The number of medical students choosing to specialize in primary care in the United States is alarmingly low, according to claims in a May 2009 letter to Congress from the Council on Graduate Medical Education. Primary care physician workforce “currently comprises 35% of all practicing physicians and is rapidly declining,” while “fewer than 20% of all US medical students are choosing primary care specialties.” With the possibility that health care reform could further increase the demand for primary care services, it is clear that action needs to be taken.

Addressing the issue, however, has proven difficult due in part to the fact that there is neither a single, dominant cause nor an efficient way to measure the effects of programs and initiatives designed to help. Although workforce studies have identified a number of different factors which contribute to the problem, the general consensus is that economics plays a key role in many students’ decisions whether or not to specialize in primary care. Non-primary care specialties usually command higher salaries, and perhaps more importantly, obtaining a degree in a primary care field has never been more expensive.

According to a report by the Robert Graham Center, “the proportion of [medical] students with debt and average debt per student rose steadily over the last 30 years.” The amount of debt that the average medical student must incur throughout her or his education is staggering. It is becoming increasingly common for graduates of medical school to accumulate a debt burden of 200 to 250 thousand dollars or more. Medical school graduates in 2008 had incurred an average of $155,000 in student debt.

Common sense would dictate that the more debt a medical student incurs, the less likely it is that she or he will focus on primary care. Despite this, the actual effect of student debt load on primary care health workforce remains “complex,” according to the Robert Graham study. Researchers found that having a debt load above 250 thousand dollars reduced the likelihood that a given student would specialize in primary care, as one might expect. Surprisingly, however, the students who were “least likely to later practice primary care” were those with little or no debt. A larger contributor, in this regard, seems to be one of perception and awareness.

The study reports that the medical students most likely to specialize in primary care were those who had some degree of exposure to rural, underserved, and/or minority populations. Specifically, students were much more likely to enter primary care if they were born in a rural county, received rural or inner-city training experiences in medical school, or attending a public rather than a private medical school. Increasingly, medical students “come from affluent families who may influence career specialty and income expectations, and [have] limited exposure to rural or underserved populations,” the authors state. “Alternatively, debt-averse students may not apply to medical school due to fear of debt.”

A significant question, however, relates to the kind of effects debt load and earning potential in primary care professions have on one another. There is little research which compares the effects of student debt load across primary care professions, and the conversation often focuses exclusively on physicians. What is often left unsaid is the fact that critical needs exist for other primary care professionals – nurses, dentists, pharmacists, and mental health providers, among others – and students in these areas face debt load issues which may parallel those of physicians. Consider the potential costs and earnings for physician assistants: the PAEA, which publishes tuition statistics for all PA programs in the United States, lists professional programs ranging from 16 to 48 months. In 2008, the average resident tuition across all programs (both public and private institutions) was $49,029, which totals to an average of $1,753 per month. While this is certainly less than the average cost of medical school, the average physician assistant also earns less than a physician: $72,600 compared to $161,200 for family physicians. In the short term, the choice isn’t as cut-and-dried as one might expect.

Students unable to face the prospect of incurring such high levels of debt do have options. Notable and successful loan repayment programs are thriving. The National Health Service Corps, which offers $50,000 toward repayment of student loans in exchange for two years of service in a Health Professional Shortage Area, recently received $300 million in funding through the American Recovery and Reinvestment Act, with which they anticipate expanding their field from 4,000 to 8,000 primary care clinicians. The Health Workforce Information Center currently links to 87 different loan repayment programs which operate at the local, state, and federal levels and which apply to a number of different primary care health professions. These loan repayment programs expose professionals to underserved areas and populations which they may not have otherwise considered. They do so effectively, evident in the case of the NHSC through statistics that the average participant continues to live and work in their placement area years after his or her service obligation is satisfied.

However, this raises an interesting Catch-22. There is no doubt that programs which trade debt for service have made a dramatic positive impact on the accessibility of primary care. But ideally, there wouldn’t be a need for these programs to exist, on two fronts: both because primary care would be accessible by everyone and also because, ideally, students would not need to incur unmanageable debt to receive training in primary care professions. In our current model, debt and service are at least partially dependent on one another: on one hand, underserved areas rely on programs such as the NHSC to supply them with primary care professionals. On the other hand, the programs themselves rely on students being saddled with debt to attract them via their loan repayment and/or scholarship incentives.

Ultimately, it would seem that fixing these problems requires some fundamental paradigm shifts, both in the way health care providers are compensated as well as our cultural attitude towards primary care.

“Changing the reimbursement system is going to be incredibly important,” states Dr. David Garr, director of the South Carolina Area Health Education Consortium, in reference to the salaries of primary care professionals. “In other countries, there isn’t anything close to the gap in earning capacity between non-primary care and primary care specialties [that exists in the United States]. As a result, they have a much higher percent of physicians in primary care specialties. Their whole system is designed to provide health care rather than medical care. There’s more support for prevention, more support for outreach, more support for taking care of populations than we have in this country. We are very much focused on disease care, rather than health care.”