Can Medical Schools Funnel More Doctors Into the Primary Care Pipeline?
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Throughout her childhood, Julia Lo Cascio dreamed of becoming a pediatrician. So, when applying to medical school, she was thrilled to discover a new, small school founded specifically to train primary care doctors: NYU Grossman Long Island School of Medicine.
Now in her final year at the Mineola, New York, school, Lo Cascio remains committed to primary care pediatrics. But many young doctors choose otherwise as they leave medical school for their residencies. In 2024, 252 of the nation’s 3,139 pediatric residency slots went unfilled and family medicine programs faced 636 vacant residencies out of 5,231 as students chased higher-paying specialties.
Lo Cascio, 24, said her three-year accelerated program nurtured her goal of becoming a pediatrician. Could other medical schools do more to promote primary care? The question could not be more urgent. The Association of American Medical Colleges projects a shortage of 20,200 to 40,400 primary care doctors by 2036. This means many Americans will lose out on the benefits of primary care, which research shows improves health, leading to fewer hospital visits and less chronic illness.
Many medical students start out expressing interest in primary care. Then they end up at schools based in academic medical centers, where students become enthralled by complex cases in hospitals, while witnessing little primary care.
The driving force is often money, said Andrew Bazemore, a physician and a senior vice president at the American Board of Family Medicine. “Subspecialties tend to generate a lot of wealth, not only for the individual specialists, but for the whole system in the hospital,” he said.
A department’s cache of federal and pharmaceutical-company grants often determines its size and prestige, he said. And at least 12 medical schools, including Harvard, Yale, and Johns Hopkins, don’t even have full-fledged family medicine departments. Students at these schools can study internal medicine, but many of those graduates end up choosing subspecialties like gastroenterology or cardiology.
One potential solution: eliminate tuition, in the hope that debt-free students will base their career choice on passion rather than paycheck. In 2024, two elite medical schools — the Albert Einstein College of Medicine and the Johns Hopkins University School of Medicine — announced that charitable donations are enabling them to waive tuition, joining a handful of other tuition-free schools.
But the contrast between the school Lo Cascio attends and the institution that founded it starkly illustrates the limitations of this approach. Neither charges tuition.
In 2024, two-thirds of students graduating from her Long Island school chose residencies in primary care. Lo Cascio said the tuition waiver wasn’t a deciding factor in choosing pediatrics, among the lowest-paid specialties, with an average annual income of $260,000, according to Medscape.
At the sister school, the Manhattan-based NYU Grossman School of Medicine, the majority of its 2024 graduates chose specialties like orthopedics (averaging $558,000 a year) or dermatology ($479,000).
Primary care typically gets little respect. Professors and peers alike admonish students: If you’re so smart, why would you choose primary care? Anand Chukka, 27, said he has heard that refrain regularly throughout his years as a student at Harvard Medical School. Even his parents, both PhD scientists, wondered if he was wasting his education by pursuing primary care.
Seemingly minor issues can influence students’ decisions, Chukka said. He recalls envying the students on hospital rotations who routinely were served lunch, while those in primary care settings had to fetch their own.
Despite such headwinds, Chukka, now in his final year, remains enthusiastic about primary care. He has long wanted to care for poor and other underserved people, and a one-year clerkship at a community practice serving low-income patients reinforced that plan.
When students look to the future, especially if they haven’t had such exposure, primary care can seem grim, burdened with time-consuming administrative tasks, such as seeking prior authorizations from insurers and grappling with electronic medical records.
While specialists may also face bureaucracy, primary care practices have it much worse: They have more patients and less money to hire help amid burgeoning paperwork requirements, said Caroline Richardson, chair of family medicine at Brown University’s Warren Alpert Medical School.
“It’s not the medical schools that are the problem; it’s the job,” Richardson said. “The job is too toxic.”
Kevin Grumbach, a professor of family and community medicine at the University of California-San Francisco, spent decades trying to boost the share of students choosing primary care, only to conclude: “There’s really very little that we can do in medical school to change people’s career trajectories.”
Instead, he said, the U.S. health care system must address the low pay and lack of support.
And yet, some schools find a way to produce significant proportions of primary care doctors — through recruitment and programs that provide positive experiences and mentors.
