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Money Key Factor in Driving Med Students From Primary Care Careers

Primary care physicians are at the heart of health care in the United States, and are often the first to diagnose patients and ensure those patients receive the care they need. But researchers from North Carolina State University, East Carolina University (ECU) and the Albert Einstein College of Medicine of Yeshiva University in New York have found that many students are choosing to pass up a career in primary care because those physicians make substantially less money than specialists, such as dermatologists or radiologists.

“We found that students who placed a premium on high income and students who anticipated having a lot of student debt were significantly more likely to pursue a high-paying medical specialty rather than become primary care physicians,” says Dr. Lori Foster Thompson, a professor of psychology at N.C. State and co-author of a paper describing the research. “This held true even for students who entered medical school with the goal of becoming primary care physicians – they often switched to high-paying specialties before graduating.”

The study, published online this week in Medical Education, surveyed more than 2,500 medical students attending New York Medical College and the Brody School of Medicine at ECU between 1993 and 2012. Students were surveyed at the beginning of their first year of medical school and just before graduation four years later. The survey asked the students what sort of medical career they planned to pursue, to estimate their final student loans and to rate the value they place on income.

The researchers then looked at those students planning to pursue a career in primary care, as well as those students planning to pursue any of the 12 specialties with a median income of more than $300,000 per year, based on 2010 salary data. By comparison, primary care physicians had a median income of just under $200,000 per year. Primary care consists of internal medicine, family medicine and pediatrics.

The study found that anticipated debt was a significant factor in the students’ career decisions. Graduating students who pursued high-paying specialties were facing average student loans of approximately $104,000, whereas those who chose primary care faced an average debt of less than $94,000. Students facing higher debt were also more likely to switch to high-paying specialties – including more than 30 percent of students who had expected to become primary care physicians when they entered medical school.

First-year and graduating students who chose to pursue one of the high-paying specialties also rated income as being significantly more important than students who chose to pursue primary care. In addition, those graduating students who felt income was more important than they had as first-years were more likely to have switched to a high-paying specialty.

Other factors that guide student decisions about what specialty to pursue include parental or peer pressure, lifestyle desires and the exposure to more specialties once students reach medical school, though this study did not look at those issues specifically.

“The other major factor in choosing a primary care career is a service commitment – wanting to help others,” adds Dr. Dale Newton, a professor of pediatrics at ECU. “Measuring such a commitment in a research setting is very difficult, however.”

The study suggests that measures should be explored to encourage primary care careers such as incentive pay, debt forgiveness, additional scholarships and higher reimbursement for primary care services in order to meet the growing need.

In addition, Newton says, “If the current efforts at health care reform continue, the incomes of primary care physicians should improve over the next few years. Primary care has to play a major role in the new health care paradigm.”

The study’s findings come as the Association of American Medical Colleges projects a shortage of 63,000 physicians by 2015, the vast majority of those in primary care.

The paper, “Payback Time: The Association of Debt and Income with Medical Student Career Choice,” was published online Sept. 19 in the journal Medical Education and was co-authored by Dr. Martha Grayson of Albert Einstein College of Medicine. Grayson was at New York Medical College at the time of the study.


Note to Editors: The study abstract follows.

“Payback Time: The Association of Debt and Income with Medical Student Career Choice”

Authors: Martha S. Grayson, Albert Einstein College of Medicine; Dale A. Newton, East Carolina University; Lori Foster Thompson, North Carolina State University

Published: online Sept. 19 in Medical Education

Abstract: Background: With impending healthcare reform in the United States, there is an imperative to increase the number of students choosing primary care careers. Research is needed to better understand the role of economic factors in medical student career choice. The objective of this study was to examine the relationships among debt, income, and career choice by comparing students planning primary care careers(PC) with those aspiring to one of the twelve non-primary care fields with median income over $300,000(high-paying non-primary care-HPNPC). Methods: Surveys (response rate=81%) were administered to first-year (M1) students scheduled to graduate between 1996 and 2012 and fourth-year (M4) students graduating between 1993 and 2010. Respondents were students at New York Medical College and East Carolina University’s Brody School of Medicine. Analyses focused on the 2674 M1 respondents choosing a PC (N=1437; 54%) or HPNPC (N=1237; 46%) career, and the 2307 M4 respondents intending to pursue PC (N=992; 43%) or HPNPC (N=1315; 57%). Longitudinal analyses examining changes in career goals during medical school were based on students who completed both M1 and M4 surveys. The outcome measures studied were self-reported debt, anticipated income, and the self-rated value placed on income. Results: Relative to their PC counterparts, students intending to pursue HPNPC careers anticipated an average of $24,904(M4) – $29,237 (M1) greater debt, placed a higher importance value on income, and anticipated an average of $58,463(M1) – $89,909(M4) more in annual income after graduation. Debt was associated with the value placed on income when choosing a career and the amount of future income anticipated. Students who valued income highly were especially inclined to switch out of PC during medical school. The switch away from PC was associated with debt as well as a marked increase in anticipated income. Conclusions: Debt and income are important concerns which may shape the future supply of primary care physicians.