In 2008, 8.2 percent of the nation’s medical-school graduates chose to specialize in family medicine, says Davis. UW Medicine’s percentage was nearly double that figure; 14.8 percent chose the profession.
“But if you look at attrition,” he says, “there are places around the country that have seen as much as a 20-percent decline in their primary-care physician population since 2000.” Some of this is simple math. Doctors who trained in the 1970s are beginning to retire. But some of the decline is caused by doctors who leave primary-care fields — doctors who are facing the same sorts of decisions as those faced by students choosing a specialty.
“The big gorilla in the room is the relative pay differential between people who go into primary care and people who specialize,” says Doescher. “The average primary-care physician, over the course of a lifetime, earns $3.5 million less than the average specialist.”
In part, this situation is connected to the relative value scale, explains Norris, a scale — set by the government, the American Medical Association and other groups — that helps determine the fees doctors can charge for their services. Specialized procedures cost more money than routine care. And some care, such as the coordination of multiple medical problems, is simply overlooked by the billing system.
“Physicians in primary care do a lot of care management and care coordination, and those kinds of activities just aren’t reimbursed,” says Davis. “You’re essentially paid almost on a production basis. It’s much better if you see more patients than if you see fewer patients and take much better care of them.” It’s not a satisfying way to practice medicine.
Students at the School of Medicine are exposed to these issues through a variety of training programs, and what they learn influences their choice of career. Amanda Keerbs, acting assistant professor of family medicine and a clinical faculty member for the family medicine preceptorship (in which students shadow doctors), knows students are paying close attention. “It’s amazing to see how observant the students are and how in tune they are with these topics… like the use of medical resources, the time issues, the ‘can you really take care of a patient in 15 minutes’ issue, the lifestyle issues,” she says.
Of course, temperament also plays a role in choosing a specialty, says Sharon Dobie, Fel. ’89, professor of family medicine and a member of the Colleges faculty. “We admit students who are perfectionists and want mastery at a very deep level,” she says. Being a generalist, the role usually taken on by primary-care physicians, may be uncomfortable for some students. Alternately, there’s a persistent rumor that students who choose primary care aren’t reaching high enough. Dobie puts that rumor to rest.
“Obviously, I don’t have the depth of knowledge about kidney care that a subspecialist in renal transplant has,” says Dobie. “But I have a different set of skills, and they are equally meaningful. It’s not about being smarter or less smart. I think that’s hard to keep clear when you’re a trainee.”
With the TRUST program, begun in September 2008, the School hopes to make this complicated decision process a bit easier to manage — and to create more primary-care doctors for the WWAMI region.
Family Medicine Interest Group students spend an evening with Acting Assistant Professor of Family Medicine Amanda Keerbs (blue sweater), learning how to apply and remove splints and casts. Student programs like these draw trainees in and inspire them. As medical student Mo FitzMaurice says, “I chose to attend the UW School of Medicine because of its focus on primary care.”