The lack of primary care infrastructure in the U.S. has been blamed for our extremely high health expenditures, as we spend about 2.5 times what other comparable countries spend (OECD Health at a Glance) without better health outcomes.
Increasing our primary care workforce is an important part of controlling health care costs while also providing coordinated care for patients who are aging and dealing with chronic conditions. So, we need more medical school students to be interested in primary care. One factor is money, as pointed out by Leigh and colleagues—specialists make much higher salaries than generalists, and this gap is wider in the U.S. than in many other countries. As a sociologist, I was interested in what factors besides money impacted these career decisions. How does the culture and structure of medical school impact whether students are drawn to primary care or pushed away?
Layered onto this question is the reality that the “primary care shortage” is a problem that has been repackaged as a new issue for decades. Researchers who have studied medical education reform remind us that calls for “fostering generalism” have long been a common theme (see articles here and here).
Interested in the historical roots of primary care place in medical education, I analyzed a collection of primary care oral histories that Fitzhugh Mullan collected and generously donated to the National Library of Medicine. These oral histories richly recount the experiences of 52 physicians and their choice of primary care. In my recent article, I found that a majority of respondents described encountering disparagement about primary care or were discouraged from choosing it. Unfortunately, these negative messages about primary care continue to persist and are all too common. Almost all primary care physicians have stories they could tell you—being told they are “too smart” to do primary care, for example. We can think of these negative comments as primary care bashing, medical bigotry, or badmouthing.
My research calls attention to the deeply embedded cultural and structural obstacles to advancing primary care. Primary care reform must recognize that the culture of the medical school environment is very powerful. Even subtle messages in the unhidden curriculum can greatly influence career decisions. Samuel Bloom has shown that medical schools are often resistant to change. Thus, addressing the primary care workforce problem will take time and mount a multi-faceted approach. Addressing reimbursement for primary care is important work; rewriting the cultural narrative about primary care is important work as well. Instead of primary care being seen as the specialty of last resort, we need to tell a new, and true story—that primary care is incredibly complex work that is rewarding and incredibly valuable.