Reframing Primary Care — by Deep Shah
Like most kids, I spent summer afternoons watching cartoons, eating watermelon, and perfecting belly flops. Mornings, however, were a little different in our family. My sisters and I started most days by accompanying our parents to their medical offices in suburban Atlanta. We went mainly to spend time with them, but the trips also exposed us to medicine at an early age.
My mother is a family practitioner, and my father is an orthopedic surgeon. It didn’t take long to realize whose job was more fun. You might expect that the shiny tools and on-call lifestyle of orthopedics would make it seem like a superhero’s profession to an eight-year-old boy, but I found these to be fleeting attractions. Instead, a key difference emerged between my parents’ practices that drew me to primary care: my mom’s patients revered her. Patients trusted her not only with their health, but also with their personal stories of triumph and tragedy. While my dad certainly had close relationships with some of his patients, these were less common and lacked the same depth and continuity. As I grew older, I also came to admire the daily need for intellectual dexterity and creative thought in my mom’s practice. With the grace of a dancer responding to a change in tempo, she would masterfully transition from diagnosing appendicitis to managing an asthma exacerbation. When I came to Harvard Medical School, I expected most of my colleagues to share my interest in becoming a primary care doctor.
I couldn’t have been more wrong. As I learned within my first few weeks at HMS, only a small fraction of my peers viewed primary care the way I did. But what was keeping them away? When I asked my classmates what attracted them to medicine, most cited patient relationships, an emphasis on critical thinking, and a stable lifestyle as important factors. Yet they also seemed either unaware or unwilling to acknowledge that these were cornerstones of primary care.
Curious for an explanation, I turned to the literature. Numerous studies suggest that the lower incomes and burdensome workloads of primary care physicians (PCPs) might be deterring prospective candidates. Given that most of these analyses were based on surveys and observational data, however, their ability to demonstrate causation is limited.
I began to suspect that there were other factors at play—ones that are more difficult to express in conversation, or capture in surveys. Perhaps prestige, competitiveness, and culture – forces whose importance we struggle to quantify and often downplay – were playing a larger role in the decision-making process than we realize. Others who have observed the same discrepancy between students’ avowed interests and their choice of field have pointed to these factors as possible explanations. But if these considerations do contribute to the aversion to primary care, how did that come to be? And can we do anything about it?
To date, most of the advocacy for primary care has focused on highlighting injustices in the field. Inequitable payment systems and unsustainable work conditions often dominate the discussion. These messages have enjoyed some success politically: certain provisions in the stimulus and health care overhaul legislation represent early steps toward improved policies.
But this “overworked and underpaid” storyline also carries a cost. By focusing on the negative aspects of a career in primary care, it discourages potential PCPs who, like me, wish to enter a field of aspiration, not last resort. These negative narratives, together with a circulating sentiment that top students go into anything except primary care, may help to explain why recruitment figures for primary care have declined.
Reversing this trend will require not only increasing the visibility of primary care, but also directly addressing students’ desires to join a prestigious branch of medicine. The current environment is marked by a stigma that dissuades potential candidates, especially those who lack the information to form an independent judgment. Countering this effect will require a new strategy that reframes primary care by focusing on its strengths.
Successful recruitment models from other professions may shed valuable light on how to implement such a campaign. In education, Teach for America’s (TFA) approach is one of the most intriguing. Regardless of one’s assessment of TFA’s impact or mission, it is difficult to contest the program’s recruitment success and positive effect on the public perception of teaching. In last year’s hiring cycle, 46,359 of America’s brightest minds applied for 4,493 spots. The number of applicants represents an approximately 88 percent increase from 2008. [2, 3] But teaching salaries have not increased, and many problems in education persist. How, then, has TFA attracted so many candidates? Is it feasible for primary care leaders to adopt any lessons from its experience?
Fundamentally, TFA recognizes that enthusiastic recruitment and cultural prestige are important in explaining professional choices. It has tapped into a crucial part of what motivates our decisions, whether we are aware of it or not. Financial institutions, consulting firms, and other medical specialties operate with a similar awareness. The primary care community can learn from their experiences.
