THE FAMILY MEDICINE MATCH: BULL MARKET OR DEAD CAT BOUNCE?

This year’s national Match Day results were somewhat encouraging to America’s family medicine residency program directors. This year, 73 more training slots in family medicine were offered than last year¹ and US seniors filled 98 more positions than in 2009. However, only 7.3% of US medical school senior applicants matched with a family medicine residency program, and US schools are still producing fewer US family medicine residency entrants (only 44.8%) than medical schools of other nations. To put it in perspective, since 1999 the total of family medicine positions offered in the match has declined 635 positions (from 3,265 to 2,630), and filled positions have decreased 293 (from 2,697 to 2,404) as the nation struggles with exploding health care costs and access to primary care.

Medical school Web sites trumpeted this year’s outcome, however. One Boston-based school wrote that 50% of their just-matched class are “headed into primary care specialties, including internal medicine, pediatrics and family practice [sic].”² The AAMC put out 2 press releases on Match Day^3,4 stating,

The AAMC is extremely encouraged that more graduating US medical students this year chose primary care for their residency training. The increases for family medicine, internal medicine, and pediatrics in this year’s Match are welcome steps in the right direction for improving our health care system and our nation’s health.⁴

Family medicine program directors do not seem to be as sanguine as the AAMC and many of its member institutions. Perhaps it’s because, according to a 2008 study published in the Journal of the American Medical Association, only 2% of medical students choosing internal medicine were planning on becoming general internal medicine physicians.⁵ Hopefully it is not lost on medical school deans that entry into an internal medicine or pediatrics residency does not insure that the ultimate product is a primary care physician.

To use a stock market analogy, is this the beginning of a bull market for student interest in family medicine or in reality only a “dead cat bounce” (a small uptick after a precipitous fall)? Are we more likely observing a halo effect resulting primarily from the widespread coverage of health care reform and spotlight on our nation’s primary care crisis during the past year?

What is the responsibility of American medical schools and our hospital-based graduate medical education system to produce actual “in-the-trenches” primary care physicians anyway? Long-term work-force trends in primary care, internal medicine, and pediatrics are problematic to meeting our nation’s primary care needs. Only 7.3% of US seniors choosing family medicine will clearly not get it done either, nor will use of retail clinics, independent nurse practitioners, and other workaround strategies, all touted to be solutions.

We believe medical school deans need to take a much more proactive leadership role in disinfecting the often toxic medical school environment that prospective generalists currently need to endure before choosing a primary care career.

Additionally, current Medicare GME caps are hospital-specific but not specialty specific. Decisions about the size and type of residency programs are largely determined by hospital CEOs who report to boards and/or shareholders. Hospital CEOs are judged primarily by the financial performance of the institution in a health care system that still rewards subspecialty and procedural care and the ability to bring in research funding. Additionally, there is currently much less accountability on quality and health outcome indicators of the population served by the institution than these consumption-driven revenue streams. New models of primary care-oriented sponsoring institutions such as teaching community health centers need be explored and supported.

America’s family medicine residencies can produce a primary care workforce that will cut health care costs and improve outcomes if given the support. As recently-enacted national health care reform begins, real physician workforce reform to create realignment via better use of public dollars is essential. Making US medical schools financially accountable for their inherent social (and fiscal) contracts with the public and insisting on accurate reporting of projected primary care physicians coming from our schools would be important first steps.

• © 2010 Annals of Family Medicine, Inc.