Researchers Note Mismatch Between GME, U.S. Population Needs

Strong Subspecialty Growth Disproportionate to That of Primary Care

November 18, 2016 11:52 am Sheri Porter

Authors of an article published( in the November/December issue of Family Medicine take a hard look the growth rate of medical specialties from 1986 to 2016.

[Young male doctor holding clipboard]

The article, titled Results of the 2016 National Resident Matching Program: 1986-2016: A Comparison of Family Medicine, E-ROADS, and Other Select Specialties, represents the latest in an annual series of studies conducted by AAFP experts who examine how family medicine and other primary care specialties perform in the annual National Resident Matching Program (NRMP), also known as the Match.

However, the 2016 research represents a change from years past.

This year, authors expanded their Match analysis to "capture historical changes in family medicine, other primary care and select nonprimary care specialties, including those that may have higher levels of average income and be perceived as having more controllable lifestyles."

Authors analyzed Match data from that 30-year time span and compared the number of positions offered and filled in primary care specialties (defined as family medicine, general internal medicine, general pediatrics and medicine-pediatrics), E-ROAD subspecialties -- emergency medicine, diagnostic radiology, ophthalmology, anesthesiology and dermatology -- and other select specialties.

Story Highlights
  • AAFP experts researched the growth rate of medical specialties based on National Resident Matching Program statistics from 1986 to 2016.
  • In an article about that research, authors note disproportionate growth in subspecialty positions offered in the Match on an annual basis, with only modest growth in the number of primary care positions.
  • The authors say U.S. medical students' choice of career, as well as the decisions of institutions that sponsor residency programs, have created an unbalanced physician workforce short on primary care physicians.

In an interview with AAFP News, corresponding author Stan Kozakowski, M.D., director of the AAFP Division of Medical Education, explained the change in tactics.

"We chose a different perspective because we thought that it was important for those entities responsible for growing the physician workforce to understand how graduate medical education (GME) workforce production has evolved over the last 30 years," said Kozakowski.

Kozakowski said the research findings highlight some important trends.

"There has been dramatic, disproportionate growth in subspecialty positions offered in the NRMP Match on an annual basis, with only very modest growth of primary care positions," he said.

For instance, authors noted that of the 10 specialties with the largest number of positions offered in the 2016 Match, all but one -- general surgery -- have experienced overall growth since 1986.

Furthermore, the overall number of positions offered in the Match increased an average of 226 positions per year. Of those, positions in the E-ROAD specialties increased by an average of 72 per year compared with growth in the primary care specialties of just 19 positions, on average, per year.

Kozakowski pointed out that the United States is the only industrialized nation without a centralized health care workforce planning authority. "As a nation, we spend approximately $15 billion dollars on graduate medical education programs, with little accountability or transparency for that spending.

"The current growth pattern is moving our nation away from the mixture of primary and subspecialty care needed to deliver on the triple aim of health care that is defined as improved health, improved experience of health care and lower per-capita costs."

Editorial Calls for 'New Reform Movement'

An editorial published in the November/December issue of Family Medicine serves as a companion piece to the research outlined in an article examining the National Resident Matching Program from 1986 to 2016.

In the editorial, titled "Family Medicine and the Social Mission of Medical Education,"( author John Saultz, M.D., says it's "long past time for a new reform movement in American medical education." He then lays out three steps family medicine departments and residencies can take to start the process:

  • redefining their core mission to support the health of the public,
  • choosing partners based on actions rather than words and
  • creating a "new covenant" with the communities they serve.

Kozakowski added that the striking trends outlined in the research should alarm all family physicians who are "concerned about having an adequate pipeline of future partners and associates to share the workload."

Drilling Down

Study authors found that during the past 30 years, the number of positions offered in family medicine increased from 2,390 to 3,238. The tally of 3,105 positions filled in the 2016 Match was the most ever. However, the number of U.S. seniors matching into family medicine "has not kept pace," noted the authors.

Here is that breakdown:

  • The number of U.S. seniors who matched to family medicine peaked in 1997, with 2,340 positions filled, and then dropped off through 2009.
  • U.S. seniors accepting positions in family medicine residencies increased 37 percent between 2009 and 2016, but the current number is 213 fewer than in 1986 and 873 fewer than the peak in 1997.
  • The percentage of positions filled by U.S. seniors has declined from 72 percent in 1986 to 45 percent in 2016.

The number of positions offered by various specialties over that time period also is telling. For instance, emergency medicine and anesthesiology positions grew by 602 percent and 242 percent, respectively, whereas family medicine positions increased by only 35 percent, and surgery-categorical positions actually declined by 6 percent.

"This study demonstrates that the majority of the growth in the number of positions offered is in nonprimary care specialties," wrote the authors.

Building the Future

The study authors pointed out that just 14.5 percent of postgraduate year-one positions offered in the 2016 Match were in primary care specialties.

"Declines in U.S. medical student choice of careers in primary care hinder the realization of the full promise of primary care to improve health outcomes, reduce health disparities and control costs," wrote the authors.

They noted that even with the 95 percent-plus filling of primary care positions in the 2016 Match, "there is not a sufficient number of graduates of these programs to fulfill current and projected workforce need."

And although discussions about medical student choice are relevant, there's no denying that institutions that sponsor residency programs have contributed to the level of disproportion documented by researchers.

Authors noted that "factors that influence the decisions of those sponsoring institutions are complex," and that revenue streams for the sponsoring institutions likely are a major factor.

"Residents and fellows in subspecialties may generate more admissions and/or procedures than primary care residents (thus) yielding higher hospital revenue in the current fee-for-service payment system," said researchers. The cost of infrastructure for ambulatory primary care training is another factor.

There is work underway to address the lack of accountability and transparency in GME funding. Kozakowski pointed to recommendations made in the (then) Institute of Medicine's 2014 report( titled Graduate Medical Education That Meets the Nation's Health Needs.

"The report recommended the creation of a GME policy council that would oversee the production of the physician workforce through the allocation of resources," said Kozakowski.

"And the AAFP released a plan(7 page PDF) in September 2014 that would increase the production of family physicians and primary care in a budget-neutral manner."

Related AAFP News Coverage
2016 Match Data Analysis
U.S. Medical Schools Still Underproducing Family Physicians


IOM Report Calls for Restructuring of Nation's GME System
Overhaul Long Overdue, Says AAFP


Graduate Medical Education
AAFP Proposal Presses for GME System Reform to Meet Nation's Primary Care Needs