I recently spoke with Elissa Clapp, TFA’s Senior Vice President for Recruitment, about the organization’s strategy. Ms. Clapp, who has led recruitment at TFA for the past eleven years, cited two especially valuable lessons from its history.
First, recruit early and aggressively. Advocates like TFA campus recruiters have been critical to the organization’s success. They provide potential applicants with extensive information on the organization and the profession in a highly personalized manner. Applying the strategy to the medical setting, young PCPs, medical school faculty, and committed medical students could undertake this role – at medical schools, and even on undergraduate campuses. Most medical students are open-minded about their field selection before beginning their clinical years. We hear about new sub-specialties and career paths every day. Not surprisingly, our preferences and biases fluctuate greatly.
Primary care leaders should take advantage of this period by proactively introducing students to the field’s intellectual rigor, space for innovation, and versatility. Hip replacements may be complex, but so is managing a 70-year-old diabetic patient who has three co-morbidities, takes eight medications, and speaks little English. During the first two years of medical school, tutorial-based coursework should demonstrate this reality. In addition, showcasing the intellectual and creative accomplishments of medical students and young physicians who choose primary care would signal to high-achievers that they belong in primary care as much as anywhere else. This can occur both informally in classrooms and formally through more primary care-focused events, publications, and research activity. Lastly, pairing first-year medical students with primary care mentors for longitudinal primary care experiences could also meaningfully influence how they see the field.
A second important lesson is that changes in attitude should begin at the most competitive institutions. Ms. Clapp highlighted TFA’s early strategic decision to begin recruiting at elite colleges, in the hope that the program would accrue prestige from this cultural association even as it spread to other universities. The plan worked. Significantly increasing the percentage of graduates who enter primary care from top medical schools, such as Harvard and Johns Hopkins, could have a disproportionate impact on recruitment to primary care nationally. To that end, the new $30 million Primary Care Center at HMS represents a potentially valuable recruitment tool even beyond Harvard’s campus.
Many of the steps I have described here have also been proposed by Harvard’s Primary Care Advisory Group (PCAG)  as potential ways to reshape how medical students think about primary care:
—Focus on the aspects of primary care that speak to medical students’ initial interest in medicine and desire to join a prestigious field
—Increase visibility and awareness through early recruitment efforts
—Promote longitudinal experiences to increase exposure to primary care
—Spotlight achievements of Harvard-affiliated faculty and residents in primary care, and institutionally promote regular interaction between these individuals and Harvard medical students
—Integrate primary care into coursework more explicitly
Over time, these initial efforts could help to transform primary care into a field that medical students at HMS and across the country regard as both noble and prestigious. As the PCAG’s blueprint argues, we need to show Harvard medical students that primary care is “worthy” of them.
The future of primary care hinges on the enthusiasm, dedication, and optimism of its practitioners. If we, as a medical community, agree that the foundation of a sustainable, high-quality health system is primary care, then we should all be committed to changing the way current and future doctors view the field. We need a new recruitment strategy that captures the true value and allure of primary care – the vision of doctoring that I fell in love with as an eight-year-old, and the one that drew so many of us to medicine in the first place.
 Ganguli I. The case for primary care – a medical student’s perspective. N Engl J Med 2010; 363:207-9.
 Winerip, M. A Chosen Few Are Teaching for America. The New York Times. July 11, 2010. (Accessed November 21, 2010 at http://www.nytimes.com/2010/07/12/education/12winerip.html?_r=3&src=me&ref=homepage.)
 Dillon, S. Teach for America Sees Surge in Popularity. The New York Times. May 14, 2008. (Accessed November 21, 2010 at http://www.nytimes.com/2008/05/14/education/14teach.html?_r=4&oref=slogin&oref=slogin&oref=slogin.)
 Report of the Primary Care Advisory Group: Strengthening Primary Care, Education, Research and Clinical Innovation at Harvard Medical School. Boston, MA: The Primary Care Advisor Group, June 2010. (Accessed November 30, 2010 at http://hms.harvard.edu/public/primary_care/pcag_recommendations.pdf.)