“Family physicians are committed to continuing, comprehensive, compassionate, and personal care for their patients. They are concerned with the care of people of all ages, and understand that health and disease involve the mind, body, and spirit and depend in part on the context of patients’ lives as members of their family and community.”
--The Future of Family Medicine Report, 2004
The information in this report is based on data from the National Resident Matching Program (NRMP) Advanced Data Tables for 2009. The information provided includes the number of applicants to graduate medical programs for the 2008-09 academic year, specialty choice, and trends in specialty selection. This information will be useful to advocates of family medicine—including family medicine departments and residency programs—as well as legislators who are interested in trends predicting the primary care workforce of the future.
This report is prepared by the American Academy of Family Physicians Division of Medical Education.
2009 Match Summary and Analysis
I. 2009 Family Medicine Match Results and Comparison to Recent Trends (See Table 1)
Preliminary information available from the 2009 National Resident Matching Program (NRMP) indicates that for family medicine residency programs 2,329 positions filled out of 2,555 positions offered (91.2%). This represents a decrease in the number of positions offered and filled but an increase in the percentage of family medicine residency positions filled through the NRMP over 2008. [Included in this category are family medicine-psychiatry, family medicine-emergency medicine, and family medicine-internal medicine programs.] Ninety nine fewer family medicine positions (3.9%) were offered in 2009 compared with 2008. Seventy five fewer positions (3.2%) were filled in 2009 compared with 2008 (2,329/91.2% vs. 2,404/90.6%)
Eighty nine fewer U.S. seniors (1,083 vs. 1,172) chose family medicine in 2009 compared with 2008. Slightly more U.S. seniors participated in NRMP in 2009 compared with 2008 (15,638 vs. 15,242), with a resulting decrease (7.4%) in the percentage of U.S. seniors who chose family medicine. Although 2008 marked the first time in over a decade that more U.S. seniors participating and matching through the NRMP matched into family medicine compared with the preceding year, this year there were fewer US seniors who matched into family medicine than 2007.
Eighty nine fewer U.S. seniors (1,083 vs. 1,172) chose family medicine in 2009 compared with 2008. Slightly more U.S. seniors participated in NRMP in 2009 compared with 2008 (15,638 vs. 15,242), with a resulting decrease (7.4%) in the percentage of U.S. seniors who chose family medicine. Although 2008 marked the first time in over a decade that more U.S. seniors participating and matching through the NRMP matched into family medicine compared with the preceding year, this year there were fewer US seniors who matched into family medicine than 2007.
II. Comparison with Other Primary Care Specialties—Family Medicine, Internal Medicine, and Pediatrics (See Table 2-9, 11)
Sixty four more positions (1.3%) were offered in 2009 compared with 2008 in internal medicine-categorical (4,922 vs.4,858). Twenty one fewer positions (1.1%) were offered in internal medicine-preliminary (1,880 vs. 1,901). Seventeen fewer positions (6.9%) were offered in 2009 in internal medicine-primary care (247 vs. 264) and eight fewer positions (2.3%) were offered in internal medicine-pediatrics (354 vs. 362). Eighteen more positions (0.2%) were offered in internal medicine-all types (7,468 vs. 7,450). Ten more positions (0.4%) were offered in pediatrics-categorical (2,392 vs. 2,382), resulting in an increase of thirteen more positions (0.5%) offered in pediatrics-all types (2,509 vs. 2,496).
One hundred and two more positions (2.1%) were filled in internal medicine-categorical in 2009 compared with 2008 (4,853 vs. 4,751), with twenty-eight fewer positions (1.0%) filled with U.S. seniors (2,632 vs. 2,660). Thirty-one more positions (0.04%) were filled in pediatrics-categorical in 2009 (2,326 vs. 2,295) and seventy-two more positions (4.3%) were filled with U.S. seniors (1,682 vs. 1,610).
