The Dean’s Lie -- Primary Care at Graduation and Practice

Context: Graduate medical education is key to helping determine the composition and location of the physician workforce. This is especially true in primary care, whose physicians have been shown to practice in high-need areas and treat underserved populations. Primary care has received more attention over the past decade and many programs tout their national primary care ranking. However, it has become clear that simply entering a primary care residency at medical school graduation does not consistently result in practicing primary care. We sought to describe the difference between primary care specialty choice at graduation and actually practicing primary care 5-7 years later.

Objective: To rank allopathic and osteopathic medical schools based on, 1) the percent of primary care specialty choice at graduation and 2) practicing primary care 5-7 years after graduation. Determine physician, medical school and specialty factors that are associated with practicing primary care.

Study Design: Retrospective cohort design

Datasets: 2021 AMA Masterfile, 2021 historic residencies file

Population Studied: Medical students who graduated between 2013 and 2015

Outcome Measures: Percentages of students who enter primary care specialty (Internal Medicine, Pediatrics, Family Medicine) at graduation, and 5-7 years later when they are in practice. Medical school rankings based on primary care specialty choice at graduation (the Dean’s Lie) versus in practice.

Results: Between 2013 and 2015 there were 52,054 graduates from medical schools, of which 26,264 (50.5%) entered a primary care residency, but 5-7 years later, just 14,151 (27.2%) were practicing primary care. While nearly every medical school’s percentage of primary care dropped between graduation and practice, those with higher rates of graduates entering internal medicine and pediatric residency decreased the most. Nearly 92% of students entering a family medicine specialty were practicing primary care 5-7 years later, compared to just 55% of pediatrics and less than 33% of internal medicine. Public allopathic medical schools and osteopathic schools had higher rates of primary care production.

Conclusion: Measuring primary care specialty at graduation from medical school offers an erroneous view of primary care production and national ranking. National rankings of primary care should continue to prioritize primary care practice over primary care residency choice as a measure of primary care production.