By Kenneth W. Lin, MD, MPH

When I started medical school almost three decades ago and expressed interest in primary care, faculty advised me that this choice would represent a career dead end. The sentiment: Subspecialization was in, generalist practice was out. Although student interest in family medicine over the succeeding years has fallen short of the numbers needed to replace retiring physicians and care for a growing population, the specialty hasn’t exactly withered away.

Family medicine has faced its fair share of both real and perceived threats. When training programs in the 2010s began producing increased numbers of nurse practitioners and physician assistants, naysayers predicted that these advanced practice providers (APPs) — who cost less to train and employ than primary care physicians — would eventually displace us. But what actually happened is the same thing that has occurred in every other area of medicine: APPs work side by side with family physicians in complementary roles.

The latest perceived threat to the viability of primary care is artificial intelligence (AI). In some studies, large language models have outperformed doctors in diagnostic accuracy. Mass General Brigham’s health system recently launched an AI chatbot to provide first-contact care for patients who don’t have primary care doctors, instead of working to retain existing physicians with higher salaries or more support staff. Although there is no doubt that family physicians will need to adapt their practices to the capabilities of generative AI, it has had mostly positive effects on my own work experience.

In contrast, a real trend has been transforming the face of American family medicine over the past decade. A rising proportion of family medicine residents — including those at my own program — are graduates of osteopathic medical schools (DOs). Between 2016 and 2021, the contribution of US osteopathic graduates to family medicine residencies increased by 5.3% per year while that of allopathic medical schools remained flat.

In part, the attraction of DOs to family medicine may be the result of osteopathic schools requiring more primary-care focused courses and clinical rotations compared to allopathic schools. However, a recent study suggested that bias against osteopathic graduates may also play a role. While researchers observed a strong association between a specialty’s average salary and the proportion of first-year residency positions filled by graduates of allopathic schools (ie, more money = more competitive), the opposite was true for osteopathic graduates. Although I love being a family physician and chose it with full knowledge that it is one of the lowest-paying medical specialties, it is difficult to believe that DOs are immune to the powerful financial incentives that drive MD career choices.

Although my specialty’s future will benefit from an influx of young osteopathic physicians, large portions of the primary care workforce remain in crisis: working too many hours with too little support, being treated by corporate bosses like cogs in a revenue-generating machine, and confronting record levels of mistrust from patients who prefer to “do their own research.” These are real problems, but my experience suggests that family medicine will survive these challenges, too — just as it has prevailed over past threats that some worried would lead to our extinction.