调查发现，过去的二十年间，越来越少的美国医学生愿意进入家庭医生培训体系，也即他或她们不愿意当家庭医生。究其原因不外是家庭医生的工作负荷大和待遇不高。统计分析表明，若按40年的工作年限计算，一个家庭医生的收入将较一名心血管专家少挣350万美元，这是一个巨大的数字。因此，专家们认为能够让更多的医学生进入家庭医生行列最好的办法就是提升家庭医生们的收入，而拥有更多的家庭医生是国家拥有一个强大的初级保健体系之前提，强大的初级保健体系可以保障以较低的代价换来更健康的国民（A strong primary care system is associated with improved outcomes and lower costs）。

Fewer Med Students Training as Primary-Care Doctors: Study

Shrinking number of general internists a 'pending crisis,' researcher says

TUESDAY, April 26 (HealthDay News) -- As researchers warn of a serious shortage of primary-care physicians, a new study finds the percentage of medical students who want to go into general internal medicine has dropped sharply over the past two decades.

General internists in the United States are "a shrinking force," said study author Dr. Mark D. Schwartz, an internist himself. "There really is a pending crisis in primary care in this country, particularly as [many older Americans] are retiring. The shrinking primary-care workforce becomes a bottleneck to health care reform."

Many health plans require that patients visit a primary-care physician before seeing a specialist, and health care reform is expected to greatly expand the number of Americans with medical coverage, creating a need for even more doctors.

But in 2008, only 264 U.S. medical students chose residency training in primary-care internal medicine compared to 575 in 　　1999, according to background information in the study.

According to Schwartz, an associate professor at New York University School of Medicine, general internists make up about half of all primary-care physicians in the country. (Family medicine physicians see many other patients).

In the new study, published April 25 in the Archives of Internal Medicine, researchers compared surveys of senior-level medical students from 1990 (1,244 people at 16 schools took part) and 2007 (1,177 participants at 11 schools).

The percentage of women grew markedly over the 17 years, from about one-third to just over one-half, as did the average level of debt ($63,000 to $101,000 in 2007 dollars).

Over the years, the appeal of primary-care medicine as a reason for entering internal medicine fell from 57 percent to 33 percent. Forty-one percent of the 2007 respondents said the primary-care aspect of general internal medicine pushed them away from the field, compared to 21 percent in 1990.

And those choosing to practice general internal medicine in 2007 fell from 9 percent to 2 percent.

Students in both surveys felt that internal medicine involved a heavier workload and more stress than other specialties.

Another explanation for the decline may be the "compensation gap" between general internists and other kinds of physicians, Schwartz said. Technology-focused fields pay much more than "diagnostic management care," he said.

"Over a 40-year career, the total difference between a cardiologist and general internist is almost $3.5 million," he said.

The best solution is to pay general internists more money, Schwartz said. "There will have to be an adjustment," he said, one that leads to less pay for some other kinds of physicians.

Dr. Yul Ejnes, a general internist in Cranston, R.I., said the shortage of primary-care doctors is a serious concern.

"A strong primary care system is associated with improved outcomes and lower costs," he noted.

"We need to change the practice of general internal medicine by reforming the payment system and coming up with better models that make the students not just respect and admire the career but actually want to do it," added Ejnes, chair of the board of regents of the American College of Physicians.

SOURCE: Mark D. Schwartz, M.D., associate professor, medicine, New York University School of Medicine, New York City; Yul Ejnes, M.D., general internist and chair, board of regents, American College of Physicians, Cranston, R.I.; April 25, 2011, Archives of Internal Medicine