The country has long had too many specialists and subspecialists, so the common wisdom holds. And, the common wisdom continues, the fault lies with the residency system, which overemphasizes specialty medicine and devalues primary care, in flagrant disregard of the nation’s needs.
It was not always that way. Before World War II, medical education practiced birth control with regard to the production of specialists. Roughly 80% of doctors were general practitioners, only 20% specialists. This was because the number of residency positions (which provided the path to specialization) was strictly limited. The overwhelming majority of medical graduates had to take rotating internships, which led to careers in general practice.
After World War II, the growth of specialty medicine could not be contained. The limit on residency positions was removed; residency positions became available to all who wanted them. Hospitals needed more and more residents, as specialty medicine grew and medical care became more technologically complex and scientifically sophisticated. Most medical students were drawn to the specialties, which they found more intellectually exciting and professionally fulfilling than general practice (which in the 1970s became called primary care). The satisfaction of feeling they were in command of their area of practice as an additional draw, as was greater social prestige and higher incomes. By 1960, over 80% of students were choosing careers in specialty medicine — a figure that has not changed through the present.
The transformation of residency training from a privilege to a right embodied the virtues of a democratic free enterprise system, where individuals were free to choose their own careers. In medicine, there were now no restrictions on professional opportunities. Individual hospitals and residency programs sought residents on the basis of their particular service needs and educational interests, while students sought the field that interested them the most. The result was that specialty and subspecialty medicine emerged triumphant, while primary care languished, even after the development of family practice residencies converted primary care into its own specialty.
This situation poses a perplexing dilemma for the residency system. More and more doubts have surfaced about whether graduate medical education is producing the types of doctors the country needed. No one doubts that having well-trained specialists is critically important to the nation’s welfare, but fear that graduate medical education has overshot the mark. Ironically, no one knows for sure what the proper mix of specialists and generalists should be. A popular consensus is a 50-50 mix, but that is purely a guess. One thing is clear, however: The sum of individual decisions is not meeting perceived public needs.
At the root of the problem is that fundamental American values conflict with each other. On the one hand, the ascendance of specialty practice service serves as a testimony to the power of American individualism and personal liberty. Hospitals and medical students make decisions on the basis of their own interests, desires, and preferences, not on the basis of national needs. The result is the proliferation of specialty practice to the detriment of primary care. This situation occurs only in the United States, for the rest of the Western world makes centralized decisions to match specialty training with perceived workforce needs. Medical students in other countries are not guaranteed residency positions in a specialty of their choice, or even a specialty residency in the first place.
On the other hand, by not producing the types of doctors the country is thought to need, there is growing concern that graduate medical education is not serving the national interests. This would be a problem for any profession, given the fact that a profession is accountable to the society that supports it and grants it autonomy for the conduct of its work. This poses an especially thorny dilemma for medicine, in view of the large amounts of public money graduate medical education receives. Some medical educators worry that if the profession itself cannot achieve a specialty mix more satisfactory to the public, others will do it for them. Various strategies have been tried — for instance, loan forgiveness or higher compensation for those willing to work in primary care. However, none of these strategies have succeeded — in part because of the professional lure of the specialties, and because of the traditional American reluctance to restrict an individual’s right to make his own career decisions. Thus, the dilemma continues.
Headline image credit: Hospital at Scutari, 1856. Public domain via Wikimedia Commons.