For the 32nd consecutive year, staff members from the AAFP's Medical Education Division have analyzed numbers from the latest National Resident Matching Program (NRMP), commonly referred to as the Match. In two companion articles published in Family Medicine in October, authors concluded that even though the number of family medicine residency programs and the number of U.S. medical students entering family medicine continue to tick upward, neither trend has been strong enough to increase the nation's primary care workforce to the overall 40 percent level recommended by graduate medical education policy experts.
"The AAFP annual report of the entry of U.S. students into family medicine residencies continues to highlight the suboptimal number of M.D. medical students entering family medicine," said authors of the article "Entry of U.S. Medical School Graduates Into Family Medicine Residencies: 2012-2013(www.stfm.org)."
- In an annual analysis of the most current data from the National Resident Matching Program, the AAFP noted small gains for family medicine but concluded the uptick was not enough to meet the country's need for primary care physicians.
- Authors noted that nearly three times as many graduates from public M.D.-granting medical schools entered family medicine as did students from private schools.
- Students who train in academic tertiary medical centers may not have a chance to see the full scope of health care family physicians provide in community-based settings.
In the accompanying article "Results of the 2013 National Resident Matching Program: Family Medicine,(www.stfm.org)" authors wrote, "Medical schools typically report all students entering pediatrics, internal medicine and family medicine as their (schools') primary care production, which substantially overestimates the number of physicians who will practice primary care because it does not accurately project future medical practice of these graduates."
In particular, the authors noted that more than 80 percent of internal medicine-categorical residents subspecialize. However, "Ninety percent of family medicine residents practice primary care five years after medical school graduation; thus, it is the number of family physicians a medical school produces that more accurately reflects its primary care production."
Corresponding author Wendy Biggs, M.D., is program director of the University of Kansas Family Medicine Residency in Kansas City. Until recently, Biggs served as deputy director of the AAFP's Medical Education Division.
In an interview with AAFP News Now, Biggs said, "When we do workforce studies in the future, we shouldn't necessarily look at what students said at their medical school graduation. Instead, we should focus on what they are doing in practice five years after they graduate from medical school.
"If you look at that, it's pretty clear that family physicians are the primary care workforce in this country."
By the Numbers
The Match analysis reiterates initial results from the 2013 Match. For example, family medicine residency programs experienced a fill rate of 96 percent in 2013, with 2,938 students choosing to enter the specialty of the 3,062 positions offered. In addition, 1,374 U.S. seniors matched to family medicine, 39 more than in in 2012, even though the percentage of U.S. seniors matching to family medicine dropped because more U.S. seniors overall participated in the 2013 Match.
But the discussion centering on new information and unique situations in 2013 make this year's dual reports stand out from previous iterations. For example, study authors noted that between 2008 and 2011, only 10 new Accreditation Council for Graduate Medical Education (ACGME)-accredited family medicine residencies were approved; however, that number nearly doubled between January 2012 and March 2013 when the ACGME gave the nod to 18 new residency programs.
Although a step forward, Biggs and her colleagues pointed out that the combined first-year classes of those programs would add, at most, 72 to 126 new family medicine residents to the training system. "This year's increases in the number of new family medicine residencies and the number of U.S. medical school graduates entering family medicine is encouraging," but far from what the country needs, wrote the authors.
They also noted that the number of D.O.-granting medical schools grew from 19 in 2002 to 37 in 2013. Furthermore, osteopathic medical school first-year enrollment nearly doubled between 2002 (2,968) and 2012 (5,627) and may reach 6,699 by 2017.
The report points out that a new "all-in" NRMP policy implemented in 2013 that prohibits residency programs participating in the Match from signing with early applicants likely affected the number of family medicine positions offered. "Residencies that previously may have signed (pre)agreements with eligible applicants … may have entered all their positions in the 2013 Match in order to fill all available positions," said the authors.
In the article on U.S. medical school graduates, the authors highlighted several factors that could influence the decisions U.S. medical school graduates make about their medical specialty. For example, 1,101 graduates from public M.D.-granting medical schools entered family medicine compared with just 380 from private schools. That's nearly a threefold difference in favor of public schools.
However, D.O.-granting medical schools -- which predominantly are private schools -- reported high numbers of students entering family medicine programs. Add to that the fact that D.O. students reported a higher debt average upon graduation ($205,674) than did M.D. students ($161,300).
"I still find it fascinating that when the question of who's going into family medicine is discussed, most people point to debt as a deterrent, but the D.O. medical school debt data don't support that argument," said Biggs.
In the report, authors noted that M.D.-granting medical schools "tend to assign their students to the hospitals that sponsor the graduate medical education programs, whereas D.O. medical education is distributed to more community-based settings."
In addition, the authors called regional variations "striking." Medical schools west of the Mississippi River reported more medical students entering family medicine than did schools in the eastern United States even though there are fewer medical schools located in the west.
According to the authors, students who had premedical experiences observing or shadowing in an urban hospital also were less likely to enter family medicine residencies. "Clinical rotations in the eastern U.S. academic health centers located in very large urban areas could have similar dissuading effects on medical students," wrote the authors.
But, Biggs asked, "In the academic tertiary medical centers, do students see robust family medicine?"
"They might if there is a department of family medicine. But for the most part, students in large academic health centers don't get to see how family physicians provide full-scope health care out in the community," said Biggs. "I think environment and culture play a substantial role in specialty selection."
As for next steps, Biggs said the AAFP could continue to encourage "community-based education," something that already is happening with medical schools that have regional (branch) campuses often located a good distance away from their urban-based teaching hospitals.
"In the end, our rapidly changing health care system will continue to drive the need for family physicians, however we get there," said Biggs. "That fact will not go away. The tide has already turned."
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