U.S. News & World Report recently ranked 168 medical schools by the percentage of graduates who were practicing primary care six to eight years after graduation.
The top 10 schools are all osteopathic medical schools, with 41% to 47% of their students still practicing primary care. Unlike allopathic medical schools, which award MD degrees, osteopathic schools, which award DO degrees, have a history of focusing on primary care and are graduating a growing share of the nation’s primary care physicians.
At the bottom of the U.S. News list is Yale, with 10.7% of its graduates finding lasting careers in primary care. Other elite schools have similar rates: Johns Hopkins, 13.1%; Harvard, 13.7%.
In contrast, public universities that have made it a mission to promote primary care have much higher numbers.
The University of Washington — No. 18 in the ranking, with 36.9% of graduates working in primary care — has a decades-old program placing students in remote parts of Washington, Wyoming, Alaska, Montana, and Idaho. UW recruits students from those areas, and many go back to practice there, with more than 20% of graduates settling in rural communities, according to Joshua Jauregui, assistant dean for clinical curriculum.
Likewise, the University of California-Davis (No. 22, with 36.3% of graduates in primary care) increased the percentage of students choosing family medicine from 12% in 2009 to 18% in 2023, even as it ranks high in specialty training. Programs such as an accelerated three-year primary care “pathway,” which enrolls primarily first-generation college students, help sustain interest in non-specialty medical fields.
The effort starts with recruitment, looking beyond test scores to the life experiences that forge the compassionate, humanistic doctors most needed in primary care, said Mark Henderson, associate dean for admissions and outreach. Most of the students have families who struggle to get primary care, he said. “So they care a lot about it, and it’s not just an intellectual, abstract sense.”
Establishing schools dedicated to primary care, like the one on Long Island, is not a solution in the eyes of some advocates, who consider primary care the backbone of medicine and not a separate discipline. Toyese Oyeyemi Jr., executive director of the Social Mission Alliance at the Fitzhugh Mullan Institute of Health Workforce Equity, worries that establishing such schools might let others “off the hook.”
Still, attending a medical school created to produce primary care doctors worked out well for Lo Cascio. Although she underwent the usual specialty rotations, her passion for pediatrics never flagged — owing to her 23 classmates, two mentors, and her first-year clerkship shadowing a community pediatrician. Now, she’s applying for pediatric residencies.
Lo Cascio also has deep personal reasons: Throughout her experience with a congenital heart condition, her pediatrician was a “guiding light.”
“No matter what else has happened in school, in life, in the world, and medically, your pediatrician is the person that you can come back to,” she said. “What a beautiful opportunity it would be to be that for someone else.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News’ free Morning Briefing.
This article first appeared on KFF Health News and is republished here under a Creative Commons license.
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Ouch. That ‘Free’ Annual Checkup Might Cost You. Here’s Why.
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When Kristy Uddin, 49, went in for her annual mammogram in Washington state last year, she assumed she would not incur a bill because the test is one of the many preventive measures guaranteed to be free to patients under the 2010 Affordable Care Act. The ACA’s provision made medical and economic sense, encouraging Americans to use screening tools that could nip medical problems in the bud and keep patients healthy.
So when a bill for $236 arrived, Uddin — an occupational therapist familiar with the health care industry’s workings — complained to her insurer and the hospital. She even requested an independent review.
“I’m like, ‘Tell me why am I getting this bill?’” Uddin recalled in an interview. The unsatisfying explanation: The mammogram itself was covered, per the ACA’s rules, but the fee for the equipment and the facility was not.
That answer was particularly galling, she said, because, a year earlier, her “free” mammogram at the same health system had generated a bill of about $1,000 for the radiologist’s reading. Though she fought that charge (and won), this time she threw in the towel and wrote the $236 check. But then she dashed off a submission to the KFF Health News-NPR “Bill of the Month” project:
“I was really mad — it’s ridiculous,” she later recalled. “This is not how the law is supposed to work.”
The ACA’s designers might have assumed that they had spelled out with sufficient clarity that millions of Americans would no longer have to pay for certain types of preventive care, including mammograms, colonoscopies, and recommended vaccines, in addition to doctor visits to screen for disease. But the law’s authors didn’t reckon with America’s ever-creative medical billing juggernaut.
