Monday, March 18, 2013

Medical Schools Continue Fraudulent Reports of Primary Care Workforce Production

It is March Madness once again!

Once again, medical schools continue their annual fraudulent and misleading statistics in regards to primary care workforce production.  The Dean's Lie is back and rampant across the country.  It only seems to get worse.  

When will they learn?

USA Today: "Match Day: More medical graduates enter primary care"
About one-quarter (11,762) of the applicants matched to resident positions that train doctors to be on the front line of care — in the areas of internal medicine, pediatrics and family medicine — where serious shortages exist. 
L.A. Times: Match Day 2013 results are good for future internal-medicine patients (apparently not for Family Medicine patients)
.... more med students are headed toward residency programs for internal medicine-primary care and med-peds, which combines internal medicine with pediatrics. Interest in med-peds programs is up 13% from last year, and interest in primary care is up 20% since 2011.
Physician News Digest: "Match Day Results - More primary care doctors than specialists"
More U.S. medical school seniors committed to primary care residencies over specialty positions in the largest Main Residency Match in the history of the program.
The American College of Physicians confused me the most:
Internal Medicine residency match results encouraging for adults needing primary care.... The great majority of current internal medicine residents will ultimately enter a subspecialty of internal medicine, such as cardiology or gastroenterology. Only about 20 to 25 percent of internal medicine residents eventually choose to specialize in general internal medicine, compared with 54 percent in 1998
Compare the title of the article to the content - so what you are saying is: the match is encouraging for primary care, but most of those residents are not going to practice primary care.  It all makes sense to me now!

Before identifying those who play along with the Dean's Lie, it is important to recognize those who finally get it.

Harvard: Always looking to set the example.  
"HMS no longer calculates the number of students going into primary care because it is impossible to determine how many of those who go into internal medicine will eventually go into primary care versus specialty care."
We are also still waiting for that Harvard Family Medicine Department.  Bueller?......  Bueller?.......  My best friend's sister's boyfriend's brother's girlfriend heard from this guy who knows this kid who's going with the girl who remembered when Harvard's Family Medicine Department existed. I guess it's pretty serious. 

Dr. Mintz' Blog: "Residency Match Results Bad For Primary Care (again)"
Musing's of a Dinosaur: Argues that OB/GYN should not be included as primary care

It is also of utmost importance to recognize those graduating medical students that stuck to their personal statement and joined the Family Medicine Revolution.  It is also very important to recognize all those matching in primary care residencies who plan to join the primary care workforce.  The Family Medicine and primary care community is counting on you to prove the following data wrong!  How often is it that an author asks to prove their data wrong?  Please, prove my data wrong.

As per the previous Dean's Lie Post, let us assume a 80-90% sub-specialization rate in internal medicine and a 50-66% sub-specialization rate in pediatrics (and some rounding, because I can).  Also, let us keep in mind the objective specialization rates: JAMA December 2012 20-25%; another JAMA article publishing results of a survey showed 98% plan to sub-specialize within internal medicine.  

Here is your list of examples of all medical schools misleading the public (additions will be ongoing as erroneous data continues to be publicized for misinterpretation by its readers):

It's extremely unfortunate that the Dean of a brand new medical school at FIU is not immune to the Dean's Lie
Dean of the medical school John Rock said more than half of this year’s graduates will be going into primary care, and about a third landed residencies in Florida. Those two numbers are key, as increasing the supply of primary-care physicians — and making sure a good number stay in Florida — were two of the main justifications for state leaders’ decision to grant FIU a medical school in 2006. FIU’s College of Medicine officially opened its doors three years later.
62% of Meharry graduates headed into primary care (not quite).

Guess what?  Indiana University to fill primary care need!  They only mention a few out of their class of 304.  No other stats mentioned.  They were probably watching basketball at the time.

55% of Marshall graduates enter "fields defined as primary care in West Virginia: family medicine, internal medicine, OB/GYN (?), IM/Peds, and pediatrics."  Why, Marshall, why?

Some 42% of UAB graduates will enter primary care residencies.  It's unfortunate that not all 42% will remain in primary care.  It's also unfortunate that the general reader does not know this fact.

