American Medical Student Association

As we begin the 21st century, medical education faces a dilemma as well as an opportunity. The dilemma is not new. There’s a shortage of physicians entering or planning to enter generalist specialties. One probable reason behind this is the number of students who change their minds during medical school about pursuing primary care careers. The opportunity lies in what medical schools can do to encourage students to maintain their commitment to primary care specialties.


According to the Association of American Medical Colleges, in 1992, 14.6 percent of graduating students surveyed stated that they planned to pursue careers in one of the generalist specialties, but no school graduated 50 percent or more students with generalist intentions and only one school reached 40 percent. In 1995, 27.5 percent planned on pursuing careers in one of the generalist specialties, five schools graduated more than 50 percent and another 15 graduated more than 40 percent who favored generalist careers. In 1997, 39.6 percent
of fourth-year U.S. medical school students planned on entering generalist specialties.


Is it possible to identify what types of factors influence students to choose primary care as a specialty? More importantly, what influences students to switch from primary care to another specialty? Several surveys—including an informal one conducted as part of the American Medical Student Association’s (AMSA’s) Promoting, Reinforcing and Improving Medical Education (PRIME) project—reveal some of the major factors influencing students’ specialty choices.


Personal characteristics. Choosing a specialty is a personal decision based, in part, on an individual’s values and disposition. Recent studies suggest that medical student characteristics that are common among graduates entering generalist careers include initial specialty preference, geographic background, gender, age, ethnicity, economic and lifestyle factors, attitudes and personal values, service orientation and premedical academic performance. For example, older students, married students, women and those for whom high salaries are not as important are more likely to enter primary care, as are students who value a diverse patient population. Students who want to provide comprehensive care and develop personal relationships with their patients also tend to choose careers in primary care.


Monetary considerations. Studies have also found that income and monetary rewards are highly, but inversely, related to a generalist career choice. The debt incurred during medical training influences specialty decision. Currently, only 30 percent of graduating physicians enter lower-income primary care specialties, including family medicine, pediatrics and internal medicine. Having electives in primary care was another variable found to be associated strongly with students’ change of interest in primary care.


Time for family. Medical students entering primary care professions, especially in rural areas, are concerned about the effect personal and professional isolation will have on their spouses or families. Will there be work available for my spouse? What kind of education and opportunities will my children have? Moving away from extended family and friends can be an important consideration for some medical students.


However, many students view primary care specialties as less demanding of their personal time than other specialties with unpredictable hours, such as surgery and obstetrics–gynecology. These findings suggest there are ways to enhance medical school curricula so that more students pursue and enter primary care as their preferred specialty. The following suggestions may have an effect on the number of medical students who switch specialties.


Primary care electives. Increase the number and quality of primary care electives during third and fourth years. Does your school have a family medicine elective clerkship? Is the elective conducive to developing personal relationships with your patients? Is your preceptor also a personal mentor?


Loan repayment programs. Effectively disseminate information on programs in primary care that offer loan repayment in addition to salary, such as the National Health Service Corps. These programs can be an excellent way to experience the benefits of primary care with fewer concerns about financial considerations.


Mentoring. Create mentoring or precepting opportunities with community-based practitioners, beginning early in medical school and continuing as part of students’ clinical years.


Curriculum reform. Encourage innovative curriculum reform commitments that include a strong focus on primary care. Does your school have a service-learning track or spend time addressing issues in cultural competence? Are there opportunities to provide longitudinal care for patients?


The “AMSA Foundation’s Fifth Annual Primary Care Scorecard” focuses on one measurable aspect of medical education: the percentage of medical school graduates entering primary care residencies. Clearly, this is only one part of a larger effort to understand why so many students switch specialty choices between matriculation and graduation. The Primary Care Scorecard shows one end of the spectrum—specialty choice at graduation—and only by actively exploring what causes students to switch between matriculation and graduation can we affect future Primary Care Scorecards.


