Saturday, March 24, 2007

How I feel this month

My residency just matched with six great interns for the coming year, but not all program directors feel the same about their prospects. Many directors have called for reductions in the number of spots available for training in Family Medicine, thereby (so the theory goes) increasing competition for the remaining spots.

I'm all for high quality students entering my specialty, but think reducing the number of training slots is the wrong way to go. The country needs primary care badly. But just as we need to lose weight and fix the mess in Iraq, some things are easier said than done.

I have two different patients in two different hospitals slowly dying of cancer and substance abuse, respectively. My experience with each provides a sobering contrast with our recent successful recruiting year, a contrast echoed by Sandra Miller's excellent essay "Endangered Species" (pdf 40k) from last week's Journal of the American Medical Association.


  1. Richard,

    Ten years of serving Sauron in the world of industry have convinced me that "excellence" is only one component of economic success.

    I personally believe that in either in a true market (personalized care, libertarian system) or in a single payor system, that primary care would be highly valued and we'd have no trouble recruiting.

    We don't live in either system. We live in a weird quasi-controlled health care economy where the connection between cost and value is broken and there's no continuity of care outside of classic medicare. In this world primary care is not valued.

    I don't think the AAFP can change this. Yes, primary care will be resurrected in 6-25 years [1], but in the meantime I think we're not doing anyone any real favors by keeping residencies alive without quality residents.

    I'm with the group that favors shuttering another 25% of residencies.

    Can you do a f/u post on why you feel differently? Are you more optimistic about what will happen to FP? Why?

    [1] There may be yet another name change ahead for FM/FP/GP. So it'll have a different name, and it probably won't have Ob, but otherwise it'll be FP.

  2. Hi John:
    Sorry for the long delay. RRC accreditation site visit coming up (insert derogatory RRC remark here - but not too derogatory since I'm on the RRC.)

    Discussion of physician manpower supply and distribution can derive from population need or from the market, but in the US these two forces drive recruiting in opposite fashion with regard to primary care.

    When I hear "close programs to raise the quality of students in those that remain" I grow frustrated that we are abrogating our responsibility to meet the health needs of our country. Not wants - needs.

    People want what's scarce. I understand the market principle with regard to recruiting.

    What bothers me is the implicit assumption that our task is to compete against other specialties for students when our task is to compete against disease. To believe that winning the first competition is necessary to win the second is to fundamentally misunderstand what residency training is about.

    I think the resurrection is possible sooner, but only if the competition is appropriately defined and, as you note, the economics of the market are restructured to support a true market where health care need (not want) is connected to resources. In that system primary care is a slam dunk.