Three of the categories of pediatrics and internal medicine are considered primary care. Two of those three filled with fewer U.S. seniors in 2009 when compared with 2008. Eighteen fewer positions (7.6%) were filled in internal medicine-primary compared with 2008 (236 vs. 254), with eleven fewer position (7.1%) being filled with a US senior (155 vs. 166). One more position was filled (1.3%) in pediatrics-primary in 2009 compared with 2008 (79 vs. 78), and three more (6.5%) U.S. seniors filled the available positions (46 vs. 43). Thirteen more positions (3.7%) were filled in internal medicine-pediatrics compared with 2008 (339 vs. 326), and seven fewer (2.9%) U.S. seniors chose internal medicine-pediatrics compared with the preceding year (241 vs. 248). For these three primary care specialties, nine fewer positions (1.4%) were filled in 2009 compared with 2008 (669 vs. 678), and fifteen fewer positions (3.4%) were filled with U.S. seniors (442 vs. 457).
In the 2009 NRMP, the primary care programs experienced some change in fill rate percentage compared with 2008. The fill rate for family medicine increased 0.6%, internal medicine-primary decreased 0.7%, pediatrics-primary stayed the same (100% vs. 100%) and internal medicine-pediatrics increased 5.7%.
One hundred and two more positions (2.1%) were filled in internal medicine-categorical in 2009 compared with 2008 (4,853 vs. 4,751), with twenty-eight fewer positions (1.0%) filled with U.S. seniors (2,632 vs. 2,660). Thirty-one more positions (0.04%) were filled in pediatrics-categorical in 2009 (2,326 vs. 2,295) and seventy-two more positions (4.3%) were filled with U.S. seniors (1,682 vs. 1,610).
Three of the categories of pediatrics and internal medicine are considered primary care. Two of those three filled with fewer U.S. seniors in 2009 when compared with 2008. Eighteen fewer positions (7.6%) were filled in internal medicine-primary compared with 2008 (236 vs. 254), with eleven fewer position (7.1%) being filled with a US senior (155 vs. 166). One more position was filled (1.3%) in pediatrics-primary in 2009 compared with 2008 (79 vs. 78), and three more (6.5%) U.S. seniors filled the available positions (46 vs. 43). Thirteen more positions (3.7%) were filled in internal medicine-pediatrics compared with 2008 (339 vs. 326), and seven fewer (2.9%) U.S. seniors chose internal medicine-pediatrics compared with the preceding year (241 vs. 248). For these three primary care specialties, nine fewer positions (1.4%) were filled in 2009 compared with 2008 (669 vs. 678), and fifteen fewer positions (3.4%) were filled with U.S. seniors (442 vs. 457).
In the 2009 NRMP, the primary care programs experienced some change in fill rate percentage compared with 2008. The fill rate for family medicine increased 0.6%, internal medicine-primary decreased 0.7%, pediatrics-primary stayed the same (100% vs. 100%) and internal medicine-pediatrics increased 5.7%.
Twenty-one fewer preliminary positions in internal medicine were offered in 2009 compared with 2008 (1,880 vs. 1,901), but thirteen more positions were filled in 2009 compared with 2008 (1,791 vs. 1,774). Thirty-three more U.S. seniors (2.2%) matched into internal medicine-preliminary (1,504 vs. 1,471). These students have chosen an internal medicine-preliminary year specifically as preparation for further training in another specialty.
IV. Contrast with Other Specialty Trends
Anesthesiology experienced an increase in positions filled (6.1%) in 2009 with forty-four more students choosing the specialty (723 vs. 679). Despite a small dip in 2004, the number of positions filled in anesthesiology has more than quintupled since 1996. The number of positions offered increased 9.1% (733 vs. 666) and eight-eight more U.S. seniors (14.4%) matched in anesthesiology in 2009 (612 vs. 524).
The number of positions filled in diagnostic radiology decreased with six fewer positions (4.0%) filled in 2009 compared with 2008 (151 vs. 157). Three fewer U.S. seniors (0.8%) matched in diagnostic radiology compared with 2008 (132 vs. 135). The 2008 NRMP match marked the highest number of positions filled since 1996.
Emergency medicine offered seventy-three more positions in 2009 compared with 2008 (1,472 vs. 1,399), representing an increase of 5.0%. Eighty-nine more positions (6.1%) were filled in emergency medicine compared with 2008 (1,459 vs. 1,370), with sixty-three more U.S. seniors (5.5%) selecting emergency medicine (1,146 vs. 1,083).
Obstetrics-gynecology offered twenty-two more (1.9%) positions (1,185 vs. 1,163) and filled twenty-eight more positions (2.4%) compared with 2008 (1,179 vs. 1,151). Eighty-eight more U.S. seniors (10.0%) chose obstetrics-gynecology in 2009 (879 vs. 838).
