Researchers Call for More Resident Training in Safety-Net Settings

New Physicians Seek Similar Settings, Care for Underserved

November 19, 2013 03:45 pm Sheri Porter

Residents who train in safety-net settings are more likely to return to practice in a similar setting, according to new research conducted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care and published in an early release of the December issue of Academic Medicine(

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Corresponding author Robert Phillips, M.D., M.S.P.H., vice president of research and policy for the American Board of Family Medicine, told AAFP News Now that the release of the study findings was well timed in terms of the country's rapidly expanding health care market. "There is a substantial shortage of primary care physicians, particularly in rural and underserved communities, and particularly in areas where many people are currently uninsured but will have access to insurance in 2014," said Phillips, alluding to the ongoing implementation of the Patient Protection and Affordable Care Act.

"Our finding that training young physicians in these settings makes them much more likely to return to work there suggests that training programs and funders should make these settings a priority for residency training expansion."

Phillips added that because family physicians make up much of the primary care workforce in rural and underserved settings, "Training in those settings could become a focus for family medicine training and teaching."

Story highlights
  • The nation's shortage of primary care physicians likely will worsen with an influx of new patients drawn into the health care market by the Patient Protection and Affordable Care Act.
  • Nearly one in 10 patients lives in an underserved area and is treated at a federally qualified health center, rural health clinic or critical access hospital.
  • Residents who train in those settings -- as do many family physicians -- are more likely to return to practice in the same type of setting.

Research High Points

Phillips and his colleagues focused their research on residency training in federally qualified health centers (FQHCs), rural health clinics (RHCs) and critical access hospital (CAHs) that together provide care to more than one of every 10 Americans.

"Currently, more than 14,000 FQHCs (federally funded), RHCs and CAHs exist in some of the most underserved and rural locations in the country, and many of these safety-net settings provide the only access to care in the area," wrote the researchers.

Study authors identified where residents trained and later practiced by looking at Medicare Part B claims filed in residents' names by a FQHC, RHC or CAH from 2001-2005 and in 2009. The authors identified 662 residents with claims from an RHC, 975 from a FQHC and 1,793 from a CAH.

The percentage of physicians practicing in a safety-net setting in 2009 after training in a similar setting from 2001-2005 was 38.1 percent (RHCs), 31.2 percent (FQHCs) and 52.6 (CAHs).

Even though theirs wasn't the first research on the topic, the team didn't expect such dramatic results. "The association was surprisingly potent," said Phillips. "About one-third to one-half of young physicians who train in one of these underserved settings -- rural health clinics, federally qualified health centers and critical access hospitals -- will return to work in one of those settings after they complete training. This is 10-20 times higher than usual."

Researchers said that although they did not compare residents in the study with those who did not train in safety-net settings, "We do know that just 2 percent of all graduating M.D. residents go on to practice in an FQHC or RHC."

Recommendations Moving Forward

To prepare for the anticipated surge in health care demand fueled by the Affordable Care Act, the authors made several recommendations that could spur an increase in training of residents in safety-net settings and ultimately put more primary care physicians in underserved areas.

They suggested that medical education policymakers

  • expand and modify the teaching health center (THC) graduate medical education (GME) program that was created to establish new residency programs in FQHCs and RHCs;
  • redistribute unfilled GME positions but with clearer guidance than was done by Congress when it redistributed 3,000 position in 2005;
  • increase current GME funding with the caveat that new funding be used to train residents in RHCs, CAHs and FQHCs; and
  • remove indirect medical education payments that go beyond training expenses, and use that money to fund a new performance-based GME program.

"We recommend reauthorizing and expanding the THC-GME program, increasing the use of cost-based GME reimbursement in CAHs, or expanding training at safety-net sites as a condition for receiving additional GME funding," concluded the authors.

In addition, Phillips urged family physicians to support the AAFP in advocating for changes in GME funding that support family medicine training in rural and underserved areas "as recommended by the Institute of Medicine in 1989 and by the U.S. Council on Graduate Medical Education at least five times since."

"At a time when less than one in five trainees is choosing primary care, less than one in 10 is interested in working in primary care, and less than one in 20 goes to work in a rural area, we are identifying important strategies for GME funding that could improve the effectiveness and accountability of our teaching hospitals," said Phillips, pointing out that teaching hospitals receive $13 billion each year to train physicians.

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