The Atlanta Journal-Constitution's headline: "More than 50% of Georgia medical students receive a primary care match."  Looking into a crystal ball, the author states that the following schools produced "Primary Care Physicians": Morehouse School of Medicine with 67 percent, Medical College of Georgia with 40 percent, Mercer with 61 percent, Emory with 38.7 percent, and Philadelphia College of Osteopathic Medicine's Georgia Branch Campus with 52 percent - and they did not even start residency yet!  That is power.  Do these schools do a better job than most at producing primary care physicians?  Absolutely.  However, how can anyone state that these schools already produced primary care physicians?  It is a shame that this author was fooled by an entire state worth of medical school deans.  Case in point:  read the following statement from Morehouse School of Medicine's dean:
According to Dr. Valerie Montgomery Rice, dean and executive vice president at Morehouse School of Medicine, 96.3 percent of MSM seniors received a match. Of those, 67 percent matched in primary care and core specialties, a testament, Rice said to “us identifying students who are aligned with our mission, which is to work in under-served areas and have a high affinity for primary care.”   
But, Dr. Rice - 3 of your 52 students that matched are going into Family Medicine = 5.8%, of your 14 graduates matching in pediatrics, maybe 7-9 will practice primary care (15%), and of your 8 that matched in internal medicine, 1-3 will stay in primary care  will practice primary care (a generous 6% of the class.  So, in actuality, maybe 26% of your class is going to practice primary care medicine in 5 years?  To be totally generous, we may get you to 30-35%.  We are still about 50% short of your number.  Where are you hiding your other primary care graduates?  Let us add OB/GYN: if we consider all of them primary care doctors, then we get to 12 more percent.  We are still very short and I am still very confused as to where this data is coming from.

33 of 55 graduates from Texas Tech will practice primary care - we are talking about practice.  Where is Allen Iverson when you need him?

In a rather sobering piece, OnCentral from South Los Angeles reported that only 1 of its 16 graduates from Charles R. Drew University matched into Family Medicine.  The report also makes mention that this program matched 18 out of 24 into Family Medicine in the 1990's.  That is old school.

We do appreciate Tufts for their Maine track - 7 of its 32 students matched into Family Medicine.  They do state that a total of 16 from that track will pursue residencies in primary care fields.  Assuming a good mix of pediatrics, IM, Med/Peds, and assuming that many going for the track are more likely to go into primary care, this may be the closest to the 40% that COGME recommends for primary care workforce.  It is unfortunate that others do not do the same.  It is also unfortunate that Tufts states that 39% of its overall class will pursue potential careers in primary care.  Good job on them to throw in the word "potential."  That is more accurate.  Hopefully the general public will read it the same way as it was intended.  

Eastern Carolina University tells its local NBC news station that 58 percent of their graduates chose primary care.  Hopefully this was also televised so that those who were unable to read this were able to watch it on their evening news.  This is a true testament of their "sense of commitment" with primary care topping their list!

A vague statement, such as "43 percent matched into a primary care residency," is also misleading.  The University of Connecticut knows that this will not accurately translate into primary care doctors.  A majority of its readers will most likely perceive this as a medical school that is pumping out primary care doctors.  A majority of its readers will also not read my comment because they still have not approved it.

Over 55% from Albany Medical College will enter primary care specialties, including family practice.  At least get the name of the specialty correct - that would be Family Medicine.  Thanks.

University of California Health gives us an action-packed story full of inaccurate information from all of its medical schools.  UC-San Diego: 40% , UC-Davis: 48.6%, UC-San Francisco: 48%, 
Lee Jones, associate dean for student affairs, said students in the Class of 2013 matched to “really solid,” high-quality programs throughout the country, including residencies at Harvard University, Stanford University, UCLA, the University of Washington and other top-flight institutions, as well as UC Davis. The percentage of students entering primary care increased once again, reaching a 10-year high, he said.
According to the University of Iowa's publication, Iowa Now, the headline reads: "More than 40 percent of the graduates chose primary care specialties."  Iowa Now must be stuck in the past.

The University of Hawaii tells Hawaii News Now: Typically, more than 60 percent choose the primary care route, one of the highest percentages in the nation.  They do not break it down further in the article.  So, I am assuming that over 65% are going into Family Medicine?  That must be a record. claims that 40% of the University of Michigan graduates will pursue primary care.  The article also states that half of Michigan State's class will pursue primary care specialties.  It is a good thing that the author used "pursue" given that many of them will not end up within the primary care workforce.  

