Fewer than 9% of internal medicine residents chose primary care in 2024–2025 — half the rate of a decade ago. The pipeline problem starts even earlier: the average medical student graduates with more than $200,000 in debt, and tuition-free programs, while growing, have not yet demonstrated a meaningful increase in primary care specialty choice.
Graham, Fazio, and Laine argue in Annals of Internal Medicine that the decline in primary care is rooted in structural factors rather than generational preferences or individual values. Despite providing 35% of ambulatory services, primary care captures just under 5% of total health care spending. Internal medicine residents spend more than 70% of their training time on inpatient services, because graduate medical education funding flows directly to teaching hospitals, incentivizing fee-for-service hospital-based care over outpatient training. The resulting outpatient training gap may contribute to residents gravitating toward hospital medicine and procedure-based subspecialties. Neither internal medicine nor family medicine alone can fill the resulting need.
The authors also emphasize the role of the "hidden curriculum" in shaping specialty choice. The authors described a 2-tiered training environment in which disparities in infrastructure, staffing, and institutional support may signal that primary care is less valued than subspecialty care. Residents encounter these differences through clinic infrastructure, staffing support, and the institutional priorities emphasized during training.
The authors acknowledged that reforming graduate medical education funding will require federal action, and meaningful policy change will be slow and politically difficult. Reimbursement reform faces resistance from subspecialists who benefit from the current structure. Because Washington will move slowly, the burden falls harder on institutions that can act now — accrediting bodies, residency programs, and medical schools are already positioned to make a sizeable impact by requiring more substantive primary care training, funding longitudinal outpatient experiences, and holding schools accountable for the workforce they produce.
As the authors put it: "In many ways, the US education, training, and health care system is perfectly designed to deplete the supply of PCPs."
They argued that current funding and training structures systematically discourage primary care career pathways.
Disclosure forms are available with the article online.
Source: Annals of Internal Medicine
