Capsule Commentary on Choi et al., Primary Care Careers Among Recent Graduates of Research-Intensive Private and Public Medical Schools

This study by Choi et al.1 investigated graduates of research intensive and non-research intensive allopathic medical schools to see if there was a difference in the proportion choosing primary care. They found that the answer depended on whether the schools were public or private. Graduates of private, research intensive medical schools were less likely to choose primary care (24 % vs. 33 %) or family medicine residencies (6 % vs. 2 %) than private non-research intensive schools. There was no difference among public medical schools, where 36 % were primary care practitioners and 7–10 % chose family medicine residencies. The authors conclude that research intensive private medical schools should be more actively promoting primary care careers.

The reported associations may have been confounded by a couple of factors. First, students may choose to attend research intensive medical schools because they are interested in research. It would have been helpful if the authors looked at the proportion of graduates who pursued research careers. If private research-intensive medical schools are producing a disproportionate number of researchers, then it can be argued they are succeeding in an important function. A second confounder could be that there are no differences in application rates from lower ranked schools for non-primary care positions, just lower rates of successfully matching these programs. This is suggested by a 2010 study found that higher ranked school graduates had a higher match rate than those from lower-ranked programs into “higher-income, controllable lifestyle specialties.”2

There are a number of important roles for our healthcare system. Academic medical centers focus on three primary missions: patient care, medical education and research. Research intensive medical schools focus a great deal of energy (and talent) on research. It may not be inappropriate that they select students who express greater interest (and potential) for research and then expose them to a more intense research curriculum and a faculty heavily invested in research. The consequences of such a process may produce fewer students choosing to do primary care.

The issue of workforce development is important. There is a large, robust literature on the failings of the US healthcare system.3 We are producing a generation of proceduralists. There are a number of reasons why this may be so. Prestige, remuneration, career satisfaction, lifestyle, opportunities for academic advancement and research may all help shape the workforce.4,5 If the goal is to increase the number of graduates choosing careers in primary care, there are more powerful forces at play than the orientation of specific medical schools.