In the Columbus Dispatch, Ohio State claims that about 40% of its seniors are entering primary care... maybe primary care residencies but definitely not the primary care workforce.

Dean Krugman at University of Colorado personally told the Denver Post that 45% of this year's class is focused on primary care.  Many of those will also be focused on pursuing a sub-specialty fellowship in 3 years.

Wright State with 50.5%.  They do not provide any good quotes from deans, etc.  Probably a good strategy.

The Medical College of Wisconsin believes that primary care attracted 38% of its graduates this year.  It's a tough bullet to swallow with 14% going into internal medicine, 12.5% pediatrics, 9.5% family medicine, and 2% med/peds.  Adjusted for the Dean's Lie, it's closer to about 17-20%.  Ouch.

Florida State School Of Medicine sending 51% of graduates into primary care residencies - also misleading given the dean's lie. Yes "primary care" residency - all practicing primary care in 5 years? False.  Initially reported at over 60% by FSUSoM on twitter, prompting this conversation.

LSU-Shreveport - 49 out of 115 graduated will geaux into primary care fields.  

Most accurate assessment of the day: courtesy of the South Jersey Times.  Apparently, some graduates from UMDNJ are studying to become primary care physicians in the specialties pediatrics and OB/Gyn. That is all.

The University of Washington did not lie.  Thank you.

University of Utah: they are watching primary care production closely, stating that 26 of its 73 matching seniors will enter primary care residencies.  We will be watching closely too.  Please report back in five years.

I understand the love affair with this piece by a Stanford medical student who defied the odds of attending Stanford to match into Family Medicine. It is definitely well-written and should be shared.  I agree and published this piece a while ago - Family Medicine is a Waste of Your Talent!  

Stanford also tripled its usual matches into Family Medicine, with its school usually producing 2-3 grads out of over 90.  This year they matched 8 out of 91, still among the nation's lowest. I did praise Stanford in the past for avoiding the Dean's Lie in my original blog post.  They just could not avoid it this year - courtesy of Dean Charles Prober, MD:
It was also somewhat unique in that almost half matched in an area of general medicine — pediatrics, general surgery, ob/gyn
Wandering back to the state where I received my undergraduate, graduate school, and medical education - Pennsylvania!

Temple made no mention of primary care production.  Primary care was nowhere to be found at UPenn Medicine.  Penn State knew better.  Jefferson did not release any information. It is probably better that way.

University of Pittsburgh - 50 of 142 students matched into primary care fields.  Did they mean Heinz Field or the primary care workforce?  They post on blogger, hopefully my comment will be approved.

Last, but not least, is my alma mater!  How could I forget about you?  My bank account receives monthly reminders.  

Drexel University College of Medicine informs CBS Philly that 39 percent of its 260 graduates matched to residencies in primary care!  I can tell you from those that matched "primary care" two years ago, many are not going to end up in primary care.  They also did not mention how many matched into Family Medicine (not many). 

If there are any schools that need to be added and I have missed, please submit your story in the comments section!

So what does this all boil down to?

According to the AAFP (and logic), it is much more accurate to analyze medical school graduate statistics from at least five years ago.  This takes into account the number of residents that do not enter fellowship training after they complete their three or four year residency program. 

In an effort to properly educate the general public who do not understand the Dean's Lie, I have initiated an effort to reach out to the various media outlets that are publishing false data with this message:

Your story is misleading, false, and contains fraudulent information provided by medical schools. Also known as "the Dean's Lie," only about 20-25% of internal medicine residents remain in primary care (this is from the American College of Physicians, confirmed by JAMA study 2012;308(21):2241-2247, down from over 50% in 1998). Internal medicine residencies should not be considered primary care residencies if an overwhelming majority do not practice primary care. Moreover, for a more accurate measurement of primary care workforce production, the percent reported that match into primary care should be based on looking at match data from 5 years ago (2 years after residency training). When looking at this data, the overall primary care workforce is trending towards and below 30%, much lower than COGME's recommended 40+ percent primary care workforce.  
Is it my personal mission to taint the mirage painted by medical schools?  Perhaps. Are some schools better than others (including those listed) at pumping out primary care doctors?  Absolutely!  

