for primary care or our health care system in general. These positive reports are based on the press release from the National Resident Matching Program or NRMP which is the group that runs the match. They stated that


"The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010 . Among primary care specialties, family medicine programs continued to experience the strongest growth in the number of positions filled by U.S. seniors. In this year’s Match, U.S. seniors filled nearly half of the 2,708 family medicine residency slots. Family medicine also offered 100 more positions this year.

The two other primary care specialties that increased in popularity among U.S. seniors were pediatrics and internal medicine. U.S. seniors matched to 1,768 of the 2,482 pediatric positions offered, a 3 percent increase over 2010. In internal medicine, U.S. seniors filled 2, 940 of 5,121 positions, an 8 percent increase over last year."

At first glance, this seems like good news for primary care. However, their use of statistics is misleading. They are not taking into account that there were almost 500 more US medical students in the match this year. This is equivalent to a drug company telling you that their medication reduces hearts attacks by 30% (from 50 to 35), but forgets to tell you that there were 1000 patients in each group, so that the real reduction in heart attacks is only 1.5%.
What you need to look at is the percent of US medical students that matched into that speciality and whether or not it changed from last year to this year. If you go to the NRMP web site, you can get the actual raw numbers. For Pediatrics, though more US seniors matched into Pediatric residencies (remember there was about 500 more students this year than last), the percent of US seniors matching into Pediatrics was unchanged. For Family Medicine, there was a slight bump, but compared to last year, only about 1/2 of a percent more of US seniors chose to go into Family Medicine (far less impressive than the relative increase of 11%). The real big bump was in Internal Medicine, where almost 1% more US seniors matched into Internal Medicine. However, we know from previous studies, that only 2% of seniors that choose Internal Medicine plan to go into primary care. (See here for previous post).


What is also in the NRMP press release (that some are paying less attention to)

"Dermatology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery, and vascular surgery were the most competitive fields for applicants. At least 90 percent of those positions were filled by U.S. medical school seniors.

The number of U.S. medical school seniors in emergency medicine increased by 7 percent and grew for the sixth year in a row, as they filled 1,268 of the 1,607 first-year positions available. Anesthesiology offered 44 more positions and matched 45 more U.S. seniors who filled 671 positions of the 841 offered "

Essentially, though there are more medical students this year than last, and thus more doctors available to society when they are done with their residencies, the same low numbers of students are choosing residencies that will lead to careers in primary care. This small increase will not make up for the many patients in the US who lack a primary care physicians and certainly won't even begin to fill the gap when many of our now close to 50 million uninsured patients suddenly gain insurance under health care reform. Rather, despite the clear need for more primary care physicians, our students continue to choose the more lucrative subspecialties.

America, this is a crisis. Many of the few primary care docs we have are retiring, leaving practice, or going cash only or retainer. Our students see this and continue to choose other specialties. 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).

Having health insurance doesn't ensure it will be easy to find a doctor

An excellent article appears in today's Washington Post entitled "Having health insurance doesn't ensure it will be easy to find a doctor," where a young, otherwise healthy and insured woman discusses her extreme difficulty in finding a doctor in Washington, DC who will see her.

"I was just 23, basically healthy and, most important, insured. So I pulled out my computer, looked up the UnitedHealthcare list of pre-approved doctors and started calling. And I got rejected. Again. And again. (Usually after being put on hold for three or four minutes.) "

Next to Massachusetts, D.C. has the largest number of physicians per patients. (The article briefly mentions the lessons Massachusetts has learned about providing health care for everyone without addressing whether there are enough primary care physicians to see them). D.C.'s doctor excess, like Mass., is somewhat exaggerated given that there are several teaching hospitals with more than a few resident physicians. However, there are more than enough docs in D.C. to see patients. The problem is that in addition to not having enough primary care physicians, more and more primary care physicians are not accepting new patients. The article suggests that this is a supply and demand issue, which is true. However, another major factor that the article neglects to mention is that there are many primary care physicians in D.C. gladly accepting new patients. However, they will not take your insurance.

I practice in a large, academic teaching center in D.C. and we stopped taking new patients several years ago. This happened because many of the physicians in D.C. stopped taking insurance, and many of their former patients who were not willing to pay out of pocket to see their former doctor came to our practice (we take virtually every insurance). The problem is that we now have so many patients, they have a very difficult time getting to see us for an appointment.

The article suggests several solutions to increase the number of primary care physicians including recruiting more primary care oriented students into medical school and funding more residency spots for graduates going into primary care. These are good ideas but will not solve the problem. In a survey we did, we found that only 2% of students going into internal medicine were going into primary care internal medicine. The main reason that they chose not to do primary care was lifestyle. Students perceived primary care physicians as too busy, doing too much paperwork, and undervalued by society. Until this problem is fixed, the primary care crisis will remain. ( See Factors Associated with Medical Students' Career Choice Regarding Internal Medicine: Pay is Not Really One of Them! )

I have previously discussed that the same issue happened with psychiatrists years ago, and this is why we have a two types of psychiatry in the US. The psychiatry that you see on the TV and in the movies only occurs for those patients willing to pay out of pocket for their care. Those who pay for mental health with insurance might see a psychiatrist once a year for a few minutes, but any counselling is done by someone else. Getting an appointment with a mental health professional that accepts your insurance is similarly challenging. (See a piece I wrote for KevinMD called "As psychiatry goes, so will primary care," and How can a psychiatrist write 100,000 prescriptions a year, and why this matters to Primary Care? )

Though I believe it is important to support health care reform, it will do nothing to fix the lack of primary care physicians nor does it address the root cause of the problem (see Why you must support health care reform, even though it won't fix our health care system. ). If you are frustrated by the system, one thing to think about is paying out of pocket to see your primary care physician. Though many doctors who see "cash paying" patients run more of boutique or concierge practice, more and more primary care physicians are seeing patients at more reasonable prices, and just desire to get the insurance middle man out of the picture ( see Insurance Free Medicine )

Update: A related post byDr. Toni Brayer was just posted on KevinMd. Primary care needs to be valued first before it can be saved . I think a lot of us are all saying the same thing.