The number of positions filled in diagnostic radiology decreased with six fewer positions (4.0%) filled in 2009 compared with 2008 (151 vs. 157). Three fewer U.S. seniors (0.8%) matched in diagnostic radiology compared with 2008 (132 vs. 135). The 2008 NRMP match marked the highest number of positions filled since 1996.
Emergency medicine offered seventy-three more positions in 2009 compared with 2008 (1,472 vs. 1,399), representing an increase of 5.0%. Eighty-nine more positions (6.1%) were filled in emergency medicine compared with 2008 (1,459 vs. 1,370), with sixty-three more U.S. seniors (5.5%) selecting emergency medicine (1,146 vs. 1,083).
Obstetrics-gynecology offered twenty-two more (1.9%) positions (1,185 vs. 1,163) and filled twenty-eight more positions (2.4%) compared with 2008 (1,179 vs. 1,151). Eighty-eight more U.S. seniors (10.0%) chose obstetrics-gynecology in 2009 (879 vs. 838).
V. Discussion
The AAFP continues to track and report on the annual NRMP results as these have significant implications for physician workforce, healthcare reform, healthcare access, and healthcare policy. In 2006, the AAFP adopted its workforce policy to identify the number of family physicians that should be produced by 2020 in order to create and prepare the physician workforce best equipped to provide the type of care that the nation states that it wants and needs.1,2 The results of the 2009 NRMP Match show that medical students continue to demonstrate a preference for non-primary care specialties as evidenced by the decrease in U.S. seniors choosing family medicine, internal medicine-primary, or internal medicine-pediatrics.
The continued trend away from primary care into subspecialties is worrisome as a shortage of primary care physicians will negatively impact the nation. Dr. Barbara Starfield, a leading researcher in health policy and the benefits of a primary care based healthcare system reported, “(T)hree lines of evidence represent a progressively stronger demonstration that primary care improves health by showing, first, that health is better in areas with more primary care physicians; second, that people who receive care from primary care physicians are healthier; and, third, that the characteristics of primary care are associated with better health.”3 In 2008, the Government Accountability Office (GAO) reviewed multiple workforce studies by various organizations and specifically pointed to the need for gathering more data that projects the need for primary care physicians.4 The GAO report goes on to recognize the value of primary care within the health system by stating,
“Ample research in recent years concludes that the nation’s over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care—all hallmarks of primary care medicine—can achieve better health outcomes and cost savings.”
Despite the clear and overwhelming evidence that speaks to the value of a primary care based healthcare system, the 2009 NRMP Match results indicate the primary care physician shortage is only going to worsen as fewer family medicine residency training slots are offered and fewer US seniors choose to become family physicians. Similarly, a recent study of students choosing internal medicine found that only 2% plan to practice general internal medicine, further shrinking the pool of primary care physicians.5 Even those students who enter medical school intent upon pursuing a career in primary care may be deterred during their training. One study found that only 30% of students initially interested in primary care maintained their interest throughout medical school, compared with 68% of those who were interested in non-primary care careers.6 The impact of lifestyle factors and income on specialty choice are complex and difficult to isolate.7 However, a recently published analysis of the relationship between physician starting salaries and specialty choice found that more US seniors are choosing the more highly compensated specialties.8 Though this information is not surprising, what has become more of an issue is the dramatic increase in the income gap between primary care and other specialties.9 Until this issue is appropriately addressed, the AAFP believes that many excellent physicians will be deterred from a rewarding career in family medicine where patients and communities receive effective, equitable, and efficient patient-centered care.
The continued trend away from primary care into subspecialties is worrisome as a shortage of primary care physicians will negatively impact the nation. Dr. Barbara Starfield, a leading researcher in health policy and the benefits of a primary care based healthcare system reported, “(T)hree lines of evidence represent a progressively stronger demonstration that primary care improves health by showing, first, that health is better in areas with more primary care physicians; second, that people who receive care from primary care physicians are healthier; and, third, that the characteristics of primary care are associated with better health.”3 In 2008, the Government Accountability Office (GAO) reviewed multiple workforce studies by various organizations and specifically pointed to the need for gathering more data that projects the need for primary care physicians.4 The GAO report goes on to recognize the value of primary care within the health system by stating,
“Ample research in recent years concludes that the nation’s over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care—all hallmarks of primary care medicine—can achieve better health outcomes and cost savings.”
