JAMA recently published an article on the career plans of internal medicine residents. The investigators found that even graduates of primary care training programs are more likely to pursue a subspecialty than a general internist path. Some may argue this is proof that primary care is a dying field, but I disagree.
I am fourth year medical student and I don't think I'm alone in believing that primary care is experiencing a revival. Personally, I am psyched for a career in primary care. I want to get to know my patients, so I understand their values and can make sure they get the right care, in the right setting, by the most appropriate practitioner.
We folks interested in relational, preventive medicine have a way of finding each other. Over the past 3 years, there's been a tremendous change in the climate around primary care at my school. A group of us coordinated a Health, Human Rights and Advocacy elective that became a human rights and social justice track. These efforts have organized a community of MD candidates with a social mission who can now easily connect to mentorship and local service- or advocacy-learning projects. I've seen my specialty-driven medical school transformed from a place with a good amount of condescension towards primary care - we were marginalized, it was something you questioned - to a place where the conversation, even among radiologists and specialists is "Ah yes, you want to do primary care - the new big thing." Well, it's kind of been around for a while...
Right now, I'm on the interview trail. I view the primary care residency programs I visit as organized communities of general internists who simply want to support anyone interested in primary care. At interviews, program directors don't want to make you feel like you're pigeon-holed, and will mention graduates who've matched in subspecialty fellowships. Whatever; that's the leadership simply attempting to make everyone feel like they aren't closing doors. I'd like to think that everyone, including specialists, benefits from training in a program that promotes primary care values.
What the JAMA study suggests is that something happens in residency that puts out the fire of say, an MS4 psyched for a career in primary care. Burn out is a very real part of that. Burn out happens to the resident, working tough hours with medically and socially complicated populations. Burn out also happens as part of the hidden curriculum - in our exhausted state, we are even more vulnerable to absorbing the at times burnt out attitudes of our seniors. This is precisely what I and my peers have been trying to address in medical school. Burn out can be a trickle down, collective experience, and I've devoted myself to energizing faculty to energize us in return.
Sure, the role of the physician in delivering primary care is changing. Nurse practitioners have a lot more responsibility. I've been told to pursue a subspecialty fellowship simply to distinguish myself from NPs in the primary care environment. Even where we practice will change: my peers are generally interested in academic primary care or community health centers without much mention of private practice. There is no doubt primary care will look different by the time I finish residency. I just feel like, with all this uncertainty and reform, we look to our mentors, who have a great opportunity to promote any efforts at progressive change.
A concern I have is that a lot of primary care types flock to California and Boston/Cambridge, since those seem to be meccas for primary care innovation. Students naturally want to train in that supportive environment. I know there's good work being done all over, but the energy seems to be dense and silo-ed in the north east and California. I only hope that my generation will see the spread of these progressive movements to other communities in need.
I know many classmates who are genuinely committed to and optimistic about primary care. These are students who used to struggle to find mentorship, support, or respect for the values that brought them to medicine in the first place. Now, there's a palpable difference, post-Affordable Care Act (also known as “ObamaCare”) and post-acceptance of delivery and payment reforms. The train has left the station! It's certainly been an exciting time to go to medical school.