Primary concern: Fewer family doctors

  • Article by: JENNA ROSS , Star Tribune
  • Updated: October 28, 2009 - 9:39 AM

Forgiving loans could draw med students to primary care and curb a projected shortage.


Dustin Sperr, a University of Minnesota medical student who sees patients at Regions Hospital in St. Paul, plans to be a family physician. He grew up in Herman, Minn., and if he moves back to western Minnesota, he’ll qualify for loan repayment programs.

Photo: Richard Sennott, Star Tribune

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It's one small piece of health care reform, but it's a big deal for medical schools and doctor's offices: forgiving the student loans of doctors who choose primary care.

With fewer medical school students choosing the lower-paying fields of family medicine, internal medicine and pediatrics, lawmakers and others say something has to be done to attract them. Helping students repay their loans could help fill a shortage of general physicians that one report estimates could reach 44,000 by 2025.

"The financial burden drives very responsible people to make decisions that may not be in our state and country's best interest," said Dr. Patricia Simmons, a member of the University of Minnesota's Board of Regents and a professor at the Mayo Clinic.

Primary care physicians now make up 35 percent of today's physician workforce, according to the Council on Graduate Medical Education. Already there are shortages in some parts of the country. But only 20 percent of medical school graduates are choosing those fields. Instead, often loaded with debt, they're picking higher-paying specialties.

If health care reform allows millions of uninsured people to get regular care, more general practitioners will be needed to do their annual checkups and treat their diseases.

They'll need people like Dustin Sperr.

Sperr, 25, plans to be a doctor, and by doctor he means family physician -- the only kind there was growing up in Herman, Minn. He loves the idea of handling everything from ear infections to Alzheimer's.

"There's a lot of ownership in that kind of patient care," said Sperr, a med student at the University of Minnesota.

He'll make less in family medicine than he would with a specialty such as surgery, but that's OK with him.

He also knows that if he moves back to western Minnesota he'll qualify for loan repayment programs. State and federal programs offer providers in areas with under-served populations yearly payments toward their debt.

In 2008 the average U medical student graduated with debt of $137,268 from that degree alone. Help repaying students' loans makes a career in primary care "feasible," Simmons said.

But as they are now, the programs are too restrictive and the sums too small to attract the number of doctors the country needs, some experts argue. Members of Congress are discussing ways more money might be granted to more providers.

"We want to see people be doctors and go into primary care," Sen. Al Franken, D-Minn., told a group of University of Minnesota students this month. "There are definitely ways to do that through loan forgiveness."

The number of medical students who plan to go into primary care drops off considerably by the time they choose a residency. Christina Brakken-Thal, a student in the Medical School's combined M.D./Ph.D. training program, said she has seen that first-hand.

"Some of my friends are more than $200,000 in debt," said Brakken-Thal, who is also a student representative to the Board of Regents. "The primary care salary is still a good salary, but when you look at that debt and the other options."

Specialists can make double

On average, specialists make nearly twice what those in primary care do, according to a 2009 report by the Medical Group Management Association. The median compensation for a urologist, for example, was $383,016 in 2008, while a family practice doctor made $179,672.

Other reforms "will be much more effective if combined with reduction on income disparities," the Council on Graduate Medical Education wrote in a letter to Congress. "The growing gap between most subspecialties and primary care is a potent driver of student career choice."

When surveyed, few students say their debt factored into which specialty they chose, according to an annual report by the Association of American Medical Colleges. The kind of specialty, the role of mentors and the length of residency training played bigger roles, students said. But while debt wasn't often mentioned, expected salary was.

Even some specialties face challenges of too-few providers and lower-than-average pay. The median psychiatrist compensation in 2008 was $195,878 -- just slightly more than the median pay for primary care -- and most of Minnesota is facing a shortage of mental health practitioners.

Minnesota offers more GPs

Minnesota does a better job graduating students into primary care than other states.

In 2009, 11.1 percent of the U's medical students chose residencies in one subset of primary care, family medicine -- compared with 6.4 percent nationally, according to a graduation questionnaire by the Association of American Medical Colleges.

That's partly because students who begin their schooling on the Duluth campus are selected because of their interest in primary and rural care, said Dr. Mac Baird, head of the U's department of family medicine and community health. It's also because Minnesota has an optimistic and philanthropic culture, he said.

"Everyone serving the under-served is going to do it sometimes under difficult circumstances," Baird said. "Measured outcomes are going to be slower and more difficult to achieve. You have to be an idealist."

Besides loan forgiveness, other tools to address the primary care shortage include educating more nurse practitioners. Proposed legislation would add nursing faculty to those eligible for loan repayment and scholarship programs, among other things.

But loan repayment programs are a band-aid for a bigger overhaul of how physicians are paid, Baird said. Paying providers for keeping people healthy will not only bring more doctors to family care, but will also lower costs and improve results, he said.

"The ultimate solution here is not to pay for units of service, but pay for outcomes."

Jenna Ross • 612-673-7168


    6.4 Percent of med students who choose family medicine, nationally

    11.1 Percent of Minnesota med students who choose family medicine

    35 Percent of today's physician workforce in primary care

    44,000 Shortage (projected) of general physicians by 2025

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