Crime doesn’t pay. Unfortunately, neither does primary care—or at least not enough, especially when you’re carrying an average of $139,000 in debt into your residency.

Two new studies published today in JAMA continue to sound the alarm bell about the future of our physician workforce. One, a survey of nearly 1,200 fourth year medical students, found that only 2 percent planned to go into general internal medicine. More than 23 percent planned a career in internal medicine—a field generally associated with primary care but which also contains more lucrative subspecialties.

The primary reasons pushing these doctors away from primary care: income and lifestyle. Close to 65 percent believed they would earn less income going into internal medicine, 68 percent believed they would have to deal with more paperwork and 42 percent were turned off by the need to bring work home with them as an internist. (See our colleague Joanne Kenen's post today about medical homes, primary care and the hamster wheel.)

A second study published in JAMA this week provided more insight into the primary care shortage. Looking at data from 2007, it reasserted the strong correlation between physician salaries and residency fill rates (the percentage of open residency positions for a medical specialty filled by U.S. graduates). The field of family medicine, with the lowest mean salary ($185,740), also had the lowest residency fill rate (42.1 percent). Boasting two of the highest mean salaries, radiology and orthopedic surgery also had two of the highest fill rates (88.7 and 93.8 percent, respectively). See the chart below for a more complete picture of this correlation.

Primary care physicians are the foundation of any health care system. They’re associated with improved outcomes and lower costs. Providing incentives like loan reimbursements may help recruit some doctors to the field. But it doesn’t really address the barriers to more physicians choosing primary care specialties: lifestyle and income. These two issues are closely related and go back to how we pay for health care in general. We pay for procedures not outcomes. We reimburse tests and surgeries at a rate much higher than office visits and consultations, without really understanding the relative value to the patient. The end result is bad for primary care docs—who have to spend less time with more patients to make a living. It’s bad for patients—who don’t get the coordinated care they need. And it’s bad for society—which ends up spending more money on less efficient care.

Source: Ebell MH. Future salary and US residency fill rate revisited. JAMA. 2008;300(10):1131-1132