Estimating Entrance Into Primary Care: Time for a Change?

Abstract

To the Editor: For as long as we can remember, leading scholarly journals, including Academic Medicine, have published articles stressing the need to produce primary care physicians in the United States. 1–3 Why has this occurred? We believe it is because medical educators want to support socially accountable systems of medical education and health care that serve those on the economic, geographic, social margins of society, 4 and they know that primary care physicians are crucial to achieving these ends. However, the Association of American Medical Colleges (AAMC) has categorized all graduating medical students entering residencies in internal medicine, pediatrics, medicine-pediatrics, and family medicine as primary care physicians. We believe this classification system misrepresents reality (as do, incidentally, statements suggesting other specialties are primary care disciplines 5). Many graduating medical students who enter residencies the AAMC has classified as producing primary care physicians end up subspecializing. This includes almost 90% of students entering internal medicine. 6,7 Over 40% of those entering pediatrics similarly subspecialize, 6,7 roughly the same percentage of those entering medicine-pediatrics who subspecialize or practice as hospitalists. 8 As well, 9% of those entering family medicine limit their practices to select areas of clinical concentration. 6,7 To correct this misrepresentation, we suggest a count based on internal medicine, pediatrics, medicine-pediatrics, and family medicine physicians’ practice patterns 5 years after residency graduation. Alternatively, the Intent to Practice Primary Care Method calculates the aggregate percentage of graduates practicing primary care by counting only those graduates who enter primary care-internal medicine, primary care-pediatrics, medicine-pediatrics, and family medicine residencies. 7 If the AAMC and other bodies, such as the National Resident Matching Program, are genuinely interested in addressing issues of equity and accountability in health care, it is important they change how they categorize who among medical school graduates enters primary care practice. Such a change is vital to establishing a more accurate estimation of medical workforce needs in relation to the health of the public.