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Show There is controversy about how much time the "ideal" residency should spend on tertiary care vs. primary care. There is a perception that "anybody can do primary care" since it is "low-tech." Common problems are seen over and over again, and despite efforts to make physicians see the complexity of individual perceptions of their disease and the treatment process, it is felt to be a simply boring routine. As one specialist, a pediatric hematologist-oncologist I interviewed, put it, "Does it really make sense to spend a large part of residency time seeing ear infections? Yes, that is what private practice pediatricians spend a lot of their time on. But similarly, pilots spend most of their flight hours on autopilot. Do you want a pilot whose training consisted of 90% autopilot experience and only 10% on takeoffs, landings, and emergencies?" At the same time, the biggest responsibility of the primary care physician is to distinguish between the sick and the healthy-which patient needs hospital care, specialty care, or high-tech intervention, and which problem can be managed with conservative outpatient care? Working in a tertiary care center exclusively means that all the patients have already been categorized, and the process of learning to distinguish is diminished. As I discussed the choice of primary care versus specialty care with medical students and residents, several common themes emerged. Those selecting primary care often had been raised in rural areas and had strong primary care role models. They frequently majored in social sciences or humanities in college. Many of those choosing to go into primary care had entered medical school at an older age, after doing something else first. They chose to go to medical school for the specific purpose of becoming a primary care physician, often planning to go to a specific location after training. They remained intently focused on this goal, without heeding any pressures that might have led them elsewhere. They frequently mentioned the appeal of variety, saying that specialty care required too narrow a focus to remain interesting~"how exciting can your 1200th case of diabetes be, especially when that's 90% of what you ever see?" The students choosing specialty care tended to be younger and pursued a medical career via an undeviating path from high school. They majored in biology or chemistry, and cited completion of pre-medical requirements as their most important goal during college. By contrast, those interested in primary care often made statements such as "I really wanted to enjoy my courses and get a broad-based education to prepare me for life, not just for medical school." Almost uniformly, those choosing specialty care cited their intimidation by primary care- "you have to know so much to be any good." They felt that the volume of medical knowledge needed in primary care was so huge and expanding so rapidly that it could not be mastered sufficiently to offer good care. It is interesting that students feel that the primary care doctor must master everything that might ever be needed by a given patient, since the specialty of family practice is currently in the process of trying to define the essential portions of its responsibility (Hosokawa & Zweig, 1990). and concluding that many areas should be de-emphasized, such as inpatient technical procedures and obstetrical care. The second reason cited was the debt burden. Many had both undergraduate and medical school loans, and were extremely intimidated by the prospect of trying to pay them back. The lure of higher salaries in specialty care pulled them further away from primary care. Potential Solutions to the Primary Care Dilemma The reasons for choosing primary care suggest another strategy for increasing the number of primary care providers. There are several indicators that can be determined prior to entry into medical school which predict interest in primary care as a career. Those who choose primary care are more likely to be older students from rural areas, with a strong interest in variety. They are more likely to choose non-science majors in college, and 98 PHYSICIAN SOCIALIZATION |