Ryoo dresses for a shift as an emergency medical technician (Photo: Jane Teeling)

Aaron Ryoo wants to be a doctor. He’s wanted to be one his whole life.

It was in the last two years, while he was applying to medical school, that Ryoo was forced to ask himself: What kind of doctor do I want to be?

After considering the thousands of dollars it was costing him to apply to medical school, and the hundreds of thousands more he expected to accrue in debt, Ryoo’s career choice became a numbers game. Specialists such as radiologists and oncologists generally earn up to three times as much as their primary care colleagues. Their fields are considered the upper echelons of the medical world. This was enough to convince Ryoo he should specialize, although he has yet to choose his specific field.

“In primary care, I feel like the stuff you do is going to be very basic, simple stuff, and I imagine 90 percent of your cases are going to be headaches or colds”

Ryoo’s decision reflects a nationwide trend. In 2011, almost 44,000 students applied to 135 medical schools around the country. Yet of recent medical school graduates, only eight percent are now practicing family medicine. The reason is simple: primary care doctors are paid less than specialists. Moreover, many would-be doctors believe a career in primary care medicine is less prestigious than one in specialized medicine.

The shrinking pool of primary care doctors in the U.S. does not bode well for a growing population that medical experts say is in need of basic preventative and consistent health care. And while New York State has a higher ratio of primary care doctors to patients than the national average, only a small percentage of those doctors practice general and preventative care. Mostly, they become internists at hospitals.

“We spend almost $12 million a year on graduate medical education yet it’s not clear if it is directed to the physical workforce needs we have as a country,” said Glen Stream, M.D., president of the American Academy of Family Physicians.

Stream wants more medical school students to devote themselves to primary care. He wants more people like Michael Needleman.

Needleman, 26, is starting school this fall. By becoming a family doctor (after graduating), Needleman hopes to serve a community that needs him. He wants to recognize his patients’ faces.

“This is really the field in which you get to know your patients, longitudinally and well,” he said. “If you’re an emergency doctor, you’re limited to triaging patients and getting them through a door. You barely learn their names.”

Money and prestige

Working on applications (Photo: Jane Teeling)

For Ryoo, the value of being a specialist can be summed in one word: more.

“It’s pretty much more everything,” he said. “Not just more money, but more prestige and more interesting work. In primary care, I feel like the stuff you do is going to be very basic, simple stuff, and I imagine 90 percent of your cases are going to be headaches or colds.”

Salary remains the biggest differential. Specialists can earn up to $400,000 a year or more, while family physicians without a subspecialty in obstetrics make less than $190,000, according to reports by the Henry J. Kaiser Family Foundation and the Medical Group Management Association.

Some of those physicians won’t see much of their salary at the start. A report in the November 2010 issue of Academic Medicine found that primary care physicians can expect expenses to exceed earnings for the first three to five years of their careers. “This reality greatly increases the financial disincentive for pursuing a career in primary care compared with other fields of medicine,” concluded the report’s authors.

Student loans make up the bulk of these expenses. Medical school costs have increased enormously in the past 10 years – and so has student debt. Medical students graduated with an average of $140,000 of debt in 2008, compared with just $63,000 in 1994 ($91,525 in 2008 dollars), an increase of 35 percent.

Not only does specializing pay more; doctors in training think it’s easier work, according to a study by Kaiser, which found that “graduating medical students perceive the lifestyle associated with primary care physicians as unfavorable, requiring more hours and less predictability than specialties.”

Medical school via the Third World

When Ryoo graduated cum laude from NYU in 2008 with a B.A. in organic chemistry, he had his sights set on medical school. His plan was to teach for a few years to get some work experience before applying.

After two years teaching high school science in Brooklyn, Ryoo quit so he could focus on the application process full time. He dropped a thousand dollars on an MCAT prep class, and aced the test. In his application, he wrote about the rewarding experience of managing a classroom and imparting knowledge on inner city 14-year-olds.