Despite the clear and overwhelming evidence that speaks to the value of a primary care based healthcare system, the 2009 NRMP Match results indicate the primary care physician shortage is only going to worsen as fewer family medicine residency training slots are offered and fewer US seniors choose to become family physicians. Similarly, a recent study of students choosing internal medicine found that only 2% plan to practice general internal medicine, further shrinking the pool of primary care physicians.5 Even those students who enter medical school intent upon pursuing a career in primary care may be deterred during their training. One study found that only 30% of students initially interested in primary care maintained their interest throughout medical school, compared with 68% of those who were interested in non-primary care careers.6 The impact of lifestyle factors and income on specialty choice are complex and difficult to isolate.7 However, a recently published analysis of the relationship between physician starting salaries and specialty choice found that more US seniors are choosing the more highly compensated specialties.8 Though this information is not surprising, what has become more of an issue is the dramatic increase in the income gap between primary care and other specialties.9 Until this issue is appropriately addressed, the AAFP believes that many excellent physicians will be deterred from a rewarding career in family medicine where patients and communities receive effective, equitable, and efficient patient-centered care.
VI. Outlook for Family Medicine
This year, 2,329 individuals chose to become family physicians. These are individuals who have chosen to provide care to children and adults, women and men, throughout the continuum of the life cycle. They will provide care in rural and urban settings. These future family physicians will provide a personal medical home for their patients, reflecting one-quarter of the office visits to all physicians in the U.S.10
In 2006, the American Academy of Family Physicians began a national demonstration project—TransforMED—to implement the recommendations of the Future of Family Medicine. The goal of the project is to demonstrate how the family medicine model of care can concurrently improve patient access, healthcare outcomes, and physician satisfaction.11 It is necessary to demonstrate to medical students that family medicine can provide great career satisfaction and financial stability.
The P4 Initiative (“Preparing the Personal Physician for Practice”) is a six-year project launched in 2006 by the American Board of Family Medicine and the Association of Family Medicine Residency Directors in conjunction with TransforMED. Three years into the project, the research team has found that not only are the participating programs finding significant benefits from innovation, but they have stimulated innovation in family medicine residencies across the nation. The P4 steering committee and participants are already disseminating their learnings from the project at national meetings and in peer reviewed publications. These findings will continue to guide the evolution of family medicine residency education and will change the way family physicians are trained to practice medicine for the future.
Initial outcomes from these projects reaffirm discussion among the other family medicine organizations regarding the need to educate the public, business leaders, and decision-makers about the concept of the Patient Centered Medical Home (PCMH). In February 2007, the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American Osteopathic Association (AOA) and the American College of Physicians (ACP) developed a set of joint principles that describe a new level of primary care called the Patient-Centered Medical Home.12 A patient-centered medical home is an approach to providing comprehensive primary care for people of all ages and medical conditions. It is a way for a physician-led medical practice, chosen by the patient, to integrate health care services for that patient who confronts a complex and confusing health care system. Undoubtedly, implementation of a broad-based PCMH initiative will be dependent upon an adequate supply of family physicians.
The Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the North American Primary Care Group, and the AAFP Foundation join the AAFP in continuing efforts to communicate the message of family medicine to medical students. The family medicine organizations also continue student interest efforts in four defined evidence-based areas of focus: 1) identification and preparation of inspiring and competent family physician mentors and role models, 2) focus on medical school admission characteristics of students likely to choose family medicine, which includes identifying and inspiring the pipeline for future medical students, 3) effective communication about the image of family medicine to medical students and to the broader community, and 4) effective education of medical students about the family medicine model of care.
A strong family medicine workforce is dependent on at least 3 factors: recruitment of students to the specialty, comprehensive training of family medicine residents to provide patient-centered care within the framework of a medical home, and support for practicing family doctors who provide the kind of care that the nation says it wants and needs. The challenge for the future is to clearly communicate with policymakers, educators, medical students, and the public the importance of a well-trained, adequately equipped, and equitably distributed family physician workforce for America.
