2015: Year in Review

GME Funding, Pipeline Issues Top AAFP's Education Agenda

January 06, 2016 04:04 pm News Staff

The importance of training tomorrow's family physicians can't be overstated -- particularly as millions of people continue to join the ranks of the newly insured and seek key preventive services. Boosting the sheer number of individuals who choose to pursue a career in medicine is a start, of course, but there's far more to it than that. Ensuring that the right candidates receive the right motivation and support is critical to expanding the primary care physician workforce.

It's a family affair for Brian Blank at the University of North Carolina at Chapel Hill, where he celebrates with his wife, Laura, and daughter Lillian after learning that he has matched to his first choice: Duke Family Medicine Residency in Durham, N.C.

Here's a look back at some of the top education and workforce issues the AAFP grappled with in 2015.

Family Medicine Sees Another Match Uptick

In March, results from the National Resident Matching Program -- known as the Match -- showed that for the sixth consecutive year, the rate of graduating medical students matching to family medicine residencies inched up, with a total of 3,060 students choosing the specialty. This despite the fact that the rate of U.S. seniors choosing family medicine slowed unexpectedly to 1,422 -- with just six more U.S. seniors matching to the specialty than last year.

(Then) AAFP President Robert Wergin, M.D., of Milford, Neb., attributed the slowdown to an unstable health care environment, and he called on family physicians to keep the fires lit by serving as role models and mentors.

AAFP News spotlighted one such mentor in June: Samuel Church, M.D., M.P.H., of Hiawassee, Ga. A small-town solo practitioner, Church opens not just his practice, but also his home, to the students he precepts. In return, students view him as a community advocate and role model, and those who have switched their specialty to family medicine credit Church for changing their minds.

Further analysis of the 2015 Match results in October revealed peaks and troughs for both primary care and family medicine. Specifically, researchers found that despite a 31 percent hike in the number of U.S. seniors who have matched into family medicine since 2009 -- the specialty's low-water mark -- the 2015 figure remained 39 percent lower than the number who matched to the specialty in its banner year, 1997.

They found some solace, however, in observing that of all U.S. seniors matching into primary care in 2015, the vast majority -- 69 percent -- chose family medicine.

Also on the positive side of the ledger, results of the 2015 American Osteopathic Association (AOA) Intern/Resident Registration Program cast primary care and family medicine in a positive light, with family medicine seeing a 6 percent rise in the proportion of graduating osteopathic students matching into the specialty compared with the previous year.

It may seem painfully obvious, but boosting the number of residents successfully matching into primary care means admitting the right candidates into medical school in the first place. That's why the AAFP joined 32 other groups in an amicus curiae (friend-of-the-court) brief in a U.S. Supreme Court case arguing that ensuring student diversity is an important component in the educational mission of medical schools because physicians' education must enable them to serve diverse populations.

In the end, though, reliable funding for residency training that builds on the enthusiasm of physicians-in-training must be assured if the full benefits of primary care -- and its promise of greater access to care for medically underserved populations -- are to be realized.

Federal GME Funding Pays Off

Two studies published in February illustrate the tie between providing federal funding for primary care residency training in underserved areas and increasing the likelihood that those primary care physicians will remain to practice in such areas.

[Residency faculty physician reviewing a patient X-ray with a medical resident]

The first study,(www.graham-center.org) conducted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, demonstrated how the federal Teaching Health Center Graduate Medical Education (THCGME) program established by the Patient Protection and Affordable Care Act (ACA) in 2011 has made headway in addressing the primary care physician shortage.

Over a five-year period, the program boosted the number of primary care physicians training in rural or underserved areas by more than 550, and the number of family medicine residencies it supported rose from nine in 2011 to 37 in 2015. But in a 2014 survey of 60 THCGME programs across the nation, Graham Center researchers found that two-thirds of programs that responded reported they were unlikely or very unlikely to be able to support their existing residency positions going forward without continued federal funding.

