Hostility During Training: Historical Roots of Primary Care Disparagement

Joanna Veazey Brooks

doi:10.1370/afm.1971

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Re: Hostility During Training: Historical Roots of Primary Care Dispargement
Michelle B. Taylor MD

Published on: 11 October 2016
Reflections on History, Power, and Hostility: Views from South Africa
William Ventres

Published on: 10 October 2016

Published on: (11 October 2016)
Page navigation anchor for Re: Hostility During Training: Historical Roots of Primary Care Dispargement
Re: Hostility During Training: Historical Roots of Primary Care Dispargement
Michelle B. Taylor MD, PGY3 Family Medicine Resident
Brooks' analysis of hostility towards primary care thoughtfully described longstanding systematic cultural and structural factors that influence specialty choice.[1] However, absent from her study is discussion of two substantial factors - the exceptionally high burnout in primary care physicians and their relatively low compensation. These issues warrant further exploration into their contribution toward the continued...
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Brooks' analysis of hostility towards primary care thoughtfully described longstanding systematic cultural and structural factors that influence specialty choice.[1] However, absent from her study is discussion of two substantial factors - the exceptionally high burnout in primary care physicians and their relatively low compensation. These issues warrant further exploration into their contribution toward the continued disparagement of primary care and its impact on specialty choice.
Much has been described about the influence of positive role models in primary care on students, including in Brooks' study. However, less is known about the influence of students' exposure to physicians facing burnout. Burnout rates are increasing in all physicians, [2] and family physicians experience higher levels of burnout than several other physician specialties.[2] Burnout and negativity are so prevalent that only 32% of family medicine physicians would choose the same specialty again if given the choice.[3] Medical students' perception of this widespread burnout may contribute to continued hostility and negative perception of primary care.
Despite the high workload and burnout associated with primary care, our compensation is significantly lower than that of physicians in other specialties.[3] Other specialists earn an average of nearly $90,000 more per year than primary care physicians.[3] Earning potential is a key factor when deciding on a specialty,[4] and physicians continue to be financially disincentivized to choose primary care. While there is hope on the horizon with the development of value-based payment systems, the negative influence of the longstanding structure of financial disparity towards primary care continues.
Hostility toward primary care has been shown to influence specialty choice among medical students.[5] Considering the discouragingly low number of new physicians entering primary care [6] and the growing shortage of primary care physicians,[6] it is imperative that our discussion of the systematic barriers to entering primary care is comprehensive. Further exploration of how all barriers are ingrained into medicine's culture and structure is essential to promote system transformation and successfully cultivate more family medicine leaders for the future.
References:
1. Brooks JV. Hostility During Training: Historical Roots of Primary Care Dispargement. Ann Fam Med. 2016;14(5):446-452. Doi:10.1370/afm.1971.
2. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings. 2015;90(12):1600-1613. Doi:10.1016/j.mayocp.2015.08.023.
3. Peckham C. Medscape Physician Compensation Report 2015. http://www.medscape.com/features/slideshow/compensation/2015/public/overview. Published April 21, 2015. Accessed September 27, 2016.
4. Phillips RL Jr, et al.; Robert Graham Center. Specialty and geographic distribution of the physician workforce: what influences medical student and resident choices? March 2009. http://www.graham- center.org/dam/rgc/documents/publications-reports/monographs- books/Specialty-geography-compressed.pdf. Accessed September 27, 2016.
5. Kernan WN, Elnicki DM, Hauer KE. The Selling of Primary Care 2015. J Gen Intern Med. 2015;30(9):1376-1380. Doi:10.1007/s11606-015-3364-9.
6. Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the Residency Expansion Required to Avoid Projected Primary Care Physician Shortages by 2035. Ann Fam Med. 2015;13(2):107-114. Doi:10.1370/afm.1760.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (10 October 2016)
Page navigation anchor for Reflections on History, Power, and Hostility: Views from South Africa
Reflections on History, Power, and Hostility: Views from South Africa
William Ventres, Family Physician
As a US family physician/educator working in South Africa, and having read Dr. Veazey Brooks article that describes the "presence and power of persistent hostility against primary care" in the United States, I offer the following three observations for consideration:
* This "hostility against primary care" is not just an historical phenomenon; it is a geographic one as well. Attitudes of arrogance based on scien...
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As a US family physician/educator working in South Africa, and having read Dr. Veazey Brooks article that describes the "presence and power of persistent hostility against primary care" in the United States, I offer the following three observations for consideration:
* This "hostility against primary care" is not just an historical phenomenon; it is a geographic one as well. Attitudes of arrogance based on scientific, cultural and economic elitism are rampant in South Africa, in Africa and around the world.
* Much has been made in the literature about the neocolonialist nature of global health endeavors, in that they commonly reproduce in the majority world the same elitist ideologies that undergird educational and service initiatives in high-income countries.
* The South African government recently decided to gradually adopt a system of National Health Insurance, in equal parts to increase access to medical services, work toward equity in health care, and rectify the abuses of Apartheid--a social structure based on elitism and domination.
Which brings me to my questions:
* When will we in the US recognize how such elitism inhibits inclusive social development around the world?
* When will we in the US begin to learn from others around the world as they work to "decolonize" their health care systems?
* When will we in the US support true universal health care at home, a system that would of necessity support family medicine and primary care?
I do not have all the answers as to how to move from the simple inquiries above to actionable intentions. Dr. Veasey Brooks has, however, demonstrated that history is an important part of understanding issues of power and hostility. Perhaps by understanding this history we may enhance our work toward change as we move forward in time.
Competing interests: None declared
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Competing Interests: None declared.