In 2006, the American Academy of Family Physicians began a national demonstration project—TransforMED—to implement the recommendations of the Future of Family Medicine. The goal of the project is to demonstrate how the family medicine model of care can concurrently improve patient access, healthcare outcomes, and physician satisfaction.11 It is necessary to demonstrate to medical students that family medicine can provide great career satisfaction and financial stability.
The P4 Initiative (“Preparing the Personal Physician for Practice”) is a six-year project launched in 2006 by the American Board of Family Medicine and the Association of Family Medicine Residency Directors in conjunction with TransforMED. Three years into the project, the research team has found that not only are the participating programs finding significant benefits from innovation, but they have stimulated innovation in family medicine residencies across the nation. The P4 steering committee and participants are already disseminating their learnings from the project at national meetings and in peer reviewed publications. These findings will continue to guide the evolution of family medicine residency education and will change the way family physicians are trained to practice medicine for the future.
Initial outcomes from these projects reaffirm discussion among the other family medicine organizations regarding the need to educate the public, business leaders, and decision-makers about the concept of the Patient Centered Medical Home (PCMH). In February 2007, the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American Osteopathic Association (AOA) and the American College of Physicians (ACP) developed a set of joint principles that describe a new level of primary care called the Patient-Centered Medical Home.12 A patient-centered medical home is an approach to providing comprehensive primary care for people of all ages and medical conditions. It is a way for a physician-led medical practice, chosen by the patient, to integrate health care services for that patient who confronts a complex and confusing health care system. Undoubtedly, implementation of a broad-based PCMH initiative will be dependent upon an adequate supply of family physicians.
The Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the North American Primary Care Group, and the AAFP Foundation join the AAFP in continuing efforts to communicate the message of family medicine to medical students. The family medicine organizations also continue student interest efforts in four defined evidence-based areas of focus: 1) identification and preparation of inspiring and competent family physician mentors and role models, 2) focus on medical school admission characteristics of students likely to choose family medicine, which includes identifying and inspiring the pipeline for future medical students, 3) effective communication about the image of family medicine to medical students and to the broader community, and 4) effective education of medical students about the family medicine model of care.
A strong family medicine workforce is dependent on at least 3 factors: recruitment of students to the specialty, comprehensive training of family medicine residents to provide patient-centered care within the framework of a medical home, and support for practicing family doctors who provide the kind of care that the nation says it wants and needs. The challenge for the future is to clearly communicate with policymakers, educators, medical students, and the public the importance of a well-trained, adequately equipped, and equitably distributed family physician workforce for America.
- Family Physician Workforce Reform. Recommendations of the American Academy of Family Physicians. Accessed March 12, 2007 from the world wide web at http://www.aafp.org/online/en/home/policy/policies/w/workforce.html.
- Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: A collaborative project of the family medicine community. Ann Fam Med. 2004 Mar-April; 2 Suppl 1:53-32.
- Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health. The Milbank Quarterly, Vol. 83, No. 3, 2005 (pp. 457–502).
- “Primary Care Professionals, Recent Supply Trends, Projections, and Valuation of Services.” United States Government Accountability Office; Testimony Before the Committee on Health, Education, Labor, and Pensions, U.S. Senate. February 12, 2008 (http://www.gao.gov/new.items/d08472t.pdf, accessed March 17, 2008.)
- Hauer KE, Durning SJ, et al. Factors Associated With Medical Students' Career Choices Regarding Internal Medicine. JAMA. 2008;300(10):1154-1164.
- Compton MT, Frank E, Elon L, Carerra J. Changes in U.S. Medical Students Specialty Interests over the Course of Medical School. J Gen Intern Med 23(7):1095-100.
- Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student and Resident Choices? The Robert Graham Center: Policy Studies in Family Medicine and Primary Care. March 2, 2009.
- Ebell MH. Future salary and US residency fill rate revisited. JAMA 2008;300(10):1131-1132.
- Bodenheimer T, Berenson RA, Rudolf P. The Primary Care–Specialty Income Gap: Why It Matters. Ann Intern Med. 2007;146:301-306.
- Cherry DK. National Ambulatory Medical Care Survey: 2002 Summary. Advance Data from Vital and Health Statistics; No. 346, Hyattsville, Maryland: National Center for Health Statistics. 2004.
- www.TransforMED.com
- Joint Principles of the Patient Centered Medical Home, AAFP, February 2007. http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File.dat/022107medicalhome.pdf, accessed March 17, 2008.
