Hostility During Training: Historical Roots of Primary Care Disparagement

Abstract

PURPOSEThe environment during medical school has been shown to dissuade students from choosing primary care careers. The purpose of this study was (1) to explore how long-standing this hostility toward primary care is historically and (2) to understand the mechanisms through which the environment conveys disparagement of primary care to students. METHODSThe study is based on a qualitative analysis of 52 primary care physician oral histories. The data are from the Primary Care Oral History Collection, created by Fitzhugh Mullan and deposited in the National Library of Medicine. Transcripts were analyzed using qualitative data analysis and the constant comparative method.RESULTS Respondents (63.5%) reported experiencing discouragement or disparagement about primary care, and this proportion remained fairly high through 5 decades. Findings indicate that hostility toward primary care operates through the culture and the structure of medical training, creating barriers to the portrayal of primary care as appealing and important. Support for primary care choice was uncommon but was reported by some respondents. CONCLUSIONThe primary care shortage and primary care's unfavorable representation during medical training is a multifaceted problem. The evidence reported here shows that cultural and structural factors are critical components of the problem, and have existed for decades. For policy responses to be most effective in meeting the primary care workforce problem, they must address the presence and power of persistent hostility against primary care during training. 2016;14:446-452. doi: 10.1370/afm.1971. Ann Fam Med INTRODUCTIONP romoting and maintaining an adequate supply of primary care physicians is extremely important for the US health care system. Primary care has been shown to improve health, increase access to health care, reduce health care disparities, and lower health care costs. [1][2][3] Geographic areas with more primary care physicians have lower overall costs and lower rates of preventable hospitalizations. 1,[4][5][6] In fact, the Organisation for Economic Co-operation and Development attributes the United States' extremely high health expenditures to an underdeveloped primary care sector. 7Despite the benefits of primary care, the future of primary care has been described as precarious. 8 Researchers project a shortage of 33,000 primary care physicians by 2035, 9 a number that is driven by a growing and aging population and by insurance expansion through the Patient Protection and Affordable Care Act.10-12 Maldistribution of primary care physicians is another serious aspect of the shortage. 12,13Given a growing need for first-contact, coordinated, patient-centered care that primary care provides, 1,14-16 the number of US medical graduates choosing to practice primary care medicine is inadequate. 17 There is evidence that fourth-year students find primary care less attractive than first-year students, 18 and only 39% of medical students who were origi- nally interested in family medicine end...

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