Most researchers, policy wonks and politicians agree that the United States is flirting with a serious shortage of primary care physicians. The numbers vary depending on the methods and data sources used by those conducting the research.
But new projections highlighted in an article(www.annfammed.org) published in the March/April Annals of Family Medicine(www.annfammed.org) titled "Estimating the Residency Expansion Required to Avoid Projected Primary Care Physician Shortages by 2035" come with a twist.
Researchers from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in Washington, D.C., the Virginia Commonwealth University (VCU) in Richmond, and the University of Virginia in Charlottesville set out to answer three questions:
- Accounting for physician retirement and using the current level of residency production, what would the primary care physician shortage look like through 2035?
- How many additional residency slots would be needed to alleviate the shortage?
- How do changes in the retirement age and panel size affect the shortage?
- New research published in the Annals of Family Medicine estimates the amount of residency expansion needed to avoid primary care physician shortages projected to occur by 2035.
- Authors projected that the United States would need an additional 44,340 primary care physicians by 2035.
- At the current rate of physician production, they projected a shortage of 33,000 primary care physicians and suggested adding 1,700 primary care residency slots.
In an interview with AAFP News, corresponding author Winston Liaw, M.D., M.P.H., an assistant professor of family medicine at VCU and a contract researcher for the Graham Center, described the finished work as a "road map" that details how many primary care specialists in family medicine, general internal medicine and pediatrics are needed to meet the anticipated demand.
"We made our research more granular in terms of the composition of the additional residents needed," said Liaw. "We felt that detailed information would be helpful to policymakers as they try to solve the shortage issue," he added.
The authors noted that their analysis was "distinct in several respects." For instance, they said their projections were more current and extended to 2035. In addition, they used 2010 U.S. census demographic projections that predicted much slower population growth than the 2000 census report.
To ensure the authenticity of their work, authors relied on the AMA Physician Masterfile to establish a 2015 baseline number of primary care physicians, as well as the number of physicians retiring at age 66, and tapped the 2010 National Ambulatory Medical Care Survey to calculate demand for primary care physicians by specialty.
Researchers estimated the current annual production of primary care physicians using data from the American Board of Family Medicine, the American Board of Internal Medicine, the American Board of Pediatrics and the American Osteopathic Association.
Projections at a Glance
Researchers projected that demographic changes and expansion of health care insurance coverage would require an additional 44,340 primary care physicians by 2035.
"Unfortunately, at current rates of physician production, we project a shortage of more than 33,000 primary care physicians during this 20-year period," wrote the authors. Accordingly, they projected an additional 1,700 primary care residency positions would be necessary by 2035, a 21 percent increase from current production.
"The magnitude of the proposed increase is daunting, but it will also be necessary to maintain current physician-to-population ratios," wrote the authors. However, "Simply adding slots to the current hospital-based graduate medical education system is unlikely to eliminate primary care shortages," they noted, because statistics show that many of those residents pursue subspecialty careers.
Researchers said that expanding community-based graduate medical education training into areas such as teaching health centers and rural training tracks had been shown to increase the number of graduates who stay in primary care. Such tactics have long been supported by the AAFP.(6 page PDF)
Researchers also factored in the effect that retirement trends among primary care physicians would have on the primary care workforce. They calculated that lowering the retirement age by just two years -- from age 66 to age 64 -- would create a need for an additional 2,400 primary care residency slots.
They also explored the effect of new models of care -- such as direct primary care, the patient-centered medical home and team-based care -- that aim to improve health care delivery but that also can also dramatically reduce the size of physicians' patient panels.
"All of these models are projected to contract panel sizes so physicians don't have to manage as many patients," said Liaw, who also sees patients in clinic and makes hospital rounds. "When physicians know their patients better, they can offer more comprehensive health care and maintain continuity of care," he added.
However, researchers projected that just a 10 percent decrease in the ratio of population to primary care physician would result in more than 3,000 additional residency slots needed by 2035.
Assessing Study Limitations
Researchers acknowledged limitations with their projections, including the possibility of shifting census projections. They noted that physician work hours have steadily decreased and that "further erosion could limit the number of visits each primary care physician sees."
They also pointed to an increase in the number of female family physicians and statistics that show female FPs work fewer hours. Furthermore, market shifts in primary care -- such as an increase in family physicians and internal medicine physicians pursuing hospitalist careers -- could skew their projections.
Authors said some researchers have suggested that an increased supply of physician assistants (PAs) and nurse practitioners (NPs) could alleviate the primary care shortage.
However, even though those clinicians are an important part of the health care team, "they fulfill different roles in delivering primary care," said the authors. Furthermore, PAs and NPs encounter the same incentives to enter subspecialty careers and consider hospital employment as physicians do.
Getting Family Physicians Involved
Liaw urged his family physician colleagues to use this latest research as a means of getting involved in advocacy efforts to build up the primary care workforce. He said legislators likely would introduce bills aimed at addressing the primary care shortage.
But he cautioned his colleagues to pay attention to the details.
"A lot of bills we've seen aim to increase residency slots, but they often don't protect primary care slots," said Liaw.
"Legislators need to hear from practicing family physicians about what they're seeing on the ground. Those conversations really give credence to any sort of legislation that is positive for the primary care pipeline," he added.
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