Side Effects of Selecting for Family Medicine

Robert C. Bowman, M.D.

Abstract - When choosing the older, lower income, rural, instate, mature, service-oriented, and lower MCAT students that tend to choose family medicine, there are some beneficial side effects. This include more physicians for rural areas of all types (older, instate, rural born), more psychiatrists (older), more for office-based primary care poverty locations (older, rural, lower income), more rural family physicians (older, rural, instate), more OB-Gyn physicians (FP and OB more likely with slightly lower MCAT at school), more rural general surgeons (rural born), more child psychiatrists (rural, older), a higher proportion of internal medicine choosing office-based primary care (lower MCAT, rural, less urban), and more primary care physicians (service-oriented and all of the above). Considering that most of these are shortage areas and front line direct patient care choices that are less and less likely from current medical students, the nation must prioritize the choice of family medicine just to get the beneficial side effects. Better cost, better quality of medical care, (Baicker and Chandra) and better health access for the Americans most in need of it are also important "side effects."

Introduction

Often in medical therapy, the final choice of a prescription often involves using a medication that has beneficial side effects. Using an antidepressant medication that has drowsiness side effects is helpful if the depressed or anxious patient has difficulty with sleep. Using a beta blocker for hypertension may be helpful if the patient has migraine headaches. Physicians often look for opportunities to get “2 for 1” or “3 for 1,” especially in these times with astronomical escalations in co-pays.

In health policy there are often side effects of “treatments” as well. Medical schools often attempt to graduate more physician researchers. In doing so they often focus the medical school admissions process on student characteristics likely to result in a student choosing medical research. More Researchers  These include choosing students with higher and higher MCAT scores and those from the most prestigious schools. Schools compete for the students that they deem most likely to be able to garner NIH grants for them. This leads to early admissions programs and feeder programs focusing on research. The side effects of this process are not well understood but involve distortions in the physician workforce primarily through admissions of students who are the least likely to choose rural, primary care, psychiatry, women's health, family medicine, and office-based primary care in poverty locations. Medicine, Education, and Social Status

There are also side effects of admissions policies that result in more family physicians. These involve admissions of students who are older, less urban, more rural, lower income, born in the same state as the medical school (allopathic public only), and slightly lower on MCAT scores. These have side effects when family medicine is not the final career choice, including better geographic distribution of all physicians (all categories), better distribution of primary care (all categories), more office-based primary care physicians in poverty locations (all categories), more physicians involved in women's health care (slightly lower MCAT), and more physicians retained in the same state as their medical school (instate born admits for allopathic public).

Governments and people also make choices that have side effects. These choices often involve education and health care policy. When primary care health policy is supported as it was a decade ago with shifts of support toward primary care and away from specialty and hospital based care, the nation had better distribution of primary care physicians to rural and poverty areas. The side effects also involved decreased health care costs, the only time this trend has been effectively and equitably addressed. The side effects also involved decreased choice of psychiatry, mainly because improvements in primary care shuttled students in primary care directions. The side effects also involved inconveniences related to restrictions in how specialty, ER, urgent care, and other physicians and hospitals could be accessed. In the end the pressures of convenience overcame good sense. Before the nation could see the "good" side effects, the "bad" side effects won out. The cost, quality, and access indicators are also side effects that take more time to understand and process and bring to public awareness. Primary Care Health Policy, Managed Care, and Choice of FP

These include graduation of enough well-trained primary care physicians to serve rural areas (900 per year needed for progress), and serve office based primary care poverty locations (another 900 per year needed). It is also likely that these physicians, encouraged by a nation supportive of primary care, will be more likely to stay in underserved locations at higher rates..........      for the rest of their physician careers.

There are side effects of the current "market forces" approach whereby specialists and their sponsoring organizations or businesses able to demand more and more funds. Cost escalations are rising at the fastest rates since the cooling of rampant inflation. When specialists, now a major focus of medical businesses, continue to demand and get ever increasing pay and support personnel, more and more assistants move into specialty care and away from support roles in primary care and hospital care. Hospital care and primary care facing increasing restrictions and medication costs continue to draw more and more health care dollars from health insurance, Medicare, Medicaid, and all of us who eventually fund such programs now and decades into the future. Increasingly physicians are able to hire more assistants, see more patients, do more procedures, and spend less and less actual time in face to face patient contact. This of course makes cost, quality, and liability risks increasing problems.

Supportive primary care health policy involves increased funding directly to primary care physicians and those that hire and support them. The recent improvements that worked so well were consistent increases in primary care pay (coupled with decreases for specialists), continued increases of Community Health Centers, improved funding for rural health clinics, increasing funding for rural hospitals and new designations of Critical Access which enabled many hospitals to support their doctors, recruit replacements, and support their communities. The rural health clinic model virtually doubled income levels for many rural family physicians.

The following characteristics are known to result in these side effects

In every case, the admissions of such students is a lower priority and each passing year brings fewer such students, a narrower range of medical student, and greater declines in physician distribution and health access indicators.

Primary Care Internal Medicine

The same socioeconomic influences also move internal medicine physicians to choose more office-based practices as compared to other types of internal medicine practice activities. This is not apparent in direct regressions involving office-based internal medicine physicians, but it is clear in regressions involving the proportion of internal medicine physicians choosing office-based practice as compared to all in internal medicine in all other activities.

Internal medicine is a broad area with many different activities. Some are related to primary care and some are not. Family medicine relates to general internal medicine in many ways. Office-based primary care includes general internal medicine, general pediatrics, and family medicine. Even though the correlations directly between family medicine and internal medicine are smaller, there are close correlations between choice of family medicine by students at a school and the proportion of internal medicine physicians choosing office-based practice. This correlation is a very strong +0.619.

For the following, allopathic schools that were typical and not the lowest scoring MCAT schools were compared to each other for the following variables. The proportion choosing office-based internal medicine was very similar to the percentage of students at the school choosing family medicine. Schools with true emphasis on primary care graduate primary care physicians of more than one type. When Medicare and Medicaid were created, both family medicine and internal medicine nearly doubled as student choices. It is actually difficult to separate the office-based primary care careers.

*    p < 0.025

**    p < 0.001

*** p < 0.0001

note that correlations are with the variable at the top of the column, not between IM and FP

Note that Asian students are a marker for those with higher income and higher education levels, not much different than high income high urban white students in choices.

Schools with broader admissions graduate a higher proportion of office-based internal medicine physicians. These schools have lower MCAT score averages, more rural born students, more older students, more instate students, fewer urban born students, and fewer Asian ethnicity students. When the nation admits more and more students with more urban, higher MCAT, and younger age indicators, there will be fewer family physicians and general internists graduated.

For the outcomes of programs that emphasize the above

Birth Origins Articles

Changing Patterns of Admission

No Change in Applicants, Just Not Admitted

Physician Workforce Studies

Accelerated Family Medicine Training Programs

Socioeconomics and Physician Distribution

Medicine, Education, and Social Status

Academic Medicine's Season of Accountability and Social Responsibility

Superselection

Baicker K and Chandra A   Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care, Health Affairs, 10.1377/hlthaff.w4.184 http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184v1   

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