Health News Review

Many journalists may have first heard the term, “The Dean’s Lie,” when Dr. Reid Blackwelder, president-elect of the American Academy of Family Physicians, used it on a panel at last month’s Association of Health Care Journalists conference in Boston.  He said at the time:

“The Deans all say they’ll graduate 50-60% into primary care, but track how many stay there after 5 years.”

Now, with “match day” in the news – the day that medical residency positions are matched to applicants – Dr. Kevin Bernstein wrote:

“Once again, medical schools continue their annual fraudulent and misleading statistics in regards to primary care workforce production.  The Dean’s Lie is back and rampant across the country.  It only seems to get worse.

When will they learn?”

From a journalistic perspective, Bernstein also argues that many news stories and news releases are misleading on the topic as well, and he lists many examples, which you can read in his post.  He writes:

“In an effort to properly educate the general public who do not understand the Dean’s Lie, I have initiated an effort to reach out to the various media outlets that are publishing false data with this message:

Your story is misleading, false, and contains fraudulent information provided by medical schools. Also known as “the Dean’s Lie,” only about 20-25% of internal medicine residents remain in primary care (this is from the American College of Physicians, confirmed by a JAMA study 2012;308(21):2241-2247, down from over 50% in 1998). Internal medicine residencies should not be considered primary care residencies if an overwhelming majority do not practice primary care. Moreover, for a more accurate measurement of primary care workforce production, the percent reported that match into primary care should be based on looking at match data from 5 years ago (2 years after residency training). When looking at this data, the overall primary care workforce is trending towards and below 30%, much lower than COGME’s (Council on Graduate Medical Education) recommended 40+ percent primary care workforce.

Is it my personal mission to taint the mirage painted by medical schools?  Perhaps.

At some point the truth must come forward.  Hopefully a major media outlet will educate the public rather than continue to publish erroneous data while glorifying institutions that minimally provide solutions to primary care workforce production.”


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Ken Miller posted on April 2, 2013 at 12:03 pm

If med schools selected students from a pool of midlevel practitioners experienced in primary care, and offered them a fast lane to an MD limited in scope to primary care, with specialties in pediatrics and female health, limitations subject to hospital privileges to enable latitude for rural areas, we would have a crop of entrepreneurs freed from captivity to set up competitive medical business filling niches that currently are filled only by trading loan offsets, which results in short-term rather than committed practices.

    John Schumann posted on April 8, 2013 at 10:39 am

    I like your idea.

sylvia kronstadt posted on April 12, 2013 at 10:14 am

I too am appalled at the misleading picture the public is receiving about the number of medical school graduates going into primary care.
The dean of the University of Utah School of Medicine recently asked the Legislature for yet another big allocation – this one for $10 million. She implied that these funds would help the U. create more primary care doctors, of which there is a large and growing shortage that has legitimately been called a crisis. She pointed to the fact that a third of this year’s graduating students accepted residencies in primary care as proof of the U.’s effectiveness in steering students toward this specialty.
I have reason to believe that not one of those 26 students intends to practice primary care. I negotiated a scholarship contract with the medical school in 2011 that provided a stipend to any student willing to practice primary care for just three years. This past year, there was not one applicant.
Even if you don’t find this anecdotal evidence persuasive, consider this: Only two percent of medical students in a recent survey expressed a desire to practice primary care. The low pay, the second-rate status, the working conditions and time commitment, the paperwork burden and the impossibility of doing the job well in the current system deter those who care the most.
The Journal of the American Medical Association’s latest data, which are consistent with those of the past 10 years, indicate that only one of every five students who accepts a primary care residency goes on to practice primary care medicine. Eighty percent do not. They seek advanced training in one of the more lucrative, prestigious specialties. Even if the University’s students had so far shown any serious interest in primary care, the JAMA data suggest that only five of them would establish a practice in family medicine. That’s a far cry from the one-third of the graduating class that the dean implied were anxious to serve their fellow man as primary care doctors.
Residencies are a scarce commodity. Students generally apply in several fields in the hope of being able to continue their medical education one way or another. “Only 78.8 percent of U.S. seniors who obtained a residency got one of their top three choices,” according to data just released by the National Resident Matching Program.
Most students, of course, don’t have a true “top three.” By the end of medical school – if not at the beginning — they have their hearts set on one particular specialty. (You don’t want to be a cardiac surgeon OR a dermatologist. You want to be a cardiac surgeon!) If they don’t get selected for what they really want, they may find themselves dumped into the dreaded primary care pool. Even worse, many medical school graduates are not matched with any residency and must find some other way to use their medical training.
How many primary care doctors might be generated by the $10 million that the Utah dean requested? The medical school already has a budget of several hundred million dollars, according to a March 12, 2013, article in the Tribune, and it’s essentially creating no primary care doctors. Since the school legitimately wants to increase enrollment, why wouldn’t the exorbitantly high tuition ($33,000 to $55,000 per year for resident vs. nonresident) pay for the additional students?
If the medical school wants additional funding, perhaps it should offer a bold, aggressive plan for recruiting and supporting students committed to primary care.
Health care in general and primary care in particular are obviously huge societal issues. It seems to me that the University Medical School, a publicly funded institution purportedly dedicated to the common good, has exacerbated the crisis rather than helping to address it. It has entrenched primary care as the “stepchild” of medicine, paying those who teach family medicine a small fraction of what those in the specialties receive, lavishing funds on the disciplines that are already overvalued in the health-care system.
It creates an environment in which the sheen and shimmer of technology are allowed to obscure the humble, unglamorous enterprise of human-to-human interaction regarding more mundane health matters. I am not just speculating. I know several young doctors, only one of whom went into primary care. She quit, absolutely exhausted, after six years. The others practice their dermatology, orthopedics, radiology and anesthesiology with ease and pleasure, raking in the money and acting as if they are a Breed Apart.
University medical schools should be giving preference to applicants who express a credible commitment to primary care. They should structure their aid to reward those students. They should increase the visibility, stature and income of professors who train future primary care doctors, family doctors and gerontologists. They should join in lobbying Congress, Medicare and the insurance industry to change how primary care doctors are compensated, making it roughly equivalent to specialists. Primary care doctors should be at the top of the pyramid, or as a Johns Hopkins author put it, “they are the cornerstone.”
Why does an institution that purports to value primary care reward its specialists with such huge taxpayer-funded salaries? Dozens of them make close to a million dollars, while those in family medicine are lucky if they reach $200,000. How might that affect a student’s perspective and values? And how do these professors justify taking so much public money for themselves (supplemented by their private patients, honoraria and clinical trials/research)? Are they not embarrassed by their big yearly pay increases, even as medical tuition becomes a burden that fewer (and less diverse) young people are willing to shoulder?
I am disappointed that the nation’s medical schools haven’t had the integrity or foresight to lead reforms necessary to get our primary care vs. specialist ratio back to where it belongs: 70 percent to 30 percent, not the other way around.
And I don’t think the schools can do it unless they force changes in the health-care marketplace. Since medical schools are, in a sense, the “parents” of medical students, it seems appropriate for them to care enough about their progenies’ future to spearhead this reform. The distribution of wealth needs to change in medicine, just as it does in the society at large. But I think the most important thing is to create an environment in which primary care doctors can have the reward of doing their jobs well. That doesn’t happen when they are dashing breathlessly from one exam room to the next, rarely if ever feeling that they’ve had the time to treat a patient with care and thoroughness and concern for “the whole person.” We deserve these compassionate doctors, and they deserve the chance to do their work in a fulfilling, medically principled way.