The results of a new survey being published Wednesday suggest more medical students, many of them saddled with debt, are opting for more lucrative specialties.
The survey of nearly 1,200 fourth-year students found just 2 percent planned to work in primary care internal medicine. In a similar survey in 1990, the figure was 9 percent.
Paperwork, the demands of the chronically sick and the need to bring work home are among the factors pushing young doctors away from careers in primary care, the survey found.
"I didn't want to fight the insurance companies," said Dr. Jason Shipman, 36, a radiology resident at Vanderbilt University Medical Center in Nashville, Tenn., who is carrying $150,000 in student debt.
Primary care doctors he met as a student had to "speed to see enough patients to make a reasonable living," Shipman said.
Dr. Karen Hauer of the University of California, San Francisco, the study's lead author, said it's hard work taking care of the chronically ill, the elderly and people with complex diseases "especially when you're doing it with time pressures and inadequate resources."
The salary gap may be another reason. More pay in a particular specialty tends to mean more U.S. medical school graduates fill residencies in those fields at teaching hospitals, Dr. Mark Ebell of the University of Georgia found in a separate study.
Family medicine had the lowest average salary last year, $186,000, and the lowest share of residency slots filled by U.S. students, 42 percent. Orthopedic surgery paid $436,000, and 94 percent of residency slots were filled by U.S students.
Meanwhile, medical school is getting more expensive. The average graduate last year had $140,000 in student debt, up nearly 8 percent from the previous year, according to the Association of American Medical Colleges.
Another likely factor: Medicare's fee schedule pays less for office visits than for simple procedures, according to the American College of Physicians, which reported in 2006 that the nation's primary care system is "at grave risk of collapse."
Lower salaries in primary care did not deter Dr. Alexis Dunne of Chicago, who is 31 and carrying $250,000 in student debt.
Last year, a parade of specialists couldn't solve the mystery of her mother's weight loss, fevers and severe anemia. Finally, an internist diagnosed a rare kidney infection. The kidney was removed, and Dunne's mother has felt fine since.
Watching her mother go through the health crisis affirmed her decision to go into primary care. She also enjoys being "the point person" for her patients.
"You become so close to them you're almost like a family friend," said Dunne, who completed her residency at Chicago's Northwestern Memorial Hospital in July.
She also found inspiration from the doctors she met during training: "They were the ones who would sit at a patient's bedside and spend more time with them rather than running off to surgery."
A separate study in JAMA suggests graduates from international medical schools are filling the primary care gap.
About 2,600 fewer U.S. doctors were training in primary care specialties including pediatrics, family medicine and internal medicine in 2007 compared with 2002. In the same span, the number of foreign graduates pursuing those careers rose by nearly 3,300.
"Primary care is holding steady but only because of international medical school graduates," said Edward Salsberg of the Association of American Medical Colleges, a co-author of the study. "And holding steady in numbers is probably not sufficient when the population is growing and aging."
And as American students lose interest, teaching hospitals will probably become less interested in offering primary care programs, said Dr. David Goodman, associate director of the Center for Health Policy Research at Dartmouth Medical School.
In a JAMA editorial, Goodman called on Congress to create a permanent regulatory commission to encourage training for needed specialties. U.S. teaching hospitals now receive $10 billion a year from the government to train doctors "with virtually no accountability," he said.
The coordinated care provided by primary care doctors can keep costs down by preventing harmful drug interactions, unneeded medical procedures and fragmented specialty care, Goodman said.
The Web-based survey was done at 11 medical schools with demographics and training choices similar to all U.S. medical students.