Ryoo sent in applications to dozens of schools across the country, and waited to hear back. Nothing.

Perhaps, Ryoo thought, he hadn’t done enough volunteer work. Or maybe he just didn’t have enough life experience.

So Ryoo decided to volunteer overseas, first in Uganda and then in Nepal.

In a village on the outskirts of Kampala, Ryoo taught basic math to students at a local school and helped farmers tend their crops.

One farmer was so happy with Ryoo’s work that he handed him a live chicken as a sign of his appreciation. Ryoo didn’t know what to do with it, so he gave it to his host parents. They killed it and cooked it for dinner.

“It was delicious,” said Ryoo, who can count on one hand the number of times he ate meat in Uganda.

Just days after his two-month stay in Uganda, Ryoo took a 26-hour flight to Nepal. (It was actually cheaper to fly from Kampala to New York to Kathmandu than to take a direct flight). There, he spent a month shadowing doctors in a clinic the size of a two-story ranch house, aiding the mostly poor and uneducated men, women and children seeking care.

One day, a man rushed into the clinic with a rear-end full of seeping wounds. Called fistula-in-ano, the condition occurs when a patient’s anal glands block up and cause multiple abscesses — in this case, six of them — to poke through to the skin. Before Nepal, Ryoo had never heard of fistula-in-ano. He misses those days of ignorance, he said.

Ryoo returned the 7,500 miles to New York with cartons of duty-free cigarettes, confident he’d be a medical school student in no time.

Enter the mentor

Unfortunately for Ryoo, his second attempt to get into medical school proved as unsuccessful as the first. Clearly, thought Ryoo, his way wasn’t working. He needed help.

So last year, Ryoo hired a consultant from Grad Prep Academy to guide him through the process.

Kyung Yoon Nam charges $500 an hour for his services, which include editing personal essays and interview coaching. Nam also analyzes clients’ strengths and weaknesses and recommends activities applicants can undertake to beef up a resumé, such as volunteering and research work.

Nam suggested Ryoo get more hands-on experience with patients. After investing about $1,000 in training, a uniform and supplies, Ryoo is now an EMT. He works 10- to 12-hour shifts four days a week and makes $11 an hour.

When he’s not driving around the five boroughs shepherding the drunk, elderly or obese to emergency rooms, Ryoo mines data points with an economist in the Social Security Administration for a study about the recession’s impact on the poor. The unpaid work fulfills another of Nam’s recommendations: more research experience.

In June, Ryoo will apply to medical schools yet again. On his list are private schools such as Stanford University in California, and public schools such as SUNY Downstate. Nam will review each application. “There is a zero percent tolerance rate at medical schools, which means if they find any typos, the applicant is out of the game,” Nam said. “The characteristic of a medical doctor is zero percent tolerance.”

Primary care as a cause

Given the time, effort, money and stress required to get into — let alone finish — medical school, the benefits of specializing would seem to far outweigh those of primary care.

So why would a medical student choose otherwise? Michael Needleman admitted the cushy salary and favorable hours of specialist work are tempting. But the former Yale undergraduate said he had primary care in mind when he embarked on a two-year mission to get into medical school.

“I’m interested in health as it reflects a lot of other problems going on in a community,” said Needleman, who does research and outreach at Mt. Sinai Medical Center’s community health program.

Needleman did not hire a fixer to assist him with the application process. But he did take the MCATs, write dozens of personal essays and sit through just as many interviews.

After applying to 27 medical schools, Needleman is now choosing between University of California, San Francisco, and Stanford University. Of the two, UCSF has the better primary care program, yet Stanford has lower average indebtedness – about $100,000, according to US News & World Report.

Unlike many other students, Needleman is entering medical school with zero debt from his undergraduate degree. A low-income student, he received scholarships to Yale and was able to pay off the remainder of his student loans in a few years’ time. He’s also benefited from the Fee Assistance Program through the Association of American Medical Colleges, which brought down his medical school application and travel costs considerably to about $2,100.

