Family Medicine and Medical Student Residency Choice in Israel and the US: A Cross-Country Comparison
Written By: Vasu Sunkara
November 2009

 

Introduction

Family physicians are often the first doctor a person sees when they get sick. In this "gatekeeper" position, the family physician assumes a variety of roles. They not only provide treatment and consultation for common problems, but also advance patients on to specialized care when warranted. They additionally help patients manage complex conditions, and address patient concerns in the practical context of their lives.

The importance of family physicians to patients is clear. However, in the United States in particular, the future of family medicine has been in doubt (Bodenheimer, 2006). Fewer American medical students are entering the field, and more practicing family medicine doctors are dissatisfied with their careers (Physician Foundation, 2008; Bodenheimer 2006). This is all taking place in the larger global context of a supply-side shift towards medical specialization, increased medical education costs, and increased payment disparities between specialists and family medicine (Jackson, 2009).

How can the future of family medicine be preserved in the United States? I address this question by performing a cross-country comparison between perceptions of family medicine in Israel and the United States. Israel is an industrialized country with a universal healthcare system that has a robust family medicine system. I believe the lessons from Israel can be instructive to the American system. By comparing the trends in residency choice over the last twenty years between the two countries, I seek to identify what factors led medical students in these countries to enter specialty care.

The United States: Family Medicine and Negative Perceptions

It is well documented that since the late 1970s, the number of American-trained medical students entering family medicine has been on the decline. From 1979 to 2007, the number of graduating medical seniors entering family medicine residencies dropped by 40 percent. In 2008, 11% of U.S. graduates entered family medicine (AAMC, 2008). These vacant slots have largely been filled by international medical graduates (IMGs) (Koehn, 2002). Meanwhile, the numbers of graduating U.S. seniors and U.S. residency slots have increased over the same time period (AAMC Questionnaire, 1979 and 2007).

The loss to family medicine has been the gain of speciality medicine. Over the same time period, the number of American medical-school graduates entering anesthesiology went up 475%, while radiology and dermatology went up 290% and 1,300%, respectively (AAMC Questionnaire, 1979 and 2007). These numbers might be inflated due to the fact that many specialty programs were just starting in the late 1970s. The growth would therefore be in part a function of the natural development of these fields. However, evidence strongly suggests that the shifting of American doctors into speciality fields is a real and disproportionate phenomenon.

In one study of U.S. medical student perceptions, lifestyle and control over work hours were major reasons for not entering primary care. Those who entered primary care cited patient interaction and mentorship as major reasons for entering it (Burack, 1997). In terms of lifestyle, there is a common perception that family physicians are plagued by long work-hours, low compensation, and excessive paperwork detracting from patient contact. In fact, increased wages and better work hours were cited as two major factors that would make medical students reconsider primary care fields like family medicine (Rosenthal, 1994). Meanwhile, the very mentors who could guide medical students into family medicine advocate the opposite. One survey found that 60% of practicing FM physicians would not recommend entering the field to new doctors (Physicians Foundation, 2008). Currently, the median salary for a family medicine doctor is $150,000, while the salary for a private-practice radiolper capita in the United States is US$46,000 (OECD). A family physician makes 3 times the average worker, while the specialist makes 6 times that amount.

Israel: Family Medicine and Perceived Job Flexibility

In contrast, in Israel family medicine is seen as a field that offers job flexibility, good work hours, and clear societal benefit (Friedberg, 2000). The percent of Israeli-trained medical students entering family medicine has stayed stable at roughly 10% from 1980 to 1995 (Reis, 2001). This stability is coupled with positive impressions of family medicine. One Israeli study found that the decision to not pursue family medicine was not due to financial incentives or a perception of overwork. Instead, those who chose specialty fields had already made the decision early in their medical school careers (Friedberg, 2000).

Those who entered specialities over primary care did so primarily because of an interest in the work itself. People entering primary care did so because of long-term patient contact, job flexibility, and good compensation, in that order of priority. The primary care culture was of even higher priority than lifestyle. The positive perception of family medicine holds despite patient visits frequently lasting only 15 minutes (Friedberg, 2000).

This difference in perception is noteworthy when considering the salary differences between family medicine and specialist physicians. The national income per capita in Israel is US$26,000 (OECD, 2009). The average salary of an Israeli family physician is US$60,000, approximately 2 times the per capita income, while the average salary of an Israeli specialist physician is US$84,000, 3 times the per capita income (Israeli Medical Association, 2009). The relative difference between speciality and family medicine salary is roughly equivalent between Israel and the U.S. However, the relative difference from the salary of the average worker is more skewed in the U.S.

Conclusion

Perceptions of family medicine in Israel and the United States provide interesting comparisons. For those entering specialty fields, Israeli-trained students appear to place higher value to the nature of the work while American-trained students prioritize lifestyle. For those entering primary care, medical students in both countries seemed to value the primary care culture and patient interaction. The relative salary differential between primary care and specialty care is roughly the same between countries. Another question is what is the difference in clinic schedule between an American and Israeli family physician that has generated such different perceptions of job satisfaction amongst medical students? Alternatively, is it that Israeli-trained medical students place less value on salary in determining overall job satisfaction versus their American counterparts?

I would encourage future work that compares the amount of time spent on paperwork versus patient care in an Israeli versus American family medicine setting. Based on my work, I would hypothesize that the Israeli physician spends much less time on paperwork than the American physician. Next, it would be worthwhile to determine how the practice lifestyle is different between Israeli and American family physicians. Is it that there are more part-time physicians in Israeli family medicine versus American, or is it that there are structural work-hour and payment regulations that create a better work environment in Israel? In summary, the case of Israel provides insight into how American family medicine can become more popular. Nevertheless, there is interesting work still to do to understand the differences between countries and how to translate these insights into effective policy.

About the Author

Vasu Sunkara will receive his M.D. from the University of Wisconsin School of Medicine in December, 2009. He is currently a first-year Ph.D student in the Department of Health Services at the UCLA School of Public Health. He became interested in the article topic after reading about the undersupply of primary care providers nationwide and by watching his classmates make their residency choices. He can be reached at ssunkara@ucla.edu. Vasu would like to thank Kusuma Sunkara, the Israeli Medical Association (IMA), Akl Fahed, Yorgos Polychronidis and Mert Karakaya for their assistance on this project as fellow members of IFMSA.

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