This summer, I stared at this graph every day as I studied for Step 2 of my USMLE boards. It describes the spread of possible board scores along with the specialty in which that board score can “match.” For example, the average successful anesthesia resident will have had a board score of 230, but a plastic surgeon will have had one of 248. As a medical student studying for these exams, these markers guide your decision-making on what’s possible as a specialty based on your board score. (Here’s the full report)
There are many reasons for the country’s shortage of primary care physicians but one is of medical student culture. To get to where we are today, we worked out the numbers in our premedical courses to beat the curve, meticulously counted our hours of community service in college for our med school applications, and scrutinized our MCAT scores to determine what tier of medical school to which we might be accepted. When we are matriculate, the attributes that got us where we are still exist and there is little rehabilitation when it comes to board exams. As we face the decision of picking a specialty, this idea that our specialty choice represents a rough public proxy of academic success lurks darkly in a corner. There is an unspoken assumption that if you had scored high enough to be a dermatologist, why wouldn’t you do it?
I am proud of all my colleagues and the vast majority of us eventually make decisions not based on our numbers, but on our hearts. We all have a mutual understanding and respect for each other’s choices. Still, I think we would all breathe a sigh of relief if the impact of our board scores on what we can and cannot do didn’t loom so menacingly above our heads.
There are many reasons why demands for the various specialties vary so much. Escape Fire: The Fight to Rescue American Healthcare describes how different compensation can be:
If I spend five minutes with you and then put in one of these stents, probably get paid $1,500. For me to spend 45 minutes on a established visit with a patient to make sure they’re doing their exercise, make sure their diabetes is going OK, and to try to figure out what their true problem is, probably get paid $15. It’s a completely irrational system.
The burden of reforming this demand falls upon first reformatting the payment structure so that compensation incentivizes primary care. In a system that financially rewards proceduralists, that’s what we will get… many many proceduralists, and many many medical students who would want to be proceduralists if they could. Many of the top tier medical schools, Harvard, Columbia, Johns Hopkins, Yale, and my home institution Vanderbilt included, do not even have a family medicine department. Our rotations are in very high acuity settings, deeply influencing our conception of what medicine and doctoring looks like.
This year, Mount Sinai School of Medicine decided to lead the charge for top schools to open a family medicine department in June. Family medicine faculty there will teach students all four years of school. From NPR:
The department grew out of a new partnership between Mount Sinai and the Institute for Family Health, a network of 30 community health clinics across New York.
Health systems are eyeing partnerships like this one, between hospitals and primary care groups, as a smart bet for the future. Under the federal health law, the government will offer bonuses to places that give patients better care for less money. To do that, many health systems are bolstering primary care services to manage chronic conditions and prevent hospitalizations.
Under the health law, financially incentivizing primary care will lead to a higher demand for family physicians, better preventative care, and a healthier nation. Mount Sinai’s lead in exposing medical students to primary care will undoubtedly lead to an impactful increase in their desire to enter primary care as well. Now those are some high numbers we should shoot for.