New research published in Academic Medicine(journals.lww.com) strengthens concerns expressed by the AAFP and others that the U.S. medical education system does not produce enough primary care physicians to support America's health care needs and that a flawed funding mechanism fuels the problem.
The study, "Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions," found a serious shortfall in the percentage of newly minted physicians who have chosen to work in America's rural and underserved areas.
Researchers from the Washington-based Robert Graham Center for Policy Studies in Family Medicine and Primary Care and the George Washington University School of Public Health and Health Services analyzed data from nearly 9,000 physicians who completed residency between 2006 and 2008 to identify their medical specialty choice three to five years after residency completion.
The research also links to a GME Outcomes Mapper tool(www.graham-center.org) created by the Robert Graham Center that allows users to click on a map of all U.S. residency training institutions and see not only how many residents the facility trains but the proportion of those residents who enter primary care specialties or practice in underserved areas.
- New research shows that America's medical education system is not producing enough primary care physicians to meet the country's needs.
- Some of the nation's biggest and most prestigious medical education programs produce few, if any, primary care physicians.
- The institutions producing the most primary care physicians receive significantly less Medicare graduate medical education funding than those producing the fewest such physicians.
By the Numbers
Specifically, researchers found that 25.2 percent of physicians included in the study practiced primary care medicine, and 4.8 percent practiced in rural and other underserved areas.
Furthermore, of 759 academic health center institutions, the study revealed that
- 158 produced no primary care graduates,
- 198 produced no rural physicians,
- 479 produced no National Health Service Corps participants and
- 283 produced no physicians who practiced in clinics designated as federally qualified health centers or rural health clinics.
Research authors pointed to flaws in the GME funding mechanism that supports the training of the country's physician workforce. For example, they found that GME funding provided more support to subspecialty residency programs than to primary care programs.
Specifically, the authors found that among teaching hospitals, the top 20 primary care producers graduated 1,658 primary care physicians, or 41 percent of their total 4,044 graduates. Those programs received $292 million in total Medicare GME payments.
On the other hand, the bottom 20 primary care producers graduated 684 primary care physicians, or 6.4 percent of their total 10,937 graduates, and received $842 million in Medicare GME funding.
According to a June 12 press release about the study(www.graham-center.org), America's physician workforce is funded, in large part, by taxpayers' investment in GME funding provided through Medicare ($10 billion) and Medicaid ($3 billion). Those billions of dollars are used to compensate teaching health centers for the extra costs associated with training physicians.
In the release, study co-author Andrew Bazemore, M.D., M.P.H., director of the Robert Graham Center, said the study results highlight the challenges of producing the necessary physician workforce. "National calls for more primary care physicians, general surgeons, psychiatrists and providers in rural and urban underserved areas are thwarted by federal funding that continues to support training programs without requiring measurement of, much less accountability for, what they produce," he said.
Analyzing the Data
In an interview with AAFP News Now, corresponding author Candice Chen, M.D., M.P.H., pointed out that the Council on Graduate Medical Education set the U.S. primary care workforce bar at 40 percent of all physicians but that the current physician workforce was only about one-third primary care.
"When you weigh those numbers against what our workforce currently looks like and what we know we need, it is shocking," said Chen.
Ditto for the difference among programs in the number of primary care physicians they produce and the percentage of those physicians who practice in rural and other underserved areas. "It's very concerning that some of our larger programs -- some of our better-known programs -- aren't necessary meeting those needs," said Chen.
The challenge is in the way the current system pays for GME by essentially turning over those funds to hospitals, who in turn, address their own needs, said Chen.
"And that's why we get a workforce that looks like it should be staffing the hospitals of America and not the primary care practices of America," she said.
Chen, a senior research fellow at the National Institute for Minority Health and Health Disparities, and an assistant research professor at George Washington University, said taxpayers may not understand that their dollars support GME. "They don't realize that the distribution of residency positions between specialties defines the specialty distribution of our physician workforce," said Chen.
"I think it's fair to ask if we're getting what we really need and maximizing the public investment in our medical education system," she added.
According to Chen, the new research proves that it's possible to gather data on residency program outcomes and that doing so "means that we can start looking at how to build accountability into the system to get it aligned with the country's workforce needs."
As for family medicine residency programs, "Those programs are out there fighting the hard fight and, oftentimes, receiving less Medicare GME money per resident than some of the larger programs," said Chen. Further complicating matters is the fact that family medicine programs "often are the ones that are producing our primary care physicians and training the people who are going into underserved areas," she added.
"My hope is that this research will highlight some of those programs that don't often get a lot of attention and give them the ability to say, 'Hey, look at what we've been doing; we're really producing the physicians that American needs,'" said Chen.