Exodus of Male Physicians from Primary Care Drives Shift to Specialty Practice

The Migration of Male Physicians Away from Primary Care

A significant departure of male physicians from primary care was driving a pronounced shift in the U.S. physician workforce toward medical specialties, according to a June 2007 national study by the Center for Studying Health System Change (HSC). Two factors had partially obscured the severity of this trend: a rising share of female physicians, who disproportionately chose primary care, and sustained reliance on international medical graduates (IMGs), who by 2004-05 represented nearly one-quarter of all U.S. primary care physicians.

Between 1996-97 and 2004-05, the number of female primary care physicians per capita rose by 40 percent, partially offsetting a 16 percent per-capita decline in male primary care physicians. Over the same period, primary care incomes fell behind inflation and lost ground relative to both medical and surgical specialists' earnings. Female primary care physicians faced a 22 percent income gap compared to their male peers, even after adjusting for differences in personal and practice characteristics. The study warned that if real incomes continued to erode, the exodus of men from primary care might accelerate, and women could eventually begin avoiding the field as well — developments that would worsen an anticipated primary care shortage.

The Workforce Tilts Toward Medical Specialties

Although the overall adequacy of the U.S. physician supply was debated, there was broad agreement that the existing workforce was not distributed among specialties or geographic locations in alignment with the country's medical needs. Physician-to-population ratios varied widely across regions, and areas with large low-income populations or rapid population growth had not attracted enough physicians to keep pace with demand.

Among U.S. physicians working 20 or more hours per week in direct patient care, only 37 percent practiced in primary care — internal medicine, family medicine, pediatrics, or geriatrics. This proportion was considerably lower than in other developed nations such as the Netherlands, Denmark, the United Kingdom, and Spain. As the U.S. population aged and the 76 million baby boomers increasingly developed multiple chronic conditions, the need for an adequate primary care workforce was becoming more pressing.

Data from HSC's nationally representative Community Tracking Study (CTS) Physician Survey documented the shift over the prior decade. The proportion of medical specialists grew from 32.2 percent of patient-care physicians in 1996-97 to 37.6 percent in 2004-05, while primary care's share dropped from 38.9 percent to 36.7 percent. Surgeons saw a parallel decline, from 28.9 percent to 25.7 percent.

Overall, there was a modest increase in the total physician-to-population ratio between 1996-97 and 2004-05. But within that total, the number of primary care physicians per capita actually fell slightly. Male primary care physicians per 100,000 population declined substantially, from 39.3 to 33.0. Only the rise in female primary care physicians — from 12.1 to 17.0 per 100,000 — prevented a larger overall reduction.

Women as the Stabilizing Force in Primary Care

The growing presence of women in medicine was one of the most notable workforce trends of the era. Women accounted for 25 percent of all patient-care physicians in 2004-05, up from 18 percent in 1996-97. Their representation was highest in primary care, where more than one in three physicians was female, compared with 22 percent of medical specialists and 17 percent of surgeons. Among female physicians, half practiced primary care, a third were in medical specialties, and only 17 percent were in surgical fields.

Since the mid-1990s, the distribution of women across specialty categories had remained relatively stable. It was the migration of male physicians toward medical specialties and away from primary care and surgery that had driven the overall workforce shift. Female physicians were far more likely than men to practice pediatrics — nearly one in six women was a pediatrician, compared with one in 17 men — and women made up about 49 percent of the pediatrics workforce. Women also constituted more than a third of obstetrician-gynecologists, a specialty that filled some primary care functions for women of childbearing age.

Female primary care physicians tended to be younger than their male counterparts (average age 44.2 vs. 50.9 in 2004-05), had correspondingly fewer years in practice (11.6 vs. 18.3), but were more likely to hold board certification (94.4 percent vs. 88.3 percent). Both genders had seen substantial increases in board certification rates over time, reflecting efforts by medical education commissions to raise physician qualifications and the growing availability of specialty board certification programs.

The Work Hours Question

Average weekly hours spent on all medically related activities by primary care physicians had declined over the study period, from 53.8 hours in 1996-97 to 51.4 in 2004-05. Women in primary care worked fewer hours on average than men (46.9 vs. 53.6 hours per week in 2004-05), but this gap had narrowed because women's hours held steady while men's declined from 55.7 hours. Interestingly, for both genders, the hours spent specifically in direct patient care increased by about one hour over the same timeframe.

These work-hour dynamics had important implications for workforce planning. Because female physicians worked fewer hours on average — likely because of competing child-care responsibilities — the increase in female primary care physicians could not compensate for departing male physicians on a one-to-one basis. And it was not only women making these choices; younger physicians of both genders were gravitating toward more controllable lifestyles with fewer weekly hours. Workforce projections needed to account for these trends to avoid overestimating the effective physician supply.

International Medical Graduates: A Supporting Pillar

Nearly one-quarter of the primary care physician workforce consisted of international medical graduates. Their share had held steady at just over 24 percent since 2000-01, after rising from 20.7 percent in the late 1990s. Primary care IMGs tended to be slightly older than U.S.-trained counterparts (average age 50.1 vs. 48.1 in 2004-05), had slightly fewer years in practice (14.8 vs. 16.4), and were less likely to be board-certified (84.4 percent vs. 92.2 percent).