Meredith Burke Lawler is the AMSA Foundation’s PRIME project manager. Pam Supanwanid is a third-year medical student at Northwestern University in Chicago and a PRIME project intern. Additional assistance was provided by Lisa Old, PRIME project associate.

Percentage of 1999 Allopathic Medical School
Graduates Entering Primary Care Specialties

	Medical School	%FP	%IM	%PEDS	%IM/ PEDS	%PC
1	Univ of Illinois-Rockford	33.3	20.4	16.7	3.7	74.1
2	Morehouse school of medicine	27.6	24.1	13.8	3.4	68.9
3	albert einstein college of medicine	5.3	47.3	16.0	0.0	68.6
4	meharry medical college	25.9	24.7	12.3	4.9	67.8
5	SUNY-Stony brook	15.1	34.9	17.0	0.0	67.0
6	univ of washington	26.9	25.1	9.0	3.0	64.0 "Times New Roman";mso-ansi-language:EN-US;mso-fareast-language:EN-US; mso-bidi-language:AR-SA">†
7	mercer univ	25.5	25.5	10.9	1.8	63.7
8	univ of missouri-Kansas city	21.0	25.9	7.4	8.6	62.9
9	univ of california, los angeles	17.3	25.6	19.2	0.6	62.7"Times New Roman";mso-ansi-language:EN-US;mso-fareast-language:EN-US; mso-bidi-language:AR-SA">*
10	wright state univ	31.3	19.8	9.4	2.1	62.6
11	univ of rochester	5.1	35.4	15.2	6.1	61.8
11	univ of south carolina	20.6	20.6	19.1	1.5	61.8
13	east carolina univ	34.3	8.6	10.0	8.6	61.5
13	univ of minnesota medical school	28.1	22.4	8.8	2.2	61.5 "Times New Roman";mso-ansi-language:EN-US;mso-fareast-language:EN-US; mso-bidi-language:AR-SA">°
15	michigan state univ	24.5	17.9	11.3	7.5	61.2
15	univ of hawaii	24.1	20.4	11.1	5.6	61.2
17	univ of vermont	8.4	25.3	24.2	3.2	61.1
18	southern illinois univ	21.1	28.2	5.6	5.6	60.5
19	eastern virginia  medical school	20.8	20.8	16.8	2.0	60.4
20	univ of south dakota	32.0	16.0	10.0	2.0	60.0
21	univ of kansas	27.4	17.7	9.7	5.1	59.9
22	medical college of georgia	19.9	25.7	13.5	0.6	59.7
23	univ of nevada	32.7	15.4	7.7	3.8	59.6
24	univ of chicago pritzker	3.6	36.9	18.0	0.9	59.4
25	northeastern ohio univ	17.5	35.0	5.8	0.0	58.3
26	MCP hahnemann univ	17.8	25.0	15.3	0.0	58.1
27	univ of massachusetts	17.9	25.3	13.7	1.1	58.0
28	rush medical college	14.3	31.7	9.5	2.4	57.9
29	oregon health sciences univ	25.0	23.1	8.7	1.0	57.8
30	east tennessee state univ	14.8	27.9	14.8	0.0	57.5
30	univ of texas-San antonio	22.7	20.2	13.6	1.0	57.5
32	univ of nebraska	21.8	23.6	9.1	2.7	57.2
33	univ of kentucky	18.3	24.7	6.5	7.5	57.0
34	univ of connecticut	6.8	27.3	18.2	4.5	56.8
35.	univ of virginia	17.8	22.5	15.5	0.8	56.6
36	univ of pittsburgh	12.1	25.0	16.4	2.9	56.4
37	univ of south alabama	15.3	20.3	15.3	5.1	56.0
38	medical college of ohio	15.5	24.0	10.1	6.2	55.8
39	univ of california, san diego	11.5	26.9	14.4	2.9	55.7
40	univ of florida	14.5	24.8	16.2	0.0	55.5
41	georgetown univ	6.8	33.5	12.4	2.5	55.2
42	west virginia univ	20.7	20.7	7.3	6.1	54.8
43	univ of new mexico	25.8	18.2	9.1	1.5	54.6
44	univ of southern california	15.2	29.7	9.5	0.0	54.4
45	northwestern univ	6.4	36.8	11.1	0.0	54.3
46	univ of cincinnati	12.4	21.2	16.1	4.4	54.1
47	univ of alabama	14.5	21.1	14.5	3.6	53.7
47	univ of iowa	27.8	15.4	9.9	0.6	53.7
49	wake forest univ	12.7	26.4	12.7	1.8	53.6
50	ohio state univ	20.7	18.1	11.9	2.6	53.3
52	new york medical college	6.8	29.2	15.1	2.1	53.2
53	univ of california, san francisco	11.4	26.9	13.4	1.3	53.0
54	harvard medical school	2.5	35.2	12.6	2.5	52.8
54	univ of arizona	19.1	14.6	169	2.2	52.8
56	saint louis univ	14.9	16.9	15.5	5.4	52.7