Over the past several years, the medical industry has eroded the ACA’s guarantees, finding ways to bill patients in gray zones of the law. Patients going in for preventive care, expecting that it will be fully covered by insurance, are being blindsided by bills, big and small.
The problem comes down to deciding exactly what components of a medical encounter are covered by the ACA guarantee. For example, when do conversations between doctor and patient during an annual visit for preventive services veer into the treatment sphere? What screenings are needed for a patient’s annual visit?
A healthy 30-year-old visiting a primary care provider might get a few basic blood tests, while a 50-year-old who is overweight would merit additional screening for Type 2 diabetes.
Making matters more confusing, the annual checkup itself is guaranteed to be “no cost” for women and people age 65 and older, but the guarantee doesn’t apply for men in the 18-64 age range — though many preventive services that require a medical visit (such as checks of blood pressure or cholesterol and screens for substance abuse) are covered.
No wonder what’s covered under the umbrella of prevention can look very different to medical providers (trying to be thorough) and billers (intent on squeezing more dollars out of every medical encounter) than it does to insurers (who profit from narrower definitions).
For patients, the gray zone has become a billing minefield. Here are a few more examples, gleaned from the Bill of the Month project in just the past six months:
Peter Opaskar, 46, of Texas, went to his primary care doctor last year for his preventive care visit — as he’d done before, at no cost. This time, his insurer paid $130.81 for the visit, but he also received a perplexing bill for $111.81. Opaskar learned that he had incurred the additional charge because when his doctor asked if he had any health concerns, he mentioned that he was having digestive problems but had already made an appointment with his gastroenterologist. So, the office explained, his visit was billed as both a preventive physical and a consultation. “Next year,” Opasker said in an interview, if he’s asked about health concerns, “I’ll say ‘no,’ even if I have a gunshot wound.”
Kevin Lin, a technology specialist in Virginia in his 30s, went to a new primary care provider to take advantage of the preventive care benefit when he got insurance; he had no physical complaints. He said he was assured at check-in that he wouldn’t be charged. His insurer paid $174 for the checkup, but he was billed an additional $132.29 for a “new patient visit.” He said he has made many calls to fight the bill, so far with no luck.
Finally, there’s Yoori Lee, 46, of Minnesota, herself a colorectal surgeon, who was shocked when her first screening colonoscopy yielded a bill for $450 for a biopsy of a polyp — a bill she knew was illegal. Federal regulations issued in 2022 to clarify the matter are very clear that biopsies during screening colonoscopies are included in the no-cost promise. “I mean, the whole point of screening is to find things,” she said, stating, perhaps, the obvious.
Though these patient bills defy common sense, room for creative exploitation has been provided by the complex regulatory language surrounding the ACA. Consider this from Ellen Montz, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at the Centers for Medicare & Medicaid Services, in an emailed response to queries and an interview request on this subject: “If a preventive service is not billed separately or is not tracked as individual encounter data separately from an office visit and the primary purpose of the office visit is not the delivery of the preventive item or service, then the plan issuer may impose cost sharing for the office visit.”
So, if the doctor decides that a patient’s mention of stomach pain does not fall under the umbrella of preventive care, then that aspect of the visit can be billed separately, and the patient must pay?
And then there’s this, also from Montz: “Whether a facility fee is permitted to be charged to a consumer would depend on whether the facility usage is an integral part of performing the mammogram or an integral part of any other preventive service that is required to be covered without cost sharing under federal law.”
But wait, how can you do a mammogram or colonoscopy without a facility?
Unfortunately, there is no federal enforcement mechanism to catch individual billing abuses. And agencies’ remedies are weak — simply directing insurers to reprocess claims or notifying patients they can resubmit them.
In the absence of stronger enforcement or remedies, CMS could likely curtail these practices and give patients the tools to fight back by offering the sort of clarity the agency provided a few years ago regarding polyp biopsies — spelling out more clearly what comes under the rubric of preventive care, what can be billed, and what cannot.
