By RICHARD GUNDERMAN, MD

One of the top students at one of the nation’s largest medical schools, Ishan Gohil has made an unusual – and to many of his colleagues – inexplicable decision.  Instead of seeking to train in one of medicine’s most highly specialized and competitive fields, he says, “I elected to pursue a career in family medicine.”  Many view his choice of primary care as ill-advised, largely because family medicine is one of the least competitive fields and ranks at the bottom for income of all medical specialties.

Until his third year, Gohil had planned to pursue orthopedic surgery, which is considerably more difficult to get into than family medicine.  In 2014, the average score on Step 1 of the US Medical Licensing Exam for students entering family medicine was 218, while for orthopedic surgery it was 245 (the overall average is 230).  Average annual salary levels diverge even more widely, at $122,000 for family physicians and $488,000 for orthopedic surgeons.

Many students evidently see additional drawbacks to primary care.  The Council on Graduate Medical Education has estimated that such fields comprise about 35% of all practicing physicians – a number that needs to reach 40% – yet they have been attracting fewer than 20% of US medical graduates.  “One problem,” Gohil says, “is the escalating debt of graduates,” which averages nearly $180,000 per student.  “Inevitably,” he says, “this turns away many students from lower-paying fields.”

Some students also opt against primary care because they don’t want to deal with large numbers of patients suffering from chronic medical problems, such as obesity, diabetes, and hypertension.  “In contrast to the kinds of problems a surgeon might be able to correct more or less permanently with an operation,” Gohil says, “the primary care physician cannot cure many routine conditions, and ends up managing them long term.”

Add to this the fact that patients often don’t follow their doctor’s recommendations.  Many obese patients do not manage to lose weight, smokers fail to heed advice to stop, and patients suffering from diabetes and hypertension neglect to take their medications faithfully.  Many students fear that caring daily for such patients, who are often labelled “noncompliant,” will lead to frustration, perhaps even a sense of futility.

Yet Gohil is unswayed.  What many of his colleagues see as drawbacks he views as unheralded opportunities.  “I believe that we can improve patient care by building better long-term relationships with patients, something many specialized physicians do not have the opportunity to do.”  Specifically, he hopes that stronger relationships will enable him “to involve patients more as allies in their own care, helping them to take better care of themselves.”

To Gohil, relationships are the key.  “If patients really know, like, and trust their doctor,” he says, “they will be more likely to follow preventive health recommendations.  And the same goes for recommendations concerning treatment of their medical conditions.  If patients know they can count on me, I will be able to count on them to make their best effort.  And this will enable us to work together to enhance the quality of their lives.”

Gohil argues that medicine has become too fragmented.  “A patient’s care is often parceled out to so many different physicians – a cardiologist, a pulmonologist, a neurologist, and an orthopedic surgeon, for example – that no single physician sees the patient as a whole person.”  By contrast, he believes, “A good family physician functions like a symphony conductor, who makes sure each section is contributing appropriately to the overall performance.”

When this doesn’t happen, patients can suffer.  Problems that don’t fit neatly into any particular specialty can fall through the cracks.  Overlapping and inconsistent treatments can leave patients on too many medications, some of which may interact badly with one another.  And as more physicians become involved, the risks of miscommunication increase.  “To prevent these kinds of problems,” Gohil argues, “someone needs to see the big picture.”

And seeing the big picture can make a big difference.  For one thing, Gohil says, “If physicians have gotten to know patients well over a long period of time, they can recognize changes that specialists, who typically interact with them only episodically, may miss.”  In addition, he says, “They can make sure that tests and treatments fit the patient’s life.”  He recalls one orthopedic surgeon who ordered physical therapy for a patient, unaware that the patient held two jobs and wouldn’t have time to go.

In many cases, Gohil argues, what patients most need is not another test or treatment but a physician who knows their distinctive needs well.  He tells the story of a woman with a history of esophageal surgeries who was losing weight.  Instead of focusing on her esophagus, he asked her about her family, the stresses her in life, and the things that brought her pleasure.  “Soon,” he says, “we made a diagnosis of depression, and she is now doing much better on treatment.”

As Gohil sees her case, the patient responded not to more sophisticated and expensive healthcare, but to time and attention.  “When we shifted the focus of attention from her esophagus to her life, she initially expressed surprise.”  “No one has ever asked me questions like that before,” she said.  To Gohil, her case is a classic example of how, “having built a good relationship, we were able to get to the bottom of the problem.  And that makes both the patient and the doctor feel good.”

Gohil’s epiphany came when he tried to picture his ideal doctor and recognized the image that came to mind as a family physician.  He likes the idea of seeing not just individual organs but whole patients, and not just whole patients but whole families.  “In a single family,” for example, “I might deliver a baby, care for a parent in the hospital, and provide end-of-life care to a grandparent.”  Many people in the community would count on him as their doctor.  “How cool is that?” he asks with a smile.

I asked Gohil about the economic downsides to primary care, and whether he would feel bad making significantly less money than many of his classmates.  “Sure, primary care doctors are not getting rich, but they aren’t starving either.  They have homes, send their kids to college, and manage to retire comfortably.  I’m not in it for the money.  I drive an inexpensive car and plan to keep it till it falls apart.  What matters to me isn’t the money – it’s making a difference in my patients’ lives.”

“Moreover,” he adds, “there is no guarantee that things will stay the same.  Someday the people who pay for healthcare are going to realize that good patient-physician relationships are worth the time and effort they take to develop.  They help to make medical care more effective and efficient, and they provide a higher level of satisfaction to both patients and physicians.  Simply put, good patient-doctor relationships are good for healthcare.”

Yet Gohil also recognizes that every medical student will never feel as he does, nor should they.  “I am not saying that everyone should go into primary care.  But I am saying that every student should keep an open mind and find out where their real passion lies.  People who choose a career based strictly on competitiveness or money are going to end up feeling miserable, and so are many of their patients.  The key is to discover your vision of the ideal physician and strive to become that.”