IMGs had historically practiced in lower-income and medically underserved areas at higher rates than U.S.-trained doctors, helping to fill access gaps for vulnerable populations. They continued to choose primary care at greater rates than their U.S.-trained peers (42.0 percent vs. 35.4 percent in 2004-05). However, IMGs were following the same trend as domestic graduates, shifting toward medical specialties: the share of IMGs in primary care fell from 47.1 percent in 2000-01 to 42.0 percent in 2004-05.

Primary Care Incomes: Falling Behind

In 2003, net income for primary care physicians averaged approximately $146,000 — a nominal increase of 8.4 percent over 1995. After accounting for inflation, however, primary care incomes had actually declined by 10.2 percent over those eight years. By comparison, medical specialists managed to keep pace with inflation, while surgeons experienced an 8.2 percent decline in real income but maintained the highest earnings of the three categories.

The gender pay gap within primary care was substantial. Female primary care physicians earned about 30 percent less than males in 2003, with average net incomes of $114,316 vs. $162,934. Sizable gaps also existed among medical specialists (22.8 percent) and surgeons (30.8 percent), but the primary care gap was particularly consequential because overall income levels in the field were already substantially lower.

The male-female income disparity persisted even after controlling for specialty, years of experience, board certification, IMG status, average hours worked, practice setting, proportions of Medicaid and capitated revenue, and practice ownership status. After these adjustments, the gender gap in primary care stood at 22 percent in 2003 — wider than the 16 percent adjusted gap measured in 1995. In contrast, women in medical specialties had narrowed the income gap with their male counterparts over the same period. Some factors that might explain part of the remaining gap, such as women's possible preference for practices with more flexible hours or less on-call time, were not captured in the survey data.

Policy Implications for the Primary Care Pipeline

Female medical school graduates had traditionally chosen primary care at much higher rates than men, and this pattern helped counteract the declining proportion of male graduates entering the field. But women still represented a smaller share of the total physician workforce and worked fewer hours on average, so their growth could not replace departing male physicians on a one-for-one basis.

Primary care had also depended on international medical graduates as a steady source of new physicians. IMGs on temporary visas continued to practice in underserved areas at elevated rates compared to U.S.-trained doctors. The continued inflow of IMGs, combined with the expanding female physician workforce, may have helped mask the seriousness of the forces discouraging physicians from choosing primary care.

Declining real incomes — both in absolute terms and relative to other specialties — had made primary care less appealing to medical students and residents. If this trend continued, the exodus could intensify and trigger a workforce shortage. The continuing commitment of female physicians to primary care despite shrinking real incomes was striking, but it was uncertain how long that commitment would hold.

The study suggested that policy makers might need to use Medicare and Medicaid payment rates to send different price signals to physicians. Primary care physicians, whose incomes depended heavily on office visits and cognitive services rather than procedures, could not simply increase their volume of procedures or tests to compensate for stagnant fees the way some specialists could. Recognizing these pressures, the most recent five-year update of Medicare relative values had incorporated increases for evaluation and management services, but the gains for primary care were projected to be small — only about 5 percent for internal medicine and family practice — partly because the update process had failed to identify many procedural services where productivity gains should have led to declining relative values.

Furthermore, activities central to primary care practice, such as care coordination and patient education, continued to go unreimbursed as separate services. Until these payment imbalances were addressed, primary care incomes were likely to continue falling further behind those of medical specialists, and maintaining a primary care physician workforce sufficient to meet the population's needs would grow increasingly difficult.

About the Data

This Tracking Report used findings from three rounds of the HSC Community Tracking Study Physician Survey, a nationally representative telephone survey of physicians in direct patient care across the continental United States. The sample was drawn from the American Medical Association and American Osteopathic Association master files. Eligible respondents were active, nonfederal, office- or hospital-based physicians in the 48 contiguous states who spent at least 20 hours per week in direct patient care. Residents, fellows, radiologists, anesthesiologists, and pathologists were excluded. The 1996-97 and 2000-01 surveys each covered approximately 12,000 physicians; the 2004-05 survey included more than 6,600 physicians. Response rates ranged from 52 to 65 percent. Physicians reported their income for the last full year before each survey's initial fielding, so income timeframes differed from other measures.

Sources and Further Reading

Blumenthal, David. "New Steam From an Old Cauldron — The Physician-Supply Debate." New England Journal of Medicine, Vol. 350, No. 17 (April 22, 2004).

Macinko, James, Barbara Starfield, and Leiyu Shi. "The Contribution of Primary Care Systems to Health Outcomes Within OECD Countries, 1970-1998." Health Services Research, Vol. 38 (2003).

Tu, Ha T., and Paul B. Ginsburg. "Losing Ground: Physician Income, 1995-2003." Tracking Report No. 15, Center for Studying Health System Change (June 2006).

Ginsburg, Paul B., and Robert A. Berenson. "Revising Medicare's Physician Fee Schedule." New England Journal of Medicine, Vol. 356, No. 12 (March 22, 2007).

Brotherton, Sarah E., Paul H. Rockey, and Sylvia I. Etzel. "U.S. Graduate Medical Education, 2004-2005: Trends in Primary Care Specialties." Journal of the American Medical Association, Vol. 294, No. 9 (September 7, 2005).

Mick, Stephen S., and Shoou-Yih Daniel Lee. "The Safety Net Role of International Medical Graduates." Health Affairs, Vol. 16, No. 2 (July/August 1997).