“If you are too specialized, you’re not dealing with a general range of problems — not just physical health, but also mental health and other socioeconomic factors. Primary care physicians tend to see a wider swath of that stuff,” Needleman said.

While such financial circumstances are beneficial to someone aiming for a lower-paying career, Needleman isn’t in it for the money. “You really have to love being a doctor to be a doctor. Personally, money just isn’t enough to justify my going into medicine.”

A family doctor crisis in New York

In 2010, there were more than 28,000 primary care physicians in New York State — about 35 physicians per 10,000 people, according to a Henry J. Kaiser Family Foundation report. Although this is more than most states, the numbers are less impressive when you consider that more than half of these physicians specialize in internal medicine, and 12 percent in obstetrics/gynecology.

General care – that is, family doctors who provide preventative care and treatments through all stages of life – accounts for just 16 percent of primary care specialization areas.

One reason for the lack of primary care doctors is a fall off in post-graduate residency positions to cultivate them. From 1998 to 2008, the number of family medicine residency positions declined by 400, while those for internal medicine subspecialists, such as cardiologists and oncologists, increased by 1,150.

The squeeze on opportunities for primary care doctors helps to explain a nationwide trend: The United States will face a shortage of 35,000 primary-care doctors by the year 2020, according to the American Academy of Family Physicians.

To meet the growing need for family care doctors, said Dr. Stream of the academy, the medical school apparatus needs to be fixed. That means more residency programs and funds for family physicians, in addition to finding and nurturing students like Needleman who are disposed toward primary care.

Stream said medical schools, too, will have to change.

Ryoo's medical tools

Ryoo's medical tools. (Photo: Jane Teeling)

“It’s not unusual in medical school that family medicine does not have the same academic status. We need to nurture their interest in their medical school years,” said Stream, whose organization pushes for legislation that guarantees financial security, autonomy and transparency in residency programs.

One model Stream would like to see implemented by more medical schools is the Kansas Bridging Program, which provides an incentive for doctors to practice in rural communities for three years after finishing their residency. In return, doctors receive partial loan forgiveness.

On Long Island, the inaugural class of Hofstra North Shore-LIJ School of Medicine at Hofstra University will test-run a new kind of training program. Admissions Director Dr. Veronica Catanese says it’s a departure from the traditional fee-for-service health care model. The program has students train as EMTs first while they are learning basic science and medicine.

“Students will understand medical care from patient’s perspective,” said Cantanese. “And that may end up pushing them toward a primary care. At the same time, they will also be more exposed to sub-specialties through the program.”

Ryoo is not wholly opposed to practicing family medicine. He likes the idea of diving into a community, whether in rural Kansas or the south Bronx, and curing the sick.

But he has to think about his future. And right now, becoming a specialist is the best way for him to make a return on his years of hard work and thousands of dollars of debt, while still improving people’s lives.

“I figure that no matter what kind of doctor I am, as long as I’m a some kind of doctor – that’s what I want to do,” said Ryoo. “I really want to heal people, to be as cliche about it as possible.”

Family medicine will simply have to wait.

9 Comments

  1. Darwin Deen
    May 22, 2012

    You are focusing too much on the area of specialization and not enough on the role of primary care. It is less important if your primary care doctor is a family physician or an internist, or even a cardiologist or gastroenterologist. What matters most is that you have an identified source of care that is accessable to you. All these specialists are also trained in medicine, so if we can remove the economic barriers, we may have a ready source of more doctors who can serve this role.

    Reply
  2. Mary Jo Holland NP
    May 24, 2012

    I think this is a great article. People have the idea that primary care is just “colds and headaches” but it is much more then this. You have to be a Cardiologist, a Psychiatrist, a Gynecologist, an Orthopedist, a Dermatologist, an ENT, a Urologist, etc. etc. You have to have a much broader range of knowledge then a specialist and to at times be somewhat of a detective to find out what’s wrong with someone.
    Tufts Medical school finally re-started their Family Practice residency program and it’s thriving. We need a lot more like this.