The stories KFF Health News and NPR receive are likely just the tip of an iceberg. And while each bill might be relatively small compared with the stunning $10,000 hospital bills that have become all too familiar in the United States, the sorry consequences are manifold. Patients pay bills they do not owe, depriving them of cash they could use elsewhere. If they can’t pay, those bills might end up with debt-collection agencies and, ultimately, harm their credit score.
Perhaps most disturbing: These unexpected bills might discourage people from seeking preventive screenings that could be lifesaving, which is why the ACA deemed them “essential health benefits” that should be free.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News’ free Morning Briefing.
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Bromelain vs Inflammation & Much More
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Let’s Get Fruity
Bromelain is an enzyme* found in pineapple (and only in pineapple), that has many very healthful properties, some of them unique to bromelain.
*actually a combination of enzymes, but most often referred to collectively in the singular. But when you do see it referred to as “they”, that’s what that means.
What does it do?
It does a lot of things, for starters:
❝Various in vivo and in vitro studies have shown that they are anti-edematous, anti-inflammatory, anti-cancerous, anti-thrombotic, fibrinolytic, and facilitate the death of apoptotic cells. The pharmacological properties of bromelain are, in part, related to its arachidonate cascade modulation, inhibition of platelet aggregation, such as interference with malignant cell growth; anti-inflammatory action; fibrinolytic activity; skin debridement properties, and reduction of the severe effects of SARS-Cov-2❞
Some quick notes:
- “facilitate the death of apoptotic cells” may sound alarming, but it’s actually good; those cells need to be killed quickly; see for example: Fisetin: The Anti-Aging Assassin
- If you’re wondering what arachidonate cascade modulation means, that’s the modulation of the cascade reaction of arachidonic acid, which plays a part in providing energy for body functions, and has a role in cell structure formation, and is the precursor of assorted inflammatory mediators and cell-signalling chemicals.
- Its skin debridement properties (getting rid of dead skin) are most clearly seen when using bromelain topically (one can literally just make a pineapple poultice), but do occur from ingestion also (because of what it can do from the inside).
- As for being anti-thrombotic and fibrinolytic, let’s touch on that before we get to the main item, its anti-inflammatory properties.
If you want to read more of the above before moving on, though, here’s the full text:
Anti-thrombotic and fibrinolytic
While it does have anti-thrombotic effects, largely by its fibrinolytic action (i.e., it dissolves the fibrin mesh holding clots together), it can have a paradoxically beneficial effect on wound healing, too:
For more specifically on its wound-healing benefits:
In Vitro Effect of Bromelain on the Regenerative Properties of Mesenchymal Stem Cells
Anti-inflammatory
Bromelain is perhaps most well-known for its anti-inflammatory powers, which are so diverse that it can be a challenge to pin them all down, as it has many mechanisms of action, and there’s a large heterogeneity of studies because it’s often studied in the context of specific diseases. But, for example:
❝Bromelain reduced IL-1β, IL-6 and TNF-α secretion when immune cells were already stimulated in an overproduction condition by proinflammatory cytokines, generating a modulation in the inflammatory response through prostaglandins reduction and activation of cascade reactions that trigger neutrophils and macrophages, in addition to accelerating the healing process❞
~ Dr. Taline Alves Nobre et al.
Read in full:
Bromelain as a natural anti-inflammatory drug: a systematic review
Or if you want a more specific example, here’s how it stacks up against arthritis:
❝The results demonstrated the chondroprotective effects of bromelain on cartilage degradation and the downregulation of inflammatory cytokine (tumor necrosis factor (TNF)-α, IL-1β, IL-6, IL-8) expression in TNF-α–induced synovial fibroblasts by suppressing NF-κB and MAPK signaling❞
~ Dr. Perephan Pothacharoen et al.
Read in full:
More?
Yes more! You’ll remember from the first paper we quoted today, that it has a long laundry list of benefits. However, there’s only so much we can cover in one edition, so that’s it for today
Is it safe?
It is generally recognized as safe. However, its blood-thinning effect means it should be avoided if you’re already on blood-thinners, have some sort of bleeding disorder, or are about to have a surgery.
Additionally, if you have an allergy, this one may not be for you.
Aside from that, anything can have drug interactions, so do check with your doctor/pharmacist to be sure.
Want to try some?