The initial ACA funding, to the tune of $230 million, expired at the end of 2015. But thanks in no small part to the AAFP's longstanding advocacy efforts, including a final push in the waning days of 2014, Congress extended funding for the program for an additional two years as part of the Medicare Access and CHIP Authorization Act enacted in April -- the same legislation that sounded the death knell of the Medicare sustainable growth rate and ushered in a new era of value-based physician payment.

The second study,(www.stfm.org) published in Family Medicine, revealed that graduates of medical residencies are highly likely to continue practicing in the location where they completed their residency training. One of the study's key findings, in fact, was that 46 percent of family medicine residency graduates wound up practicing within 50 miles of their training location, and 55 percent were working within 100 miles of their residency.

"To get primary care physicians in practices in areas of greatest need, you either have to create new residences or expand the residences in those areas," observed study co-author Ernest Blake Fagan, M.D.

It's a conclusion further buoyed by the results of more recent Graham Center research, which revealed that a higher percentage of residents who trained in THCs are choosing to work in areas of greatest need compared with their peers from traditional residencies.

Researchers from the Health Resources and Services Administration also weighed in on physician pipeline issues in an article published in the May issue of Health Affairs, finding -- among other things -- that medical students who train in public institutions are more likely to pursue primary care careers. The authors also concluded that physicians trained in rural areas tend to practice in rural areas.

Still, a basic question remains: Just how many primary care physicians will be needed in the coming years to care for a burgeoning population of insured patients?

Players Agree on Shortage Projections

Again, researchers from the Robert Graham Center stepped up, joining with colleagues from the Virginia Commonwealth University in Richmond and the University of Virginia in Charlottesville to execute an in-depth analysis(www.annfammed.org) designed to answer three key 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?

Their findings, published in the March/April issue of the Annals of Family Medicine, indicated that with demographic changes and expansion of health care insurance coverage, an additional 44,340 primary care physicians would be required by 2035 to answer the nation's health care needs.

[Group of medical students sitting at desk]

"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. To bridge the gap, they noted, an additional 1,700 primary care residency positions would be needed by 2035, a 21 percent increase from current production.

Notably, a study commissioned at about the same time by the Association of American Medical Colleges (AAMC) reached much the same conclusion. According to The Complexities of Physician Supply and Demand: Projections from 2013 to 2025,(www.aamc.org) the nation faces an estimated shortfall of between 46,000 and 90,000 physicians overall in just the next 10 years, including 12,500 to 31,100 primary care physicians.

"The doctor shortage is real -- it's significant -- and it's particularly serious for the kind of medical care that our aging population is going to need," AAMC President and CEO Darrell Kirch, M.D., said in an accompanying news release.(www.aamc.org)

That report fed into the development of a five-year AAMC road map for aligning the U.S. GME system with the nation's current and future health care needs. The plan(www.aamc.org) laid out three broad strategic areas -- investing in future physicians; optimizing the environment for learning, care and discovery; and preparing the physician and physician scientist for the 21st century.

Not surprisingly, the AAMC document enumerated many of the same concerns raised in the AAFP's own groundbreaking 2014 reform proposal,(7 page PDF) which addressed the serious lack of transparency and social accountability in the nation's GME system and offered a clear and sustainable path forward.

"In its road map for optimizing GME, the AAMC has developed a set of priorities and goals that aim to increase accountability in GME and align the health care workforce with the kinds of physicians our patients need in their cities, towns and communities," AAFP Senior Vice President for Education Clif Knight, M.D., commented at the time.

"We look forward to opportunities to synergize our efforts with the AAMC to achieve our shared ideals."

Research Illuminates Residents' Views

Another AAMC report published in early 2015 was designed to tease out specifics about today's medical residents. The association's 2015 Report on Residents(www.aamc.org) painted an intricate picture of residency applicants and residents, including details about residents' career choices and practice locations after they complete their training.

And in August, a Medscape report examined residents' satisfaction with their career choices. In a survey fielded from May 14 to June 22, researchers asked U.S. residents a wide range of questions about salaries, debt load, work environment, and the quality and relevance of training provided in their residency programs. Among key findings were

  • some 62 percent of respondents said they were paid a fair wage,
  • about 63 percent of residents surveyed said relationships with patients were the most rewarding part of their job, and
  • 84 percent overall were satisfied with their career choice.

