For 21 years, the University of Washington School of Medicine has dispatched its rising second-year students across the Northwest to provide primary care in rural or underserved areas. The monthlong program is elective, but a record number of students took part this year — 117 from a class of 216.  The school has a cooperative agreement to train medical students from Alaska, Idaho, Montana and Wyoming, none of which has a medical college of its own. The summer program is one of several vehicles, along with loan forgiveness enticements, designed to lure students back to their home states to practice in areas with a shortage of primary care givers.  This year, the students set out as negotiations were intensifying in Washington over wholesale changes to the health care system they will soon be joining. Whether there will be improvements to the system remains to be seen, but few students returned thinking there was little to fix.  Payment policies that leave primary care providers struggling to cover their costs have pushed family practitioners and internists into early retirement, and discouraged newly minted doctors from replacing them. To make a living, and chip away at immense educational debt, general practitioners often find they must churn patients and work long, unsatisfying hours.  The result is that only a third of today’s graduates of American medical schools train in internal or family medicine, the two largest primary care disciplines, compared with nearly half only 25 years ago, according to the National Resident Matching Program, which matches medical school graduates with residency openings. The figure at the University of Washington, despite a persistent emphasis on primary care, is only slightly higher.  For some students, like Mr. Opfer, 23, their summer experience persuaded them that primary care was not for them. The three pediatricians Mr. Opfer followed, who ran the only children’s clinic in Gillette, filled their 13-hour days with hospital rounds and staccato five-minute appointments, he said. One was about to retire because of burnout.  Mr. Opfer said he thought that the lifestyle would be too harsh to raise a family, and that it would take many years to pay off his anticipated medical school debt of at least $120,000.  “I don’t think you can practice optimal medicine,” Mr. Opfer said. “There is too little incentive after going through all this education and being in school for the majority of your life to want to pursue a career just in primary care.”  Other students, like Kylie G. Boggess, 24, witnessed how integral a federally qualified health center could be to a community like Nampa, Idaho, and became all the more committed. “This just sold it to me,” Ms. Boggess said. “You get to have a very personal relationship with your patients. You get to know them.”  Nonetheless, Ms. Boggess, who is from Twin Falls, Idaho, said she had been struck by how much time was devoted to scavenging resources for patients who had little money.  “I would really like to practice in a world where I can just take care of my patients and that’s the end of it,” she said, “where the big elephant in the room is not whether or not my recommendations mean anything because of cost.”  Mr. Olsgaard, 28, also found that money drove medical decisions at the community health center where he worked. “You know the patient, you know the patient’s financial information, and then you make clinical decisions based on that,” he said.  Ben J. Ruffatto, 26, said that after working with a family practitioner in Dillon, Mont., he had become convinced that rationing health care was “a socioeconomic national cultural inevitability.”  “It is right now,” Mr. Ruffatto said. “There simply isn’t enough money in the system for everyone to get absolutely everything that they want.”  There were differing opinions among the students about critical components of the plans being discussed by President Obama and Congress, like whether health coverage should be mandated and whether the government should create a public insurance option. But even those favoring the Democratic approach said they felt momentum had stalled.  “I really like Obama, but I’m a little bummed,” Ms. Boggess said. “He has yet to really strongly make the moral argument for providing health care to our citizens.”  Some, like Elizabeth M. Stuhlmiller, 25, who worked in a clinic in Tonasket, Wash., said they had not paid much attention to the debate, but had learned this summer to take satisfaction in improving the country’s health one patient at a time.  “I think I can fill a hole; I think that there’s a big need,” said Ms. Stuhlmiller, who plans to pursue primary care. “I don’t necessarily have the goals of changing a system. To feel at the end of the day that I’ve treated a patient and helped them, that would be enough for me.”  A version of this article appears in print on , on Page A18 of the New York edition with the headline: A Summer of Work Opens Medical Students’ Eyes. Order Reprints| Today's Paper|Subscribe
After providing primary care in underserved areas this summer, medical students from the University of Washington returned to campus with their idealism tempered.