Editorials

The Family Physician Workforce: Quality, Not Quantity



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Am Fam Physician. 2005 Jun 15;71(12):2248-2253.

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During the past 25 years, most physician workforce studies have concluded that primary care physicians were not being supplied in sufficient numbers. The most recent studies,14 however, present a mixed picture, in which primary care physicians may be in sufficient supply, but the number and types of physicians that will be needed in the years ahead remain unsettled. In response to these studies, new recommendations from the Association of American Medical Colleges5 and guidelines proposed by the Council on Graduate Medical Education4 reverse the previous positions of both organizations regarding the physician workforce. The Future of Family Medicine Project leaders,6 rather than asking, “How many physicians do we need?,” recently began with the question, “What should the family physician’s role be in the future, and how can it be realized?” In answer to that question, the committee proposed a set of services to which all patients should have access, and a new model of practice for family physicians.6 The convergence in the direction of these organizations indicates the need for, and timeliness of, a reconsideration of the family physician workforce.

To inform such reconsideration, the American Academy of Family Physicians commissioned a workforce study to be carried out by the Robert Graham Center in Washington, D.C., in collaboration with the Center for the Health Professions in San Francisco.7 The full text of this study is posted on the Robert Graham Center Web site at http://www.graham-center.org. A series of nine “one-pagers” from the Robert Graham Center that stem from this study will be published sequentially in American Family Physician during the next few months, beginning with this issue, with the intention of stimulating thought and decision making about the next steps for the physician and health care workforce. The main findings of the workforce study are summarized in this editorial.

(1) Family physicians are in the enviable position of having accomplished, to a large extent, their previous workforce goals.

In the 1980s and 1990s, there was substantial growth in the physician workforce. This growth included a resurgence of family physicians more than sufficient to counter the decline in the number of physicians in general practice that was apparent when family medicine became a specialty. In 2004, the number of active family physicians and general practitioners in the United States (31.2 per 100,000 people) was similar to the demand projected for 2015 by the 1998 Kindig study (35.1 per 100,000 people).8 With current entry and retirement rates, the projected demand is likely to be met or surpassed.

(2) The population of the United States is growing and will include a larger cohort of older people as the baby-boomers age and immigration continues.

The population in metropolitan and non-metropolitan areas of the United States has grown steadily since the 1980s. This larger, older population will require more services from physicians for a longer period than generally is recognized. However, the rate of population growth has consistently been exceeded by the rates of growth in the number of physicians in primary care and other specialties.

(3) Millions of people across the nation rely on family physicians as a usual source of care. Their versatility enables them to serve any segment of the population, and they are critically important to people in rural areas and those receiving care in community health centers.

An estimated one third of the nation consults with a family physician each year.7 Rural populations are especially dependent on family physicians, and their needs represent a floor beneath which the family physician workforce cannot be permitted to drop. Community health centers depend on primary care physicians for a majority of their physician staff, more than one half of whom are family physicians or general practitioners.

(4) Projections of the number of family physicians that might be in practice in the next 15 years vary substantially according to the methods and assumptions used.

When three different modeling approaches (i.e., supply and demand, needs-based, and planning) were used to project the number of family physicians expected to be in practice from 2004 to 2020, the highest projection exceeded the lowest by more than one half. It probably is best to avoid making claims of shortage or surplus with great confidence, for even moderately distant forecasts.

(5) Specifying the number of people for whom family physicians can provide their services is a useful way to estimate the need for family physicians.

Based on estimates derived from published literature and considerations of family medicine’s proposed set of services for the new model practice, a reasonable ratio is 1,200 patients for each family physician. Although there are reasons a lower or higher number might be more appropriate, this number is close to ratios reported for primary care physicians in staff model health maintenance organizations (HMOs).9

(6) The current number and expected supply of family physicians is reasonable, in the context of one patient-care–focused primary care physician for every 1,321 persons in the United States.

