Making doctors brings to mind the the aphorism about making sausage: we may like the result but the process is not for the faint-of-heart. Maybe this is one of the reasons the public knows so little about medical training.

Policy makers often know just as little as the rest of the lay public. A few years ago a prominent senator suggested increasing the number of internal medicine residency spots to mitigate the shortage of primary care physicians (PCPs) in the US.

This same 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. PCPs tend to work longer hours and get paid less then their specialist colleagues, but their debt burden isn't any less. With average medical school debt approaching $200,000 its no wonder doctors reach for higher-paying positions.

As health care reform rolls along, some of this pay differential will shrink, but I doubt it will be enough to convince people to go into primary care. The only way to make PCPs is to make it economically advantageous. This will require subsidies for medical education, perhaps in exchange for service. While I like the idea of service, it probably isn't viable in the US. Doctors wishing to avoid further disruptions to their lives will continue to choose high-paying specialties.

If we want primary care doctors, we need to pay them enough to live and repay their debt (remember that they enter the workforce far later than their non-physician friends). We have to also reduce the costs of medical school.

The person who figures out how to implement this in a cost-effective way may not yet have been born, but I remain cautiously hopeful.