The journal Family Medicine has published two related articles based on research undertaken by AAFP staff experts that look at, among other things, the entry of medical school graduates into family medicine residency programs in 2016-2017 and the growth of the U.S. primary care workforce.
The articles, published in the October issue of the journal, both conclude that the current medical school system is failing to produce the workforce that the nation needs if it is to achieve optimal health outcomes for the population.
The 2017 articles mark the 36th year of a series that historically has provided an in-depth analysis of statistics from residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), as well as from the National Resident Matching Program (NRMP) Match.
Corresponding author Stan Kozakowski, M.D., director of the AAFP Division of Medical Education, pointed out that the 2017 undertaking was more inclusive than those of years past.
For example, the authors of the article titled "Entry of Medical School Graduates Into Family Medicine Residencies: 2016-2017"(www.stfm.org) included data on the performance of D.O.-granting and international medical schools for the first time.
"It gives a more complete look at the complexity of the production of the nation's primary care workforce," Kozakowski told AAFP News.
- Two articles published in the October Family Medicine as part of a long-running series find that the current U.S. graduate medical education (GME) system is failing to produce the physician workforce the nation needs.
- The 2017 articles included, for the first time, data on the performance of D.O.-granting and international medical schools, as well as trends in the American Osteopathic Association residency matching program.
- The authors conclude that a major overhaul of the GME system is needed and suggest corrective changes such as "limiting the funding of subspecialty GME and using the savings to fund a greater number of primary care positions, mostly family medicine."
Kozakowski also pointed out that the article titled "Results of the 2017 National Resident Matching Program and the American Osteopathic Association Intern/Resident Registration Program: An Examination of Family Medicine and Primary Care"(www.stfm.org) reported on trends in the American Osteopathic Association (AOA) Match for the first time.
Kozakowski and his co-authors concluded that a major overhaul of the graduate medical education (GME) system was needed. "Corrective changes could include limiting the funding of subspecialty GME and using the savings to fund a greater number of primary care positions, mostly family medicine," they wrote.
The end goal would be to "rebalance the U.S. physician workforce to achieve the triple aim of better health care experience, improved health of populations and reduced per capita costs of health care," said the research team.
Trends: NRMP, AOA Match
After digging into statistics for the both the 2017 NRMP and AOA Match, the authors made several observations in their discussion. First off, they noted that the purpose of medicine as a profession is to "meet the health needs of people and communities."
However, despite the growth of family medicine and primary care in the past several years, "the widening gap between the growth of subspecialties over primary care is very concerning."
For instance, during the past 32 years, the number of nonprimary care postgraduate year one (PGY-1) positions grew at an annual rate of 225 per year; by comparison, primary care positions added just 21 positions per year.
"The Council on Graduate Medical Education (COGME) recommended that the proportion of primary care increase to at least 40 percent," wrote the authors, but it stands at about 32 percent and is falling.
The authors also noted that during the past decade, family medicine has seen increases both in positions offered and positions filled with U.S. seniors at a greater rate than other primary care specialties.
"This may reflect the interest by institutions that sponsor GME to grow their primary care base in the community through family medicine rather than other primary care specialties," they wrote.
The authors noted the uneven growth in the number of new primary care positions by specialty since 2009 -- specifically, family medicine (823), medicine-pediatrics (27), medicine-primary (94), and pediatrics-primary (4) -- and said the numbers "reflect the priorities of those sponsoring institutions."
However, they pointed out, more graduates of primary care internal medicine residency programs are becoming hospitalists (increasing from 28.3 percent in 2012 to 32.9 percent in 2015) and are "thereby reducing the contribution of primary care internal medicine programs to the practice of traditional primary care."
By comparison, the rate of family medicine graduates turning to hospitalist positions was far more modest, increasing from 6.5 percent to 7.4 percent during that same period.
Highlights: Producing a Primary Care Workforce
The authors noted that their 2017 report builds on previous reports in the series by creating rank order lists for U.S. M.D.- and D.O.-granting medical schools along with separate lists by absolute numbers and percentage by state for those institutions, as well as by ranking international schools by absolute numbers of graduates entering family medicine.
The numbers, said Kozakowski, provide a "snapshot in time."
The authors also pointed to the growth of both U.S. M.D.-producing and D.O.-producing medical schools in the past 15 years and the slower growth in the number of family medicine GME positions offered as "creating a greater level of competition for these positions."
Family medicine accounts for about 80 percent of primary care positions offered in the NRMP Match each year, they said.
Furthermore, U.S. M.D.-granting schools produced 49 percent of the physicians entering their first year of family medicine residency in 2016, "a percentage that is not statistically significant when compared with the 11-year mean of 46 percent," said the authors.
Regarding the composition of medical school graduates earning first-year spots in ACGME-accredited family medicine residency programs, authors noted that in the past decade, D.O. graduates and international graduates have "changed in a nearly reciprocal fashion." Specifically,
- D.O. graduates have increased about 1 percent per year -- from 14 percent in 2006 to 21 percent in 2016, and
- international graduates have had a reciprocal annual 1.4 percent decrease -- from 38 percent in 2006 to 31 percent in 2016.
Authors also pointed out that even though M.D.-granting medical schools outnumber D.O.-medical schools by about four to one, D.O. graduates entered family medicine at a higher rate than their U.S. M.D. counterparts (15.1 percent versus 9.6 percent).
It must be noted that D.O. graduates also can enter AOA-only accredited residency programs, and those graduates were not included in this analysis.
The authors also highlighted some details about medical schools and their graduates. For example,
- among M.D.-granting schools, 10 schools produced 30 or more graduates entering family medicine in 2016,
- 54 percent of those schools produced 80 percent of the M.D. graduates choosing family medicine;
- the eight lowest schools on the rank list each produced only one graduate entering family medicine;
- all D.O.-granting schools with graduates in 2016 had students enter ACGME-accredited family medicine programs;
- 12 of those schools had 30 or more students enter the specialty;
- 20 of the 34 schools with graduates produced 80 percent of the D.O.-graduates entering family medicine; and
- six international medical schools each produced 30 or more graduates entering the specialty and, combined, accounted for 74 percent of the total number of international students entering family medicine programs.
And as noted in previous articles, medical school location is a big piece of the puzzle when it comes to graduates entering family medicine residency programs.
For instance, in aggregate, schools east of the Mississippi River "had almost double the total number of graduates of schools west of the Mississippi, and had 506 more graduates enter family medicine" than those western schools.
However, noted the authors, the western medical schools "graduated students entering family medicine at a higher rate than schools east of the Mississippi (13 percent versus 9.7 percent).
The authors devoted some discussion to the displacement of international medical graduates (IMGs) by D.O. graduates.
"IMGs currently represent approximately one fourth of the practicing physician workforce, disproportionately serve socioeconomically disadvantaged populations and are more likely to be practicing one of the primary care specialties," they wrote.
"Foreign-born IMGs increase the diversity of the U.S. workforce," the authors added, and may be more likely to practice in rural areas. They urged further research on the impact of displacement of IMGs.
Finally, the authors contended that firm steps should be taken if the nation's GME system is to "address the mismatch between the health needs of the population and the specialty makeup of the physician workforce."
They called for a nonpartisan oversight group to
- develop a strategic plan for Medicare GME funding;
- research and implement policies regarding the adequacy, geographic distribution and specialty configuration of the physician workforce;
- collect data; and
- provide accountability to the public.
Kozakowski wrapped up the research findings by saying, "The current GME system has failed to match the work force needs of the nation and deliver the triple aim of health care. The AAFP presented a proposal in 2014(7 page PDF) that is budget-neutral and offers a plan to address these issues."
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