New physicians still choosing specialties despite government efforts, billions invested in training.

(HealthDay)—Amid signs of a growing shortage of primary care physicians in the United States, a new study shows that the majority of newly minted doctors continues to gravitate toward training positions in high-income specialties in urban hospitals.

This is occurring despite a government initiative designed to lure more graduating medical students to the field of primary care over the past eight years, the research shows. Primary care includes family medicine, general internal medicine, general pediatrics, preventive medicine, geriatric medicine and osteopathic general practice.

Dr. Candice Chen, lead study author and an assistant research professor in the department of health policy at George Washington University in Washington, D.C., said the nation's efforts to boost the supply of primary care physicians and encourage doctors to practice in rural areas have failed.

"The system still incentivizes keeping medical residents in inpatient settings and is designed to help hospitals recruit top specialists," Chen said.

In 2005, the Medicare Prescription Drug, Improvement and Modernization Act was implemented with the goal of redistributing about 3,000 residency positions in the nation's hospitals to primary care positions and rural areas.

The study, which was published in the January issue of journal Health Affairs, found, however, that in the wake of that effort, care positions increased only slightly and the relative growth of specialist training doubled.

The goal of enticing more new physicians to rural areas also fell short. Of more than 300 hospitals that received additional residency positions, only 12 appointments were in rural areas.

The researchers used Medicare/Medicaid data supplied by hospitals from 1998 to 2008. They also reviewed data from teaching hospitals, including the number of residents and primary care, obstetrics and gynecology physicians, as well as the number of all other physicians trained.

The U.S. government provides hospitals almost $13 billion annually to help support medical residencies—training that follows graduation from medical school—according to study background information. Other funding sources include Medicaid, which contributes almost $4 billion a year, and the U.S. Department of Veterans Affairs, which contributes $800 million annually, as of 2008.

Together, the cost of funding graduate medical education represents the largest public investment in health care workforce development, the researchers said.

An earlier study, published in the December 2012 issue of the Journal of the American Medical Association, showed fewer residents are choosing primary care in the United States. Of third-year residents, only 21.5 percent were planning on becoming internists. Experts estimate that the nation will be short 50,000 primary care physicians in the next decade.

Chen said hospitals are likely to recruit specialty residents because their presence benefits their facilities. "Having residents in the hospital frees up the attending doctors to do more procedures, which increases revenue for physicians and for the hospital," she said.

What is driving the interest in medical specialties?

Dr. Perry Pugno, vice president for education at the American Academy of Family Physicians, said he thinks the trend is based on perceived quality of life. "Student interest in lifestyle has pushed the pendulum away from primary care," he said. "You can make more money and not work as hard. The income is somewhat a proxy for prestige too."

Pugno said he thinks the primary care situation is even worse than the numbers suggest. Many of the residents in primary care and internal medicine will go on to pursue specialties, such as cardiology or general surgery, he explained.

"Only 5 percent of those who go into internal medicine will actually stay in primary care," he said.

Pugno said the situation calls for a national workforce commission to assess workforce needs, especially in shortage areas such as primary care, general surgery and pediatric psychiatry. He added that graduate medical education should be funded by a more straightforward payment system than Medicare.

Chen, who practices in primary care once a week in an underserved area of Washington, thinks part of the answer is to ensure that primary care physicians are paid commensurate with the other specialties. "It's not just about paying primary physicians more; it's also about bringing down the pay of other physicians," she said.

It's also important for medical students and residents to understand the importance and personal rewards of a career in primary care, Chen said. "It's one of the hardest areas of practice, but physicians often are told they're too smart to go into family medicine."

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