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Show begin to wonder if they really want to be the despised "LMD" (Local Medical Doctor, the term often used in a derogatory way when describing "inappropriate care" provided prior to the diagnosis by a specialist at a tertiary care center). They are rarely exposed to primary care providers, and in addition to the negative images presented by specialists and professors in school, they read of primary care providers who are burned out and frustrated. "Not only has being a family practitioner become frustrating, less lucrative, and unrewarding, but the future looks bleak" (Bennett, 1990). In addition, most students begin to accumulate huge amounts of student loan debt, and start to notice comparative salaries of the different fields. Facing a burden of a $100,000 debt upon graduation, many students feel that they must choose a high-paying specialty simply to keep financially afloat. Even students exposed to good primary care practitioners can come away with negative images. One future neonatologist I interviewed said she chose neonatology because she like to spend a lot of time with her patients and their families, and in primary care the pressure is to see a large volume of patients. Based on my experience with pediatric practitioners in Utah, a specialist will usually allot an hour or more to a new patient and at least 15 minutes for follow-up visits, while a primary care doctor typically allots 15 to 30 minutes for a new patient and 5 to 10 minutes for follow-ups. Generally, when people think of physicians, the first image is that of the kindly old family doctor, who sees patients throughout their lives and serves as their intermediary with the medical system. In 1963, almost half of all physicians in the U.S. were primary care providers; by 1986, that percentage had dropped to only one-third (Bennett, 1990). This means that despite an overall increase in the number of physicians relative to the population during this time period (from 128.5 per 100,000 population to 198.9 per 100,000) there was a decline in the number of primary care providers in proportion to the population. During this time period, however, rural primary care providers declined by almost 10% (Bennett, 1990). Over the last 10 years, there has been less and less interest in primary care specialties. Between 1982 and 1989, fourth-year students' preferences showed a decline of 24% in family practice, 58% in general internal medicine, and 23% in pediatrics. By contrast, the preference for radiology increased by 34%, anesthesiology by 35%, internal medicine subspecialties by 76%, and dermatology by 145% (Noak, 1980). Rural primary care receives much of the attention in discussions about altering the focus of medicine. Canada has experienced similar problems recruiting physicians for rural areas. A 25% fee differential was created to try to lure practitioners into rural areas, but has met with little success. The problem of recruitment seems to be centered around domestic issues-no jobs for working spouses, poor quality schools for children, lack of professional contacts forcing solo decision-making, and typically heavier call schedules make rural life less attractive for physicians and their families. Medical education, from medical school through residency training, is typically conducted in tertiary care hospitals. There is little exposure to ambulatory care at all, and much of that exposure is in the specialty fields. This means that the educational needs for training in primary care are difficult to achieve, while specialty fields get particular emphasis. The reasons for this are primarily financial in origin. "The pressure on tertiary care centers to function as 24-hour-a-day acute hospitals requires inexpensive labor, i.e., physicians who can be persuaded or coerced into working 80-hour or more weeks and 36-hour shifts" (Reuben, et al., 1988). Thus, residency programs are designed to demand this quantity of work on a salary usually far below minimum wage if calculated on an hourly basis. With primary care services reimbursed at lower rates than specialty care, there is an emphasis on provision of specialty care by these residents in order to improve the financial posture of the training institution. Utah's Health: An Annual Review 1993 97 |