Prime example: University of Minnesota-Deluth 
44.1% of the 59 students who will graduate in May selected Family Medicine as their choice of residency 
From the AAFP 2012 Top 10 for Family Medicine production:

The Brody School of Medicine at East Carolina University: 20.9 %
Oregon Health & Science University School of Medicine: 18.4 %
The University of North Dakota School of Medicine & Health Sciences: 18.1 %
Uniformed Services University of Health Sciences: 17.2 %
The Joan C. Edwards School of Medicine at Marshall University: 16.8 %
The University of New Mexico School of Medicine: 16.2 %
The University of Iowa Roy J. and Lucille A. Carver College of Medicine: 15.9 %
The University of Kansas School of Medicine, with 15.4 %
The University of Washington School of Medicine: 15.3 %
The Sanford School of Medicine at the University of South Dakota: 15.2 %

There are other great primary care, rural, urban, and similar pipeline pathways at medical schools producing primary care physicians at alarming rates.  These are the success stories that need to be shared and recognized as best practices for contributing to our primary care workforce.

In summary:

At some point the truth must come forward.  Hopefully a major media outlet (NYT, WSJ, etc) will educate the public rather than continue to publish erroneous data while glorifying institutions that minimally provide solutions to primary care workforce production.

Forbes did:
"(This) error was widely reported in the media after Match Day last week. On Match Day, medical students learn where they will continue their training.This year, the number choosing primary care specialties such as internal medicine, pediatrics, and family medicine rose.... About four percent of American medical graduates are choosing careers in primary care. As the number of primary care residents grow, this number will probably increase a bit, but I wouldn’t count on it. About eighty percent of the time, primary care residents choose to move on to a subspecialty. The reasons are complex, but not unknowable." 


  1. Excellent article. NRMP contributes to "the Dean's Lie" by suggesting that tiny increases in US seniors matching to primary care fields is good news. In reality, about the same percentage of medical students (and in fact slightly lower) go into primary care fields in 2013 as they did in 2011. See the table in my blog post here:

  2. While we all decry the inaccurate reporting, we also must be careful to contribute positively as well. There are successes that we should be trumpeting! So here goes:

    Once again this year, the students who matriculated on the Duluth campus of the University of Minnesota Medical School are well represented in this important area. 44.1% of the 59 students who will graduate in May selected Family Medicine as their choice of residency. This continues a fantastic record of successes in service to our mission in Duluth. Since 1976 (the first class that graduated after starting in Duluth), the proportion of students choosing Family Medicine has been 47.56% - consistently about four or five times the national rate. This is achieved by consistently selecting the "right" students at admissions and then structuring a reinforcing curriculum fostering their choice of Family Medicine. These data are for the entire Duluth class, and the numbers translate to 830 family physicians from our small program. We are very proud of this record, and we believe others should know that it IS possible to achieve success.

    OK, I am off my soapbox now.


  3. Thank you for the above comment. The efforts at your program are best practices and highlight what SHOULD be happening to select the right students and reinforcing Family Medicine rather than having them succumb to the hidden curriculum. A number of programs are also making attempts at this type of curriculum with success.

    What would be optimal? Take those hundreds to thousands of internal medicine slots and convert them into residency training slots that can serve as pipeline positions for programs dedicated to what you are accomplishing. In theory, this would streamline physicians where they are needed. In the military, our detailer figures out where our primary care workforce is needed and puts us there. It works pretty well!

    Thank you again for sharing this information. Your efforts are much appreciated and should be brought front and center. The bottom 20 medical schools that produce Family Doctors (some considered "top" for primary care) could learn a lot from you!

  4. Great stuff, Kevin! Of course each individual Dean will tell you that if THEY told the truth they would look bad compared to all those OTHERS who are lying. We just have to put the lie out there.
    At KU, which over the 10 years 2002-11 put out the highest average % and second highest average # of students into FM, we went up in 2012 to 24% (40) and it looks like down this year to 16.7% (26).

  5. I don't see the 2013 match stats for Temple Univ. up yet, but they matched 10 to FM (out of 208, about 5%), which was more than my match in 2010. All this with no FM residency, and a small but mighty FM Dept with amazing mentorship. I'm encouraged, and can vouch for the primary care emphasis in the Temple Med curriculum.