Medical Education Community Makes Concerted Call for Changing the System

As the nation faced growing recognition of the expected shortage of primary care physicians in 2011, the medical education establishment responded with a concerted call for change.

The increased attention to the lack of family physicians and other primary care physicians needed to meet the nation's growing needs may have had an effect on medical students' choice of specialty. For the second year in a row, the number of medical students who chose to enter family medicine rose, according to the National Resident Matching Program. In fact, the fill rate for family medicine in 2011 was a record high of 94.4 percent, up 3 percent from 2010.

The increase suggests an upswing in interest in family medicine among U.S. medical school students, said (then) AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas. "This year's results mark the second consecutive year of increased interest in family medicine. Although several factors likely contribute to the increase, we believe an important element is recognition that primary care medicine is absolutely essential if we are to improve the quality of health care and help control its costs."

But even with a higher fill rate for family medicine, the medical education system still lags in preparing students to meet future demands for primary care physicians. In fact, a report from the Council on Graduate Medical Education, or COGME, released in early 2011 called for boosting the primary care physician workforce and narrowing the gap in incomes between primary care physicians and those in other specialties -- two changes that the Academy has been promoting for years.

The report to HHS and the U.S. Congress recommended that the percentage of primary care physicians increase from 32 percent to 40 percent of the total U.S. physician workforce and that these physicians' average incomes be increased to at least 70 percent of the median incomes of all other physicians.

Higher income is vital to boosting interest in primary care, said COGME. It recommended that medical schools develop accountable mission statements and reform their admissions processes to favor students who are more likely to go into primary care.

Many of the recommendations in the COGME report were echoed by the Josiah Macy Jr. Foundation in its "call to action" to change the U.S. GME system to make it more responsive to the needs of the American people. The call to action, which arose out of a conference convened by the Macy Foundation and the Association of Academic Health Centers, was applauded by the Academy and a number of other family medicine education groups.

According to a summary of the conference, reports recently issued by various medical education groups and federal government agencies project that the current supply of new physicians entering practice each year "is not adequate to avoid a significant shortage in the years ahead." In addition, said the summary, these and other reports indicate that the specialty mix of physicians entering practice "is not in keeping with the needs of the population."

Other organizations weighed in, as well. For example, at a July primary care forum hosted by the AAFP's Robert Graham Center, speakers pointed out that cross-training FPs and general surgeons could result in better care for patients in rural areas. According to former AAFP President and residency director Ted Epperly, M.D., of Boise, Idaho, rural areas often lack an adequate supply of primary care physicians and general surgeons. Often, FPs and general surgeons in these areas provide coverage for each other and collaborate to ensure rural patients get the health care they need.

Every U.S. medical school should have a rural training program for all of its medical students to enhance student knowledge and awareness of the health care issues facing rural America and what can done to resolve them collaboratively, said Epperly.

At a follow-up primary care forum on GME accountability sponsored by the American Board of Family Medicine and convened by the Graham Center in October, speakers pointed out that the United States annually spends $13 billion on GME, but the medical education system here still is "disjointed." According to George Thibault, M.D., president of the Macy Foundation, it is time for a much better and smoother set of transitions between medical schools and residencies.

Thibault referenced a couple of Macy Foundation reports, including one issued in September that called for a sweeping overhaul of content and format in GME.

The authors of that report noted that finding a new way of doing business in GME is imperative. "Physicians in training must understand the financial implication of their patient management decisions, and their training must include new and efficient models of care so that they will be prepared to practice cost-effective medicine and be responsible stewards of resources while providing high-quality patient care," said the report.

Family medicine also is likely to benefit from proposed revisions in the Medical College Admission Test, or MCAT, that call for testing behavioral and social sciences concepts that underlie students' capacity to learn about the human and social issues of medicine.

According the Association of American Medical Colleges, or AAMC, who issued the proposed revisions, the revamped recommendations also propose revising the current verbal section of the MCAT to test the way examinees reason through passages in ethics and philosophy, cross-cultural studies, population health, and other subjects, thus communicating the need for students to read broadly in preparation for their medical education.

"The new framework to the MCAT will clearly give admissions committees more information to help them identify those applicants whose personal characteristics forecast a greater likelihood of seeking careers in family medicine," said Perry Pugno, M.D., M.P.H., AAFP vice president for education.

With the increased focus on boosting the nation's pipeline of primary care physicians, medical schools appear to be following the trend. In fact, a study from the AAMC Center for Workforce Studies found that U.S. medical schools are on track to meet a 30 percent increase in first-year medical school enrollments called for in 2006.

The report found that first-year medical school enrollment has increased from 16,488 students in 2002 to 18,665 in 2010. And the news is particularly good for family medicine and other primary care physicians. Seventy-five percent of the medical schools questioned have current or future plans to institute programs or policies to encourage student interest in primary care, including new or expanded elective clinical rotations, refined admissions criteria, modified required clinical rotations, modified preclinical curriculum, expanded primary care faculty and/or resources, and new or expanded extracurricular opportunities.

However, for a time in 2011, it looked as though cuts to GME funding were going to result in losses rather than gains in GME for primary care physicians. A survey released by the Accreditation Council for Gradual Medical Education in November found that cuts in GME funding would severely damage the primary care physician pipeline.

"The fact is that any cuts to GME that go across the board are going to hurt primary care -- especially those of us who disproportionately take care of adults with chronic illnesses," said the AAFP's Pugno.

In fact, the ailing economy has already caused cutbacks in residency programs as states scramble to make up for budget deficits. Texas, for example, which had been working assiduously to beef up its primary care training programs, saw some of its gains evaporate in 2011 when legislators slashed millions from the Texas Higher Education Coordinating Board and a physician loan repayment program.

Family medicine residencies frequently are a favorite target during state cutbacks because they are based on providing cognitive services, not procedures, making it difficult for them to earn a profit in the prevailing fee-for-service payment structure. As a result, family medicine and other primary care residencies are seen by some lawmakers as cost centers and, thus, are a prime target for spending cuts.

"Across the country, we have been losing half a dozen (family medicine residency) programs a year for almost 10 years," said Pugno. "There are a total of 451 (family medicine) residency programs right now. The economic downturn has basically stopped the initiation of new programs and has made other ones more economically vulnerable."

As the AAFP rallied its members at the end of 2011 to oppose any cuts in Title VII training grants for primary care physicians, news came that the U.S. Congress had approved a final fiscal year 2012 appropriations bill that kept spending for these grants relatively level rather than imposing any large cuts.

As 2012 kicks off, however, the AAFP will continue to advocate for better funding for GME and primary care physician training programs, because, as 2011 showed, these physicians will be critical to the future of health care in the United States.