Reports Highlight Importance of Residency Training in Underserved Areas

February 18, 2015 04:34 pm Michael Laff

Two recently published studies highlight the need to provide continued support for primary care training in areas with the greatest shortage of primary care physicians.

[Residency faculty physician reviewing a patient X-ray with a medical resident]

A federally funded initiative, the Teaching Health Center Graduate Medical Education (THCGME) program, is attempting to make inroads in this area, but its efforts could be stymied without continued financial support.

THCGME residency sites must be community-based ambulatory care centers and are generally located in underserved areas, such as community health centers and rural health clinics. Funds flow directly to the program sites rather than to sponsoring hospitals, as is the case with most residency training programs.

In addition, accountability is built into the THCGME program, which requires institutions to report and reconcile annually the number of enrolled residents in primary care and dentistry specialties.

GME Funding Success Story

A study published by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, "Teaching Health Center GME Funding Instability Threatens Program Viability," tracks the growth of residency programs that have received funding since the program began in 2011.

Story highlights
  • Two recently published studies illustrate the tie between federal funding for primary care residency training in underserved areas and a greater likelihood that primary care physicians will remain to practice in such areas.
  • One study demonstrates how the federal Teaching Health Center Graduate Medical Education program is making headway in addressing the primary care shortage, but notes that those efforts could be stymied without continued financial support.
  • The second study reveals that graduates of medical residencies are highly likely to continue practicing in the location where they completed their residency training.

The program has increased the number of primary care physicians and dentists training in rural or underserved areas, and the number of family medicine residencies it supports has risen from nine in 2011 to 37 in 2015. The program, which was established by the Patient Protection and Affordable Care Act, has provided $230 million in funding, but that funding expires this year.

The study findings were based on a survey of the 60 THCGME programs that train more than 550 full-time residents in 24 states. If federal funding is not continued, recruitment of future residency candidates -- and even entire residency programs -- could be in jeopardy. Among the 80 percent of residency program leaders who responded to the survey, two-thirds said they are unlikely to be able to continue to support current residency positions in the future without ongoing funding.

The Health Resources and Services Administration has projected more than 700 residents will be funded during the 2015-2016 academic year, but that estimated capacity may be in jeopardy if recruitment falls off because of unstable funding.

Locating GME programs specifically for family medicine in rural or underserved areas has become particularly important in recent years because many hospital-based residencies are increasingly focused on other specialty training -- largely because surgical specialties and other subspecialties generate more revenue than primary care and pediatrics.

In contrast, primary care supports patient care services such as chronic disease management and preventive medicine that keeps patients out of hospitals.

"There's little incentive for hospitals to increase primary care training," said Kathleen Klink, M.D., Graham Center medical director and co-author of the report. "Specialty and subspecialty training and funding decisions in our current GME system are dependent upon the priorities of the hospital."

Practicing Near Residency

A second study demonstrated that medical residency graduates are highly likely to continue practicing near the location where they completed their residency training, an indication that training in medically underserved areas may lead to improved primary care distribution in these communities.

Published in the February issue of Family Medicine, "Family Medicine Graduate Proximity to Their Site of Training: Policy Options for Improving the Distribution of Primary Care Access(" used data obtained from the 2012 AMA Physician Masterfile and AAFP membership files to identify 64,972 physicians who graduated from medical school between 1970 and 2006. Researchers were able to determine where these graduates completed their residency training and track their current practice location.

Among the study's key findings was that 46 percent of family medicine residency graduates are practicing within 50 miles of their training location, and 55 percent are working within 100 miles of their residency.

In most states, the number of family medicine residents who remain in the state after completing residency was well over 50 percent and reached 70 percent in a handful of states. The rate has been rising in the past couple of decades.

Thus, addressing the primary care shortage -- particularly in the underserved areas that federal government initiatives are targeting -- will require an increase in the number of residency positions in those locations, researchers said.

"To get primary care physicians in practices in areas of greatest need, you either have to create new residences or expand the residences in those areas," said Ernest Blake Fagan, M.D., one of the authors.

Expecting residency graduates to move cross-country to fill a shortage area need is unlikely to achieve success, he added.

"If you want a physician to work for 35 years in a poor or underserved area, you have to train him in those areas," Fagan said. "If a resident is trained in the suburbs of Chicago, San Francisco or New York, asking them to move to western North Carolina is not going to happen," Fagan said.

Two states with the highest retention rates, Texas and California, showed expected results because of their overall size and greater availability of positions. Louisiana and Mississippi also reported very high retention rates, which Fagan found surprising.

Northeastern states had lower retention rates, but that could be a product of smaller state size and greater regional mobility, said Fagan. Someone could practice in Washington, D.C., or Rhode Island, for example, and still be within 50 miles from his or her residency despite being in a different state.

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