You can just eat pineapples, but if you don’t enjoy that and/or wouldn’t want it every day, bromelain is available in supplement form too.
We don’t sell it, but here for your convenience is an example product on Amazon
Enjoy!
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Sweet Potato vs Cassava – Which is Healthier?
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Our Verdict
When comparing sweet potato to cassava, we picked the sweet potato.
Why?
For any unfamiliar with cassava, it’s also called manioc or yuca/yucca, and it’s a tuber that can be used a lot like sweet potato. It’s popular in S. America, often in recipes that aren’t the healthiest (deep-fried chunky “cassava chips” are popular in Brazil, for example, and farofa, a flour made from cassava, is less healthy even than refined white flour from wheat), but today we’re going to judge it on its own merit—since after all, almost anything can be deep-fried and many things can be turned into flour, but it doesn’t mean we have to do that.
Let’s talk macros first: sweet potato has nearly 2x the protein, while cassava has nearly 2x the carbs. As for fiber to soften those carbs’ impact on our blood sugars, well, sweet potato has about 2x the fiber. All in all for macros, a clear and easy win for sweet potato.
Important note: as for the impact that has on glycemic index: the exact glycemic index will depend on what you do with it (different cooking methods change the GI), but broadly speaking, sweet potatoes are considered a medium GI food, while cassava is a very high GI food, to the point that it’s higher than sucrose, and nearly equal to pure glucose. Which is impressive, for a tuber.
In terms of vitamins, sweet potato’s famously high vitamin A content raises the bar, but it’s not all it has to offer: sweet potato has more of vitamins A, B1, B2, B3, B5, B6, E, and K, while cassava has more of vitamins B9 and choline. Just for amusement’s sake, let’s note that the sweet potato has over 1,478x the vitamin A content. In any case, the vitamins category is another clear win for sweet potato.
When it comes to minerals, it’s again quite one-sided: sweet potato has more calcium, copper, iron, magnesium, manganese, phosphorus, and potassium, while cassava has more selenium. So, sweet potato wins yet again.
In short: definitely a case of “the less widely-available option is not necessarily the healthier”!
Want to learn more?
You might like to read:
Glycemic Index vs Glycemic Load vs Insulin Index
Take care!
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What is PMDD?
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Premenstrual dysphoric disorder (PMDD) is a mood disorder that causes significant mental health changes and physical symptoms leading up to each menstrual period.
Unlike premenstrual syndrome (PMS), which affects approximately three out of four menstruating people, only 3 percent to 8 percent of menstruating people have PMDD. However, some researchers believe the condition is underdiagnosed, as it was only recently recognized as a medical diagnosis by the World Health Organization.
Read on to learn more about its symptoms, the difference between PMS and PMDD, treatment options, and more.
What are the symptoms of PMDD?
People with PMDD typically experience both mood changes and physical symptoms during each menstrual cycle’s luteal phase—the time between ovulation and menstruation. These symptoms typically last seven to 14 days and resolve when menstruation begins.
Mood symptoms may include:
- Irritability
- Anxiety and panic attacks
- Extreme or sudden mood shifts
- Difficulty concentrating
- Depression and suicidal ideation
Physical symptoms may include:
- Fatigue
- Insomnia
- Headaches
- Changes in appetite
- Body aches
- Bloating
- Abdominal cramps
- Breast swelling or tenderness
What is the difference between PMS and PMDD?
Both PMS and PMDD cause emotional and physical symptoms before menstruation. Unlike PMS, PMDD causes extreme mood changes that disrupt daily life and may lead to conflict with friends, family, partners, and coworkers. Additionally, symptoms may last longer than PMS symptoms.
In severe cases, PMDD may lead to depression or suicide. More than 70 percent of people with the condition have actively thought about suicide, and 34 percent have attempted it.
What is the history of PMDD?
PMDD wasn’t added to the Diagnostic and Statistical Manual of Mental Disorders until 2013. In 2019, the World Health Organization officially recognized it as a medical diagnosis.
References to PMDD in medical literature date back to the 1960s, but defining it as a mental health and medical condition initially faced pushback from women’s rights groups. These groups were concerned that recognizing the condition could perpetuate stereotypes about women’s mental health and capabilities before and during menstruation.