Notably, research published in June examined family medicine residencies' efforts to keep pace with a health care system increasingly focused on providing patient-centered care, teasing out a handful of leadership actions needed to achieve successful program redesign.

Specifically, the authors challenged residency directors and faculty to learn how to

  • manage change,
  • develop financial acumen,
  • adapt best-evidence educational strategies to their local environments,
  • create and sustain a vision to engage stakeholders, and
  • demonstrate courage and resilience.

National Conference Builds Leadership Skills

The National Conference of Family Medicine Residents and Medical Students is always an educational, networking and inspirational high point of the year, and 2015 was no different. In fact, it once again set attendance records, netting a total of 4,195 attendees, including 1,225 medical students and 1,120 family medicine residents.

Last year brought a new twist to that attendance total.

The AAFP Foundation has long offered scholarships to pay for students and residents to attend National Conference. But last year, in addition to its usual complement of 220 Family Medicine Leads scholarships,(www.aafpfoundation.org) 30 additional awards were allocated for the nascent Family Medicine Leads Emerging Leader Institute program, which aims to expand the leadership pipeline for family medicine and ensure the specialty's future.

The awards paid for the scholars to attend National Conference, where they were placed into one of three tracks: Policy and Public Health Leadership, Personal and Practice Leadership, and Philanthropic and Mission-driven Leadership. Participants in the program were assigned a mentor, and each will complete a project in their chosen track.

In addition to electing new leaders to serve their respective constituencies in the coming year, residents and students at the 2015 conference took full advantage of opportunities to air their views on issues important to family medicine.

Among residents, expanding funding for THCs and patient care issues took top billing, with the National Congress of Family Medicine Residents adopting resolutions on topics as varied as mandatory drug testing for pregnant women, nutrition education in residency and climate change.

For its part, the National Congress of Student Members focused on such disparate issues as educational debt and loan repayment, drug pricing transparency, and FDA approval of novel antibiotic and antifungal agents.

Both residents and students expressed concern about professional burnout, and both constituencies called for policies to increase access to naloxone for patients who use opioids.

During a panel discussion at the 2015 AAFP National Conference of Family Medicine Residents and Medical Students, moderator Lauren Hughes, M.D., M.P.H., M.Sc., (far left) discusses the Health is Primary campaign. Panel speakers were (from left) solo practitioner Karen Smith, M.D.; patient advocate Manisha Sharma, M.D.; and home care expert Thomas Cornwell, M.D.

Last year's National Conference, however, may best be remembered for a Health is Primary session on different career opportunities and practice models that energized students and residents alike. The Health is Primary campaign(www.healthisprimary.org) is a product of Family Medicine for America's Health,(fmahealth.org) which is a partnership of the AAFP and seven other family medicine organizations.

Panelists discussed the fine points of solo practice and home-based care, as well as patient advocacy, and fielded numerous questions from students and residents eager to learn more about all the specialty has to offer.

Educational Innovations Show Promise

AAFP News covered a number of novel concepts in education in 2015, highlighting, for example, the Family Medicine Accelerated Track program at the Texas Tech University Health Sciences Center School of Medicine. The three-year curriculum allows a handful of students to begin their residency one year sooner and includes a scholarship for at least one year of medical school.

In addition, the Academy hosted its inaugural CME PerformanceNavigator Workshop. The workshop, which focused on three cardiometabolic conditions, gave participants the chance to complete both their Maintenance of Certification for Family Physicians Part II Self-Assessment and Lifelong Learning and Part IV Performance in Practice requirements during a comprehensive, live peer-to-peer session.

And finally, physician-learners who attended the 2015 AAFP Family Medicine Experience in Denver were treated to a first: CME delivered in a "flipped classroom" format. The flipped classroom method aims to optimize individual and group learning time by moving activities that have traditionally been considered "homework" into the live classroom and vice versa. Learners consume video lectures and complete their reading on their own time, saving classroom time for working as a group and engaging with the faculty and each other.

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