    Reply
  3. J-Lab university news sites #jnewslab
    June 11, 2012

    [...] readiblity is improved with the use of subheads and some photos. NY City News Service has an article about medical training, where the writer (or editor) makes use of subheads, sidebar and pull quotes to improve the reading [...]

    Reply
  4. Julian Tepper
    April 16, 2013

    Two things:

    First, Ryoo underestimates the areas of care a PCP must be prepared to deal with.

    And second, if he cannot get into a US medical school (why, I could not even guess with his credentials), he might wish to consider European schools, especially in France).

    j

    Reply
  5. Kimberly Sheets
    May 1, 2013

    As a family practice physician, I wish my days were filled with headaches and colds! Instead, my “bread and butter” is managing diabetes and hypertension, with hypercholesterolemia, anemia, tobacco abuse and obesity thrown in. My challenges come in the form of the patient that passed out with no explanation, the patient with the abdominal pain without obvious cause, the patient with intermittent chest pain; the list goes on and on. The challenge is not in the treatment; it is in the diagnosis. By the time I refer a patient to a specialist, I have the differential diagnoses down to one or two (at most). It takes a long time to get to that point, using clinical skills, and as little technology as possible, to save on health care costs. I would be ashamed to send a patient to see a specialist under any other conditions. It is because of this that I find primary care so challenging, yet so rewarding.

    Reply
  6. Ron Levy MD
    May 3, 2013

    So did Needleman get accepted? The article says he is choosing from three schools implying he got accepted to those schools but the article is not clear about whether he got in? I find it hard to believe he got accepted to the three schools mentioned after not getting into any for several years as those are hard schools to get in to.

    Regarding the main subject of this article this is a long standing problem. I am now 64 years old and started as an internist but found the pay poor and the work hard. Talk to the patient, write a note, talk to the family, give orders to the nurse all take time. I quit that long ago and now I read nuclear medicine scans and run stress tests for four times the pay and much less work of “direct patient care”. The long term solution I think is allowing the family doctor to greatly expand his practice with physician assistants and nurse practitioners. This will increase his income and allow him to concentrate his time where really needed.

    Reply
    • Michael
      November 13, 2013

      Whoa, blast from the past! I remember getting interviewed for this, sitting on a stoop in San Francisco while visiting the schools in question. I ended up choosing Stanford, and I couldn’t be happier with my decision. I’m still considering primary care, like a strong number of my classmates.

      To clarify, although the article mentions it was a two-year process for me, I only applied once to medical school. The other student they interviewed applied more than once.

      While the article does not necessarily represent my opinions on the matter (although I do agree that salary is a motivating factor for a lot of people to specialize), the idea of a zero-tolerance medical school admissions office is not my experience at all. Unfortunately, this sounds like something that keeps “application fixers” in business, and my experience is that the most productive approach—for admissions committees, and for yourself—is just to be yourself.

      At the end of the day, like several have suggested here, primary care is not a singular profession. There are so many opportunities for clinical care, research, and advocacy— and yes, even specialization within primary care—and my hope moving forward (as primary care continues to evolve in the era of the ACA and changing medical education) is that primary care will be, in some ways, what I make of it.

      Reply
  7. Michael Needleman
    July 31, 2013

    I have been a family doctor in Louisville, Ky for 38 years. Often frustrated with primary care salaries, the rewards of patient relationships and contributions to my community have been worth the sacrifice. If the other Michael Needleman reads this, please contact me.

    Reply
  8. Dr. Timothy Bates
    August 13, 2013

    I suggest Ryoo reevaluate his motivations for pursuing a career in medicine. Citing lack of prestige and training in “basic stuff” as his main deterrents from primary care exemplify his naivete with respect to our world as physicians. If he has the privilege of gaining admission to a medical school, I am certain he will discover what we do as more complicated and dynamic than he expected. Good luck, young man.

    Reply

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