Residency Closures Can Affect Access to Care

Physician workforce analysts would do well to study residency program closures as they try to determine whether America faces a shortage or surplus of primary care physicians, say health policy analysts at the AAFP's Robert Graham Center in Washington.

That's because current workforce studies focus on medical school enrollment and fail to include the number or rate of residency program closures in their calculations. But those closures have a direct, immediate impact on local access to care and promise to exacerbate access problems in current shortage areas, according to data maps recently published by the Graham Center.

Currently, the Association of American Medical Colleges and Council on Graduate Medical Education call for a 30 percent increase in medical school admissions. But the Graham Center maps indicate increased enrollments alone may not resolve primary care health professional shortage areas, or HPSAs.

Decisions to close a residency program are made and implemented on a local level, often by the hospital sponsoring the residency, and are based on local financial and political considerations without regard to local or national primary care needs. Meanwhile, national workforce studies overlook the real-world effects of local decisions to close primary care residency programs, say Graham Center analysts.

The Graham Center maps "provide a window on what is lost" in a community's access to health care when a family medicine residency program closes, according to Andrew Bazemore, M.D., the center's assistant director. The maps visually demonstrate that most family medicine residency programs serve counties already listed as full or partial primary care HPSAs. When a family medicine residency program closes, access to health care in these areas may diminish further.

That consequence may receive little consideration when officials decide to close a family medicine residency program, however. Research (PDF file: 5 pages / 61 KB. More about PDFs.) in the November-December 2003 issue of Family Medicine found the most common reasons for closing a family medicine residency programs were financial or political considerations unique to the sponsoring hospital. Factors such as community access to health care or the secondary benefit of replenishing community-based primary care generally were not a part of a closure decision, the researchers reported. (See "Academy to Examine Impact of Residency Closures.")

"The impact of a single program closing is likely to go undetected in national workforce studies," said Bazemore. National workforce models "fail to capture regional impact," he added. "They're very blunt instruments. And recommendations (to close) that are based on politics and finances are made without the benefit of an impact assessment. These maps are a first step" to bringing the two sides of the workforce equation together.

Graham Center analysts identified and mapped the counties directly served by family medicine residency programs. They then calculated the number of graduates who stayed in residency programs' service areas, the number of graduates who opened practices in rural areas and the number of graduates practicing in primary care HPSAs. They found that, in most cases, a closed residency program had played a vital role in minimizing or preventing a primary care professions shortage.

Without studying the implications of program closures, physician workforce analysts risk implementing policies that could increase the number of closures, thereby worsening the physician distribution problems already plaguing the nation's HPSA counties, said Bazemore.

That reality, said Bazemore, may give legislators pause when they use national physician workforce studies to make state and federal budget and appropriations decisions. The Graham Center maps offer family medicine advocates a tool to use as they work with legislators, health policy-makers and academic health officials in plotting future medical education.

Although they are not a projection of physician distribution, the Graham Center maps "give an idea of the areas where family medicine residents have gone in the past and where they're likely to go in the future," said Bazemore. "If those residents are moving to points of threatened health care access, policy-makers should be concerned at the closure of a residency program that feeds those key communities."