Abstract
Introduction
Much has been written about the need for more primary care physicians in the United States. 1 Though there has been a slight increase in the past few years, the number of medical school graduates choosing primary care residencies remains less than the subspecialties.2,3 Studies have speculated about the causes. Factors such as income expectation and prestige figure widely as important reasons for the decline.4,5 We asked premed and former premed undergraduate students about their perceptions of primary care as a career to try to clarify some early factors in the career choice decision and to better understand when negative thinking starts.
Methods
Open-ended, semistructured interviews were conducted with 58 students with the purpose of determining how premedical education affects a student’s decision to apply to medical school and shapes their undergraduate experience. Participants at a large, northeastern research university were recruited via e-mails sent to departmental, course, and organizational list servs (ie, Biology, Health and Societies, and the Penn Emergency Medical Response Team) known to cater to the populations of interest. Students interested in participating responded to the investigator, and using consecutive sampling, interviews were scheduled. Participants came from 3 groups: those who were currently premed and science majors, those who were nonscience majors and were currently premed, and those who were formerly premed. “Former premed” included any participant who at one time considered themselves “premed”, but had since altered their career path. Near the end of the study, participants were purposively selected in order to recruit adequate representation by gender, or premedical and science major status. Snowball sampling was also utilized by asking if participants had interested friends. However, sample selection was not made on other characteristics.
An interview guide was created using previous studies on premedical students to guide the questioning.6-8 Among other questions, we asked, “Why do you think there is a shortage of people who go into primary care?” Interviews were recorded and transcribed and all identifiers were removed during transcription. Interviews were entered into NVivo 8.0 (QSR International, Doncaster, Australia), a qualitative analysis software package that allows for electronic organization and coding. A coding dictionary was developed and grounded theory was used for the analysis. The methods of recruitment and the subsequent interviews were approved by the University of Pennsylvania Institutional Review Board and all participants signed informed consent statements.
Results
The sample consisted of 58 participants. There were more females than males (60% vs 40%) and nearly equal numbers of participants in science and nonscience majors (52% vs 48%; see Table 1).
Sample Characteristics. a
N = 58. For this study, majors were classified according to AMCAS science/nonscience course criteria and for students enrolled in 2 majors, they were classified as a “science major” if one of the majors was a scientific discipline. Former premeds were self-identified and when answering other questions involved in this study (not discussed here) identified the curriculum and its difficulty, bad grades, and alternative career interests as the main reasons for their change in career path.
Students revealed negative attitudes about choosing primary care as a profession (see Table 2). They cited the lack of adequate compensation for primary care doctors especially in light of debt load, as a reason for not going into primary care. They also suggested that primary care was not “glamorous.” One student said, “I think people think of primary care as maybe more like flat line, not as interesting.” Another student went so far as to say that even the term “primary” suggested that as a career, it was “elementary and basic.” This was, in their minds, in opposition to the lure of “specialization.” In addition to being less interesting, students stated that preventive medicine was less appealing and less “cool” than “curing disease.” One student elaborated, “Being a primary care doctor does get overshadowed in the glamorous factor. I mean, you know, looking at little kids’ chicken pox and rashes and strep throat, it’s not the most glamorous thing in the world.” Misunderstanding about the field was tied to its lack of prestige or “cool” factor. One student said, “I think to some degree it might have to do with publicity. How often do primary care doctors become really famous and gain notoriety, versus someone who’s, you know, [a]cardiothoracic surgeon or things like that?” This student and others went on to point out that there were no primary care physicians depicted in current television, which tended to minimize the exposure of the field. Additionally, the theme of “negative stigma” arose. One student said, “Being in primary care, it’s sort of like you did the minimum, which is kind of the opposite of whatever a premed student, or a person who gets into med school has always been like in their life. It’s like if you end up in primary care, you might feel like you failed.” This belief was considered to be in direct contrast to the reason many students wanted to enter medicine, and perhaps, because of this, most of the students interviewed said that they had never considered going into primary care. Even an increase in salary, when asked as a follow-up question, was not enough for respondents to choose a career in primary care. In fact, the only difference among the subgroups in this study was that the few who had considered primary care, were the students who had dropped out of premed in favor of other majors.
Primary Themes Identified in Response to the Question “Why Do You Think There Is a Shortage of People Who Enter Primary Care?”
Students themselves held many negative beliefs about primary care (see Table 2). They felt that insurance companies were affecting the specialty, and that primary care physicians had less autonomy and responsibility because they were compelled to refer to specialists. Others thought that primary care physicians work too hard. One student noted that there was more respect for primary care doctors in other countries. In addition, a number of students did not know what a primary care physician was and many harbored significant misconceptions of what a career in primary care actually entailed. For example, one student suggested that you did not have to be board-certified, and another suggested that there was only one family practice residency in the United States. Even still, others asked for the career to be explained further.
Discussion
The Future of Family Medicine 1 found that many people were unable to define family medicine. 9 This is borne out of our interviews and is troubling to find in students who are likely to be our future doctors. The perceived lack of glamour and prestige may be due, in large part, to the perceived lower income of these physicians. 10 However, even when students were presented with the option of more money to enter the career, most students still lacked excitement or interest about a future in primary care. Our results, similar to a survey of first year medical students finding job satisfaction and enjoyment to be significant factors in career selection, 11 suggest that a simple increase in salary might not fix the shortages of primary care physicians.
Additional issues beyond salary may be important. More medical students in 2007, as compared with 1990, held negative perceptions of the workload and stress associated with a primary care career. 12 Our undergraduate students echoed this view citing time constraints, insurance company pressure, the trend toward specialization, and the breadth of knowledge required as reasons for this opinion. The image of primary care described by our informants may be because of a lack of understanding and a misconception of what a primary care physician is and does. It might also be a result of “badmouthing” primary care physicians and the stigma of the field created by medical school culture. 13 To counter these images and negative attitudes that are in evidence as early as freshman year of college, primary care proponents might consider highlighting the “rock star” status of primary care physicians who solve creative puzzles related to diagnosis and who provide resources and insights into addressing health disparities. Well-placed stories about the population-wide benefits of prevention strategies such as human papillomavirus vaccines and breast cancer screening could raise awareness of the “drama” inherent in primary care that can match even the most dramatic “rescue” stories that emerge from specialty practices. Additionally, exposure to role models in primary care and positive clinical experiences as early as the undergraduate years might boost interest in the career, as has been seen in medical schools, especially those with innovative programs to promote early and continuous exposure.13,14
In addition, some students interested in primary care were discouraged by the premedical program and dropped out. Premedical curricular reform and application requirement changes might help increase the number of applicants into primary care in the future. 15
Limitations of this study are that this took place in a single, elite northeastern university, which may have biased the sample and limits its generalizability, and the interviewer was a part of the population herself. Bias was limited by following a strict coding process, by peer and mentor debriefing, and by “member checking” the results with premed and former premed undergraduates.
Primary care has an image problem among pre-med students. The field needs to market itself to highlight the great satisfaction there is in practicing primary care and to abolish misconceptions, misunderstandings, and an overall lack of knowledge about the career. By targeting the future doctor population early, and also trying to keep those interested in primary care still interested in medicine through curricular reform, perhaps these negative opinions can be abolished.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.