Today, many women-led organizations are supportive of PMDD being an official diagnosis, as this has helped those living with the condition access care.
What causes PMDD?
Researchers don’t know exactly what causes PMDD. Many speculate that people with the condition have an abnormal response to fluctuations in hormones and serotonin—a brain chemical impacting mood— that occur throughout the menstrual cycle. Symptoms fully resolve after menopause.
People who have a family history of premenstrual symptoms and mood disorders or have a personal history of traumatic life events may be at higher risk of PMDD.
How is PMDD diagnosed?
Health care providers of many types, including mental health providers, can diagnose PMDD. Providers typically ask patients about their premenstrual symptoms and the amount of stress those symptoms are causing. Some providers may ask patients to track their periods and symptoms for one month or longer to determine whether those symptoms are linked to their menstrual cycle.
Some patients may struggle to receive a PMDD diagnosis, as some providers may lack knowledge about the condition. If your provider is unfamiliar with the condition and unwilling to explore treatment options, find a provider who can offer adequate support. The International Association for Premenstrual Disorders offers a directory of providers who treat the condition.
How is PMDD treated?
There is no cure for PMDD, but health care providers can prescribe medication to help manage symptoms. Some medication options include:
- Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants that regulate serotonin in the brain and may improve mood when taken daily or during the luteal phase of each menstrual cycle.
- Hormonal birth control to prevent ovulation-related hormonal changes.
- Over-the-counter pain medication like Tylenol, which can ease headaches, breast tenderness, abdominal cramping, and other physical symptoms.
Providers may also encourage patients to make lifestyle changes to improve symptoms. Those lifestyle changes may include:
- Limiting caffeine intake
- Eating meals regularly to balance blood sugar
- Exercising regularly
- Practicing stress management using breathing exercises and meditation
- Having regular therapy sessions and attending peer support groups
For more information, talk to your health care provider.
If you or anyone you know is considering suicide or self-harm or is anxious, depressed, upset, or needs to talk, call the Suicide & Crisis Lifeline at 988 or text the Crisis Text Line at 741-741. For international resources, here is a good place to begin.
This article first appeared on Public Good News and is republished here under a Creative Commons license.
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Trout vs Haddock – Which is Healthier?
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Our Verdict
When comparing trout to haddock, we picked the trout.
Why?
It wasn’t close.
In terms of macros, trout has more protein and more fat, although the fat is mostly healthy (some saturated though, and trout does have more cholesterol). This category could be a win for either, depending on your priorities. But…
When it comes to vitamins, trout has a lot more of vitamins A, B1, B2, B3, B5, B6, B12, C, D, and E, while haddock is not higher in any vitamins.
In the category of minerals, trout has more calcium, copper, iron, magnesium, potassium, and zinc, while haddock has slightly more selenium. Given that a 10oz portion of trout already contains 153% of the RDA of selenium, however, the same size portion of haddock having 173% of the RDA isn’t really a plus for haddock (especially as selenium can cause problems if we get too much). Oh, and haddock is also higher in sodium, but in industrialized countries, most people most of the time need less of that, not more.
On balance, the overwhelming nutritional density of trout wins the day.
Want to learn more?
You might like to read:
Farmed Fish vs Wild Caught: It Makes Quite A Difference!
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Mango vs Pineapple – Which is Healthier?
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Our Verdict
When comparing mango to pineapple, we picked the pineapple.
Why?
It was close! Both of these tropical fruits have almost identical macros, and when it comes to vitamins and minerals, mango has slightly more vitamins while pineapple has slightly more minerals, so that balances out too. Their glycemic loads are 11 and 13 respectively, so: very low, and very similar.
See also: Which Sugars Are Healthier, And Which Are Just The Same?
In terms of what sets them apart:
Mango has a lot of vitamin A, to the point that it can interfere with blood-thinners if you take those.
Pineapple has bromelain, an enzyme with unique anti-inflammatory properties that we must devote a Research Review Monday to one of these days, because there’s a lot to say, but the short version is, it’s very powerful.
Since bromelain is found only in pineapples, whereas vitamin A is easy to find in abundance in many foods, we went with the pineapple.
Enjoy!
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