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Dr. Ebell authors study in JAMA linking primary care shortage with salary disparities


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September 17, 2009

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The nation’s shortage of primary care physicians has been linked to a host of poor health outcomes, and a new study published in the Journal of the American Medical Association suggests that salary disparities play a major role in the shortage.

Dr. Mark Ebell, a professor and assistant to the provost at the University of Georgia, compared 2007 starting salary data for various physician specialties with the percentage of medical school graduates choosing those specialties. He found a strong, direct correlation between salary and the popularity of a specialty.

“Countries with the healthiest primary care systems tend to have the best health outcomes,” Ebell said. “We rank behind many countries in the quality and efficiency of health care, and I think a lot of that is because we have neglected primary care.”

Among his findings:
  • Family medicine had the lowest average salary ($185,740) and the lowest percentage of filled residency positions among U.S. graduates (42 percent).
  • Radiologists and orthopedic surgeons, who had an average salary of more than $400,000, had the highest percentage of filled residency positions among U.S. graduates (88.7 percent and 93.8 percent, respectively).

The link between average salary and the popularity of a specialty is not surprising, particularly to Ebell. He conducted a similar study nearly 20 years ago and found the same relationship. Since then, however, the salary disparities have grown and the shortage of primary care physicians—which includes those who specialize in family medicine, pediatrics or general internal medicine—has become more pronounced. In the past decade alone, for example, the number of U.S. medical school graduates entering family practice residencies has dropped by 50 percent. Studies have linked a lower percentage of primary care physicians with higher infant mortality rates, higher overall death rates and more deaths from heart disease and cancer.

Ebell said he conducted the study to draw renewed attention to the role of salary disparities in the primary care shortage and to encourage policymakers to enact meaningful reforms to increase the percentage of primary care physicians.

“The problem of salary disparities is not something that anyone is going to solve locally,” Ebell said. “This is something that will require reform at a national level.”

He said one possible reform is expanded debt relief for students who choose primary care practices and in particular those who choose to practice in underserved areas. He notes that the average debt for a medical school graduate has quadrupled—from $35,000 to $140,000—in the nearly 20 years since his original study. When students graduate with the equivalent of a mortgage in debt, he said, they can’t help but be drawn to high-paying specialties rather than primary care.

Changes to insurance reimbursements, which currently hurt primary care by rewarding the delivery of diagnostic tests and medical treatments over time spent communicating with patients, are also needed to reduce salary disparities, he said, and have the potential to improve quality of care by reducing unnecessary or duplicative interventions.

Ebell said the broad knowledge base of primary care can be intimidating to students, so creating information technology systems to manage information will be important. Exposing students to primary care physician role models is another way to sustain interest in primary care throughout a student’s training.

“A career in primary care can be very rewarding,” Ebell said, “and mentors can show students the satisfaction that comes from building relationships over time with patients.”