Primary care physicians are at the heart of health care in the United States, they are the first to diagnose patients and ensure those patients receive the care they need.  But faced with increased regulations, paperwork, the onslaught of defensive medicine, malpractice costs and staggering medical school bills, many are instead opting to become specialists.

In Medical Education, a survey of more than 2,500 medical students attending New York Medical College and the Brody School of Medicine at ECU between 1993 and 2012 solicited answers at the beginning of their first year of medical school and just before graduation four years later. It asked the students what sort of medical career they planned to pursue, to estimate their final student loans and to rate the value they place on income.

The researchers then looked at those students planning to pursue a career in primary care, as well as those students planning to pursue any of the 12 specialties with a median income of more than $300,000 per year, based on 2010 salary data. By comparison, primary care physicians had a median income of just under $200,000 per year. Primary care consists of internal medicine, family medicine and pediatrics.

The study found that anticipated debt was a significant factor in the students' career decisions. Graduating students who pursued high-paying specialties were facing average student loans of approximately $104,000, whereas those who chose primary care faced an average debt of less than $94,000. Students facing higher debt were also more likely to switch to high-paying specialties – including more than 30 percent of students who had expected to become primary care physicians when they entered medical school.

"We found that students who placed a premium on high income and students who anticipated having a lot of student debt were significantly more likely to pursue a high-paying medical specialty rather than become primary care physicians," says Dr. Lori Foster Thompson, a professor of psychology at N.C. State and co-author of the paper describing the research. "This held true even for students who entered medical school with the goal of becoming primary care physicians – they often switched to high-paying specialties before graduating."

First-year and graduating students who chose to pursue one of the high-paying specialties also rated income as being significantly more important than students who chose to pursue primary care. In addition, those graduating students who felt income was more important than they had as first-years were more likely to have switched to a high-paying specialty.

Other factors that guide student decisions about what specialty to pursue include parental or peer pressure, lifestyle desires and the exposure to more specialties once students reach medical school, though this study did not look at those issues specifically.

"The other major factor in choosing a primary care career is a service commitment – wanting to help others," adds Dr. Dale Newton, a professor of pediatrics at ECU. "Measuring such a commitment in a research setting is very difficult, however."

The study suggests that measures should be explored to encourage primary care careers such as incentive pay, debt forgiveness, additional scholarships and higher reimbursement for primary care services in order to meet the growing need.

You read that right.  Their solution is to let schools charge whatever they want, 30X the rate of inflation in the last 20 years, and then forgive the student loan debt. 

Yet Newton believes the Affordable Care Act will raise income of primary care physicians, which will make taxpayers nervous. "If the current efforts at health care reform continue, the incomes of primary care physicians should improve over the next few years. Primary care has to play a major role in the new health care paradigm."

The study's findings come as the Association of American Medical Colleges projects a shortage of 63,000 physicians by 2015, the vast majority of those in primary care. Given that, recommendations have come out saying that as the government takes over more of health care, doctors should do less of it. But patients want to use specialists more and more and that will only increase as government and insurance companies are required to take over more costs.