57	howard univ	4.0	34.3	13.1	1.0	52.4`
57	tufts univ	9.6	26.5	14.5	1.8	52.4
57	univ of missouri-Columbia	19.8	12.8	14.0	5.8	52.4
60	loma linda univ	17.3	25.6	7.1	1.9	51.9
60	loyola univ - stritch	13.5	25.6	9.8	3.0	51.9
62	brown univ	14.1	27.1	8.2	2.4	51.8
64	jefferson medical college	19.8	18.0	12.9	0.5	51.2
65	wayne state univ	17.2	25.0	6.6	2.0	50.8
66	univ of mississippi	15.1	24.7	8.6	2.2	50.6
67	emory univ	7.5	29.0	14.0	0.0	50.5
67	univ of illinois-Chicago	8.8	26.9	13.2	1.6	50.5
69	univ of maryland	10.1	22.3	15.8	2.2	50.4
70	temple univ	8.2	27.7	13.0	1.1	50.0
70	texas a & m univ	16.1	11.3	16.1	6.5	50.0
70	VCU medical college of virginia	16.3	18.1	12.5	3.1	50.0
73	albany medical college	13.6	18.9	15.9	1.5	49.9
74	SUNY-Buffalo	11.3	18.4	16.3	3.5	49.5
75	univ of california, irvine	15.3	21.2	12.9	0.0	49.4
76	weill medical colelge-Cornell	1.0	37.8	10.2	0.0	49.0
77	marshall univ	25.5	6.4	10.6	6.4	48.9
78	mt sinai school of medicine	2.4	30.7	15.7	0.0	48.8
79	univ of oklahoma	18.8	14.6	13.2	2.1	48.7
80	ponce school of medicine	6.3	28.1	12.5	1.6	48.5
81	new york univ	1.9	33.5	12.4	0.6	48.4
82	univ of california, davis	12.0	20.7	15.2	0.0	47.9
84	univ of wisconsin	17.6	14.0	14.0	2.2	47.8
85	univ of colorado	16.7	21.2	9.8	0.0	47.7
86	louisiana state univ - new orleans	11.9	21.9	8.8	5.0	47.6
86	medical univ of south carolina	16.7	14.2	15.0	1.7	47.6
88	univ of illinois-Peoria	12.3	15.8	12.3	7.0	47.4
88	univ of miami	11.5	19.9	14.1	1.9	47.4
88	washington univ	5.1	25.4	16.9	0.0	47.4
91	univ of michigan	14.2	19.5	8.9	4.7	47.3
92	texas tech univ	24.8	12.8	9.6	0.0	47.2
93	medical college of wisconsin	14.8	18.4	11.7	2.0	46.9
94	george washington univ	10.3	21.8	14.7	0.0	46.8
95	univ of texas-Galveston	21.2	15.6	8.0	1.9	46.7
96	UMDNJ-Robert wood johnson	7.4	26.4	10.8	20.6	46.6"Times New Roman";mso-ansi-language:EN-US;mso-fareast-language:EN-US; mso-bidi-language:AR-SA">∞
97	univ of tennessee	12.7	22.4	6.1	4.8	46.0
98	columbia univ	0.7	31.7	13.1	0.0	45.5
99	univ of texas-Houston	15.3	14.3	10.2	5.6	45.4
100	finch univ/Chicago medical school	9.1	24.7	10.8	0.5	45.1
101	univ of north dakota	18.4	14.3	8.2	4.1	45.0
102	univ of north carolina-Chapel hill	10.4	18.7	14.2	1.5	44.8
102	vanderbilt univ	3.1	22.9	14.6	4.2	44.8
104	case western reserve univ	10.3	17.1	15.8	1.4	44.6
105	dartmouth medical school	17.5	12.7	14.3	0.0	44.5
106	johns hopkins univ	0.9	28.7	11.3	3.5	44.4
107	SUNY-Syracuse	12.9	23.8	6.1	1.4	44.2
108	uniformed services univ	16.8	16.1	11.2	0.0	44.1
109	univ of texas-Southwestern	6.2	31.1	6.2	0.5	44.0
110	boston univ	5.2	25.8	11.6	1.3	43.9
111	indiana univ	19.8	11.7	9.3	2.7	43.5
112	tulane univ	8.0	20.0	12.7	2.7	43.4
113	yale univ	2.2	26.1	13.0	1.1	42.4
114	SUNY-Brooklyn	2.7	23.2	15.1	1.1	42.1
115	pennsylvania state univ	13.3	16.2	11.4	1.0	41.9
115	UMDNJ-New jersey	5.2	22.1	9.9	4.7	41.9
117	baylor college of medicine	8.7	16.8	13.9	2.3	41.7
118	stanford univ	4.9	25.6	11.0	0.0	41.5
119	louisiana state univ-Shreveport	12.9	10.8	12.9	4.3	40.9
120	univ of louisville	13.3	12.5	8.6	6.3	40.7
121	univ of pennsylvania	2.2	22.5	13.8	1.4	39.9
122	univ of south florida	11.1	17.8	8.9	1.1	38.9
123	univ of illinois--Urbana-Champaign	16.0	8.0	8.0	4.0	36.0
124	duke univ	1.0	20.8	7.9	4.0	33.7
124	univ of puerto rico	8.0	18.6	6.2	0.9	33.7
126	mayo medical school	5.7	5.7	20.0	0.0	31.4