Family physicians in the United States are not the only primary care physicians; they are joined by general internists and general pediatricians. In addition, there are many physician assistants and nurse practitioners also providing primary care, with whom family physicians can work effectively to the benefit of people in the community and the general population. Calls to improve health care and ensure robust frontline medical care have never had such a large, well-trained workforce positioned to respond.

(7) Sustaining 3,200 family medicine residency positions is sufficient to maintain the current family physician workforce.

Even with the decline in match rates for family medicine residency positions, the growth rate of the family medicine workforce is greater than a decade ago. Although retirement rates among family physicians have increased, they remain below average for physicians in general.

(8) The large increase in the number of international medical graduates filling family medicine residency positions in the United States is a significant change, and its impact on the United States and other nations is not completely positive.

The number and proportion of family medicine resident positions filled by international medical graduates has increased dramatically. International medical graduates compose nearly one third of family medicine residents—twice the proportion in the existing workforce. Many international graduates remain in the United States after residency, possibly representing a loss to their native countries.

(9) The basic workforce requirement of family medicine has shifted from production of more family physicians to their effective deployment. The key task is to implement new models of practice and effectively provide a set of necessary services in collaboration with patients and with other members of the health care team.

Family medicine has entered a new era in which a steadily increasing “head count” is not necessarily the primary objective. Perhaps the time has arrived when further attention can focus on enhancing practice performance and the worklife of family physicians and improving the interfaces between primary care and the rest of the health care enterprise.

We do not expect universal agreement with these conclusions. Because another period of transformation of clinical practice is underway and physician workforce policy is in flux, it is timely and important to know and debate the current situation, explore further possibilities, and identify how family physicians can best fulfill their commitment to providing a high-performance medical home for everyone. We hope that this series of “one-pagers” and the complete report will stimulate this debate and lead to policies that promote family medicine’s ability to reach its goals.

The Authors

LARRY A. GREEN, M.D., is Senior Scholar in Residence at the Robert Graham Center: Policy Studies in Family Medicine and Primary Care, in Washington, D.C., and a professor in the Department of Family Medicine at the University of Colorado, Denver.

ROBERT L. PHILLIPS, JR., M.D., M.S.P.H., is director of the Robert Graham Center. He is a faculty member in the Department of Family Medicine at Georgetown University, Washington, D.C., and practices in Fairfax, Va.

Address correspondence to Robert L. Phillips, Jr., M.D., M.S.P.H., The Robert Graham Center, 1350 Connecticut Ave., NW, Suite 201, Washington, DC 20036 (e-mail: bphillips@aafp.org). Reprints are not available from the authors.

REFERENCES

1. Blumenthal D. New steam from an old cauldron—the physician-supply debate. N Engl J Med. 2004;350:1780–7.

2. Lurie JD, Goodman DC, Wennberg JE. Benchmarking the future generalist workforce. Eff Clin Pract. 2002;5:58–66.

3. Shipman SA, Lurie JD, Goodman DC. The general pediatrician: projecting future workforce supply and requirements. Pediatrics. 2004;113(3 pt 1):435–42.

4. Draft physician workforce policy guidelines for the U.S. for 2000–2020. Rockville, Md.: Council on Graduate Medical Education, 2003.

5. The physician workforce: position statement. Washington, D.C.: Association of American Medical Colleges, 2005. Accessed online April 26, 2005, at: http://www.aamc.org/workforce/12704workforce.pdf.

6. The future of family medicine: a collaborative project of the Family Medicine Community. Ann Fam Med. 2004;2:S3–32.

7. Green LA, Dodoo MS, Ruddy G, Fryer GE, Phillips RL, McCann JL, et al. The physician workforce of the United States: a family medicine perspective. Washington, D.C.: Robert Graham Center, 2004.

8. Kindig DA, et al. Family physician workforce reform: recommendations of the American Academy of Family Physicians. Leawood, Kan.: AAFP, 1998.

9. Hart LG, Wagner E, Pirzada S, Nelson F, Rosenblatt RA. Physician staffing ratios in staff-model HMOs. Health Aff. 1997;16:55–70.



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