Most students going into medicine imagine that they will have daily contact with their patients; but the reality is that only a minority will end up as primary care physicians, causing what some experts say could be a critical shortage in the United States, where there are long waits in both doctors' offices and emergency rooms.
With the Supreme Court's decision in June to uphold the Affordable Care Act, the need for primary care doctors is expected to grow even more.
"The A.C.A. will put a stress on the system immediately," said Dr. Russell Phillips, director of the Center for Primary Care at Harvard Medical School, where he is also a professor.
Some U.S. medical schools are now creating programs that emphasize the importance of family medicine and encourage students to collaborate more with nurses, pharmacists and specialists.
Despite the fact that about half of medical students indicate an interest in primary care on their first day of medical school, by the third year, that number decreases to 20 percent, said Dr. Andrew Morris-Singer, the president and co-founder of Primary Care Progress , an organization working to increase interest in the field.
Fewer than 20 percent of students end up working in primary care, according to the Council on Graduate Medical Education.
The actual number is probably 15 percent or less, said Dr. Marjorie A. Bowman, the Chair of the Department of Family Medicine and Community Health at the University of Pennsylvania.
This is because students who study internal or general medicine, both of which fall under the label of primary care, often go on to specialties after they complete their residency.
The Association of American Medical Colleges projects a shortage of 45,000 primary care doctors in the United States by 2020 and a shortage of 65,000 primary care doctors by 2025.
"There's a crisis in primary care, probably much worse than most people realize," said Dr. Steven Berk, dean of the School of Medicine at Texas Tech University.
Waiting times to see physicians are high, and emergency rooms are overcrowded, according to Dr. Morris-Singer of Primary Care Progress. "Patients are making it clear that they are having difficulty getting access to services," he said.
But medical schools tend to steer students away from the pursuit of family medicine.
"There's a culture of discouragement that exists in most medical schools around primary care," Dr. Morris-Singer said. "A lot of medical schools disparage primary care. They say primary care isn't a good use of medical school resources, and this is communicated to students in a direct way."
"It is absolutely clear that it is a lower-prestige thing to do; if you're looking for prestige, family medicine is not where you go," said Dr. Bowman of the University of Pennsylvania.
"Deans and leaders should be showing respect for family medicine," she said. "If there are disparaging remarks made, the person would be told that's inappropriate behavior."
Finances also play a role. Primary care physicians in the United States make $140,000 to $150,000 annually, but specialists can make up to two to three times as much.
In the short clinical rotations during a student's fourth year, many see primary care doctors burdened by administrative tasks instead of actively engaged in family medicine. Professors say that the value of the long-term relationships cultivated between family physicians and their patients may not be obvious to a student during a short observation period.
Dr. Phillips of Harvard said that students observed "primary care doctors unhappy doing with what they are doing." "Practicing doctors feel overworked and undersupported and are generally unhappy," he added.
"The values of primary care don't come out in a two-week rotation. You don't get that experience that a primary care physician loves," said Jon Kole, a fourth-year medical student at the University of Pennsylvania.
But some medical schools and students are taking active steps to reverse this trend.
Texas Tech is one of a handful of universities trying to encourage students to choose family medicine, in part by reducing the cost of medical school with an accelerated three-year program that allows primary care physicians to graduate a year early.
The first class from the Texas Tech family medicine program will graduate in 2013. Since they know what field they will go into, students in the program can skip medical school's fourth year. "Much of the fourth year of medical school is elective," Dr. Berk said. Without the need for such rotations, students have all the training they need to be primary care physicians after three years.
Students at Texas Tech say that the mind-set around primary care at their university is much more positive than the national trend.
"If anyone has a negative perception, its something they brought with them, or during their time here picked them up from outside of school," said Clay Buchanan, a student in the program.
A handful of other schools have expressed interest in Texas Tech's model, according to Dr. Berk. Mercer University School of Medicine in Georgia and Louisiana State University are planning to begin similar programs within the next three years.
There are also other ways to enhance their primary care curriculum.
Mr. Kole, the University of Pennsylvania student, spends much of his time outside of class working in a free clinic nearby that emphasizes the role of teamwork in medicine.
A typical shift might start at 5:30 p.m., when Mr. Kole and students from other disciplines like nursing and pharmacy get together to plan for the evening. Social workers are also present, and might leave the meeting early to meet with patients. Later, they will report to Mr. Kole and his fellow physicians about concerns patients might have.
"It's going to be critical to have health care workers as members of a team to take care of a patient," said Michael Song, a student studying oncology at Texas Tech. As a cancer specialist, Mr. Song said that partnerships were an important part of his patients' care. It is his job to make sure that a primary care physician continues appropriate treatment.
There is also a focus outside of the United States. Massachusetts General Hospital introduced a Global Primary Care program this year, which focused on training its physicians to practice beyond American soil.
Harvard Medical School also began working with the Rwandan Ministry of Health this year to teach a course called Global Health Delivery in the country.
Both programs came after the Lancet Commission released a report in 2010 that concluded that medical schools needed to increase their global reach.
"It's the biggest reform call for education strategy that has come out in recent years," said Dr. Patrick Lee, the director and co-founder of the Global Primary Care Program.
Many academics say that medical schools themselves could still do a lot more to encourage students to study primary care.
Professors say that even medical school admissions departments could encourage primary care by selecting more students whose applications indicate a preference for family medicine.
Earlier exposure to the field would also help, said Dr. Phillips of Harvard. Yearlong clerkships at the beginning of medical school could show students the kinds of long-term relationships primary care physicians build with their patients.nation
This article originally appeared in The New York Times.