Unranked

- Universidad Central del Caribe -- no data submitted.

Percentage of 1998 Osteopathic Medical School
Graduates Entering Primary Care Specialties

	Medical School	%FP	%IM	%PEDS	%IM/ PEDS	%PC
1	chicago COM	88.4	5.3	2.1	0.0	95.8
2	UMDNJ SOM	66.7	20.6	7.9	0.0	95.2
3	michigan state univ COM	66.1	23.2	5.4	0.0	94.7
4	univ of new england COM	85.5	5.5	1.8	0.0	92.8
5	west virginia SOM	89.1	3.6	0.0	0.0	92.7
6	kirksville COM	81.2	9.4	1.7	0.0	92.3
7	philadelphia COM	76.6	11.0	4.6	0.0	92.2
8	ohio univ COM	76.0	13.5	2.1	0.0	91.6
9	univ of north texas COM	76.5	14.7	0.0	0.0	91.2
10	univ of osteopathic medicine & Health serv	79.6	8.8	2.7	0.0	91.1
11	new york COM	81.3	5.4	3.6	0.6	90.9
12	NOVA southeastern univ COM	74.2	13.3	3.3	0.0	90.8
13	lake erie COM	72.1	14.8	3.3	0.0	90.2
14	univ of health science COM	70.8	9.2	4.2	0.0	84.2
15	western univ COM	74.6	5.9	3.4	0.0	83.9
16	oklahoma state univ COM	60.9	10.1	7.2	0.0	78.2

Unranked

- Arizona COM - First class graduates in May 2000.

- Pikeville College SOM - First class graduates in May 2001.

- Touro Univ COM - First class graduates in May 2001.