To Be or Not to Be (a Super-specialist)

Check out my latest on the Differential: To Be or Not to Be (a Super-specialist)

Finding the Right Specialty

Check out my latest post on The Differential: Finding the Right Specialty.

Primary Care Physician Shortage

By 2014, the Patient Protection and Affordable Care Act (ACA) will expand the Medicaid health insurance program to over 15 million people. Among many things, this expansion will allow millions of people access to regular primary care. But is the field of primary care prepared to deal with such an expansion?

Primary care physicians (PCP's) serve as the initial contact person for a patient’s health issue. PCP's work with the patient over a long duration of time, treating routine conditions and providing preventive services like vaccinations. PCP's also refer the patient to specialists (e.g. cardiologists, endocrinologists) when necessary. Depending on the scope of the physician’s practice, primary care providers are internists and pediatricians, but can also be geriatricians or obstetricians and gynecologists. Nurse practitioners and physician’s assistants are increasingly providing primary care to patients as well.

For many years there has been talk about a physician shortage in the field of primary care. At one time, primary care physicians constituted the bulk of American physicians. However, advances in technology, increased medical educational debt, lower reimbursements and higher patient loads for primary care physicians have caused most doctors in training to enter a specialty field. The Association of American Medical Colleges predicts that in the decade that began in 2010, nearly one-third of all practicing physicians will retire. As a result, Americans will need an estimated 45,000 primary care physicians by 2020.

This trend has far-reaching consequences. Many ethnic minorities, people with low socioeconomic status or no health insurance may use primary care physicians and/or community health centers as their only source of health care; however, access to these providers is already limited for some patients because of factors like geography and a lack of transportation, or more complex issues like language barriers. The actual shortage of physicians and lack of funding for community health centers only exacerbates this problem.

Also, one statistic from the Kaiser Family Foundation says that 56% of patient visits in America require primary care, but only 37% of physicians practice primary care medicine, and only 8% of the nation’s medical school graduates go into family medicine. Furthermore, a higher ratio of specialists to patients has been correlated with higher mortality rates overall. This suggests that a higher ratio of primary care physicians will contribute to better health. With better access to primary care, patients can prevent disease and receive early treatment in the event of an illness.

The ACA has proposed several pieces of legislation to help solve the primary care physician shortage (the following was summarized from a Kaiser Family Foundation brief):

• Add 15,000 new primary care providers to the workforce by 2015
• Allocate $300 million for the National Health Service Corps which recruits the primary care workforce in underserved areas 
• $230 million in award grants will go to “teaching health centers” to start primary care residency programs 
• 10% bonuses for primary care providers under the Medicare fee schedule (started in 2011)
• Increase PCP reimbursements at the state level from Medicaid rates to Medicare rates by 2014 
• Increase the number of Accountable Care Organizations (ACO's) which thrive on the quality and not the quantity of patient care. ACO's encourage collaboration among physicians and allied health professionals rather than overuse of medical services
• Increase the number of community health centers 

Lastly, medical education institutions are charged to shape medicine’s leaders of tomorrow. This means medical schools should continue to educate students about issues related to primary care and the state of the health care system. Shadowing and networking with primary care physicians may increase interest in the field. Curricula should include such activities. Also, the number of residency programs must increase in order to accommodate the growing number of medical school graduates.

Match Day!

Students search for their Match envelopes
Photo taken from: whsc.emory.edu

Today the National Resident Matching Program (NRMP) released their results. On “Match Day”, thousands of medical students across the country open envelopes at the exact same time and learn their fate—at least that of the next 3-5 years! According to an NRMP report, close to 47,000 students participated in the Match in 2011.

In medical school students spend four years studying the basic science material and rotating through clerkships in various medical specialties. Each clerkship serves to train the student, but also to allow the student to develop an idea of which medical specialty she will pursue. Will it be Pediatrics? Pathology? Perhaps Preventative Medicine?

Within the four years of medical school, students are required to pass Steps 1 and 2 of the United States Medical Licensing Examination (USMLE) in order to receive their degree. After graduation, novice physicians complete more extensive and hands-on clinical training program called “residency” that will transform them into full-fledged, autonomous doctors.

The difference between the NRMP and other application processes is that the applicant can only be matched to one residency program. This is a stark contrast to the college and even medical school application processes, in which an applicant can be accepted to multiple schools. The Match is like any other application process—on steroids!

Once decided on a medical specialty, medical students sometimes apply to fifteen programs or more! They travel all over the country to interview with program directors and medical faculty. They meet current residents in each program and explore the geographic area. Finally, medical students rank each program according to their preferences. However, residency programs also rank the applicants. Programs evaluate the applicant's academic record, USMLE scores, letters of recommendation, personal statement, professionalism and many other aspects of the student's application. Both parties submit their rank lists to the NRMP system which uses a mathematical algorithm to generate the best match possible. In an ideal scenario, a program’s very highly ranked candidate will also rank that particular program very high. Voilà! A match made in heaven!

However, creating a rank list is challenging for both applicants and programs. One of the most troubling points for applicants is coping with a lack of control over the process. Students are matched to one program and one program only. Beyond creating their rank list, students do not have control over where they will end up. The student may have preferred to match with a program in California but match to a program in Massachusetts. This can have a profound impact on the student's professional and personal life and loved ones.

A book entitled, “Match Day,” by Brian Eule, addresses this issue exceptionally well. Eule endured Match Day with his medical student-girlfriend. The non-fiction book tells the story of three medical students (including Eules girlfriend) and the way in which the Match impacted their lives; the book also brings in facts about the history and development of the match process. This book is useful for medical students and their loved ones, and anyone interested in learning more about Match Day.

After a 6-month hiatus, Match Day prompted me to write a post. I recently had my own “Match Year” as I learned which medical schools had accepted, rejected or waitlisted me for admission to their programs. This year has been one of celebration as I was accepted to several of my top-choice medical schools. However, I cannot help but think this is the quiet before the storm! In just four months, I will officially begin my transformation into a physician. In just four months, I will be studying for biochemistry and dissecting a cadaver. While this process began many years ago when I first decided to pursue medicine, August 2012 will mark the month in which school officially starts, and